Abstract
Background
A bladder diverticulum is a source of infections, urinary stones, and malignancy. Until recent years, patients suffering from large obstructive prostate and diverticulum were treated with open surgery, which also allowed diverticulectomy. The transition to a closed approach has led to diverticulum preservation. The clinical implications of this preservation strategy have not been sufficiently studied.
Materials and methods
A retrospective comparison was made between holmium laser enucleation of the prostate (HoLEP) patients with a diverticulum (≥2 cm) and HoLEP patients without any diverticulum. For each patient with a diverticulum, two patients without a diverticulum who were operated on around the same time were matched (1:2). Patients operated on until March 2022 were included to allow for a relatively long follow-up period.
Results
Out of 602 HoLEP patients, 32 (5%) had a diverticulum ≥2 cm, and they were matched with 64 patients without a diverticulum. The median diverticulum size was 37 mm (interquartile range: 25, 51). A comparison of preoperative data between the two groups revealed no significant differences. Two patients with a diverticulum required a temporary urinary catheter at discharge, but there were no significant differences in surgical, perioperative, or postoperative measures between the two groups, except for a clinically insignificant difference in residual urine volume. With a median follow-up of 3.3 years (interquartile range: 2.5, 4.5), no patient required or was referred for diverticulectomy.
Conclusions
HoLEP is an effective treatment method for patients with bladder outlet obstruction and concomitant bladder diverticulum. By effectively relieving the bladder outlet obstruction, HoLEP can avoid the need for more invasive surgical interventions.
Keywords: Bladder, Bladder outlet obstruction, Diverticulum, Lower urinary tract symptoms, Prostatic hyperplasia, Prostatectomy, Transurethral
1. Introduction
Bladder diverticulum (BD) represents herniation of the urothelial lining projecting through congenital or acquired weakness in the muscular bladder wall.1 They can be single or multiple in nature, and most are acquired, resulting from increased intravesical pressure secondary to bladder outlet obstruction (BOO).2 BD functions as a low-pressure pocket where urine may become trapped during voiding. Most BDs are of a small size and asymptomatic, typically managed through observation. However, a subset of these diverticula grows and may lead to high residual urine volumes and urinary stasis complications.3, 4, 5 Management options in the treatment of BD include observation, endoscopic management, and surgical excision. The classical indications for intervention include the presence of tumor, persistent infection, stones, ureteral obstruction, severe reflux of the diverticulum, and retention.6,7
In the last seven years, holmium laser enucleation of the prostate (HoLEP) has superseded open suprapubic prostatectomy,8,9 becoming the sole surgical technique at our institution for individuals with BOO due to a significantly enlarged prostate (>60 cc). Owing to the minimally invasive nature of HoLEP, BDs were routinely preserved.
Limited data exist regarding the conservative management of BD following HoLEP. This study aims to compare the early and intermediate-term outcomes of patients with and without BD who underwent HoLEP.
2. Methods
A systematic retrospective review of all patients who underwent HoLEP at our institution starting in 2016 was conducted (IRB approval: RMC-971-20). To enable a relatively long follow-up period, the review was concluded in March 2022. Preoperative prostate gland measurement was conducted with ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI). The presence and diameter of a BD were determined based on these preoperative imaging studies and intraoperative cystoscopic findings. In most cases, the diverticulum was measured once. In a few cases, when more than one imaging modality was available, the scan in which the bladder was fuller was selected. The study group included patients with at least one BD with diameter ≥2 cm. Two control patients (without BD) were matched to each study patient based on the date of their HoLEP procedure (1:2 ratio).
All HoLEP procedures commenced with a formal cystoscopy to thoroughly assess the bladder and any existing BD. Laser enucleation was performed using a 100- and 120-W holmium laser. The surgical approach used either a two-lobe or three-lobe technique, with the choice determined by the size of the median lobe and surgeon preference.10 Tissue morcellation was performed using a rigid nephroscope after completion of enucleation. A 22-French 3-way catheter was inserted at the end, and patients were initiated on continuous bladder irrigation, typically discontinued by postoperative Day 1. All patients had their catheter removed on postoperative Day 1 and were given a trial of voiding with postvoid residual (PVR) measurements.
All patients attended at least one follow-up appointment at our clinic one month after the surgery. Those with uncomplicated recovery continued follow-up at their local community clinics. Postoperative data were obtained from our medical record system and from Ofek, an integrated online information system that includes computerized medical records from various sources, including laboratories, diagnostic systems, and medical records from both public and private hospitals, as well as all health maintenance organization clinics nationwide. Persisting lower urinary tract symptoms (LUTSs) were defined as occurring more than 6 months after surgery.11
2.1. Statistical analysis
A comparison between the two groups was performed to assess the impact of the preserved BD on the rates of postoperative complications and functional outcomes. Descriptive statistics were used to summarize the data. Continuous variables were reported as median and interquartile range (IQR), while categorical variables were reported as frequencies and percentages. The Chi-square test was used to compare categorical variables between the groups, and the Mann–Whitney U test was used to compare continuous variables. All statistical analyses were performed using SPSS software 28.0 (IBM Corp., Armonk, NY, USA) with a two-sided significance level set at a P value <0.05.
3. Results
Among the 602 patients who underwent HoLEP at our institution until March 2022, 32 patients (5%) had BD measuring 2 cm or larger. These patients were matched with 64 patients who did not have BD. Table 1 presents a comparison of preoperative characteristics, which revealed no significant differences between the two groups. The median diverticulum size was 37 mm (IQR: 25, 51). Measurements were performed using US in 20 (62.5%) patients, CT in 7 (22%), and MRI in 5 (15.5%). Preoperatively, approximately 50% of patients in the BD group required an indwelling urinary catheter. In the remaining patients, the median preoperative PVR was 330 mL in the BD group and 260 mL in the control group (P = 0.6).
Table 1.
A comparison of preoperative characteristics between patients with and without bladder diverticula who underwent HoLEP
| Diverticula group (n = 32) | Control group (n = 64) | P | |
|---|---|---|---|
| Age, y, median (IQR) | 72.5 (67, 79) | 73 (68, 79) | 0.9 |
| BMI, kg/m2, median (IQR) | 26.1 (22, 28) | 26.8 (24, 29) | 0.2 |
| Comorbidities (diabetes, blood thinners, and neurologic), n (%) | 19 (59.5) | 44 (69) | 0.3 |
| Prostate volume, ml, median (IQR) | 92.5 (80, 120) | 108 (82, 149) | 0.09 |
| Indwelling catheter, n (%) | 16 (50) | 34 (53) | 0.8 |
| α-blocker use, n (%) | 25 (78) | 48 (75) | 0.9 |
| α-blocker, duration in years, median (IQR) | 5 (3, 6) | 5 (3, 5) | 0.8 |
| 5α-reductase inhibitor use, n (%) | 13 (37.5) | 22 (34.5) | 0.9 |
| 5α-reductase inhibitor, duration in years, median (IQR) | 3 (1, 5) | 3.5 (1, 5) | 0.8 |
| Previous prostate surgery, n (%) | 2 (6) | 1 (1.6) | 0.3 |
| Post void rest, ml, median (IQR) | 330 (161, 900) | 260 (130, 500) | 0.6 |
| Positive urine culture, n (%) | 11 (34.4) | 18 (28) | 0.5 |
| Hemoglobin, g/dl, median (IQR) | 13.8 (13, 14.5) | 13.6 (13, 14.3) | 0.6 |
| Creatinine, mg/dL, median (IQR) | 1.1 (0.9, 1.2) | 1 (0.9, 1.1) | 0.1 |
| PSA, ng/mL, median (IQR) | 4.2 (2.1, 6) | 3.7 (2.4, 6.8) | 0.6 |
| Prostate MRI due to suspicious PSA elevation, n (%) | 4 (0.12) | 8 (0.12) | 1 |
BMI, body mass index; BOO, bladder outlet obstruction; CT, computed tomography; HoLEP, holmium laser enucleation of the prostate; IQR, interquartile range; MRI magnetic resonance imaging; PSA, prostate-specific antigen; US, ultrasound.
Perioperatively, two patients with BD required a temporary urinary catheter at discharge. However, no significant differences were observed between the two groups regarding surgical or immediate postoperative parameters, as presented in Table 2.
Table 2.
A comparison of perioperative characteristics between patients with and without bladder diverticula who underwent HoLEP
| Diverticula group (n = 32) | Control group (n = 64) | P | |
|---|---|---|---|
| Length of operation, minute, median (IQR) | 115 (90, 138) | 111 (95, 126) | 0.7 |
| Prostate resected weight, g, median (IQR) | 79 (46, 101) | 81.5 (60, 110) | 0.4 |
| Postoperative hemoglobin, g/dl, median (IQR) | 13 (11.8, 13.6) | 12.5 (11.8, 13.3) | 0.3 |
| Postoperative creatinine, mg/dL, median (IQR) | 1 (0.9, 1.2) | 0.94 (0.8, 1.1) | 0.2 |
| Fever, n (%) | 0 (0) | 1 (1.6) | 0.7 |
| Blood transfusion, n (%) | 1 (3) | 1 (1.6) | 0.6 |
| Length of catheter, day, median (IQR) | 1 (1, 2) | 1 (1, 1) | 0.5 |
| Length of hospitalization, day, median (IQR) | 2 (1, 2) | 2 (1, 2) | 0.9 |
| Post void rest at discharge, ml, median (IQR) | 127 (57, 220) | 71 (43, 115) | 0.053 |
| Discharge with catheter, n (%) | 2 (6) | 0 (0) | 0.1 |
| Prostate cancer on pathology, n (%) | 1 (3) | 3 (4.7) | 0.6 |
HoLEP, holmium laser enucleation of the prostate; IQR, interquartile range.
Within the 30-day postoperative period, 5 patients (15.6%) in the BD group and 5 patients (7.8%) in the control group presented to the emergency department (P = 0.2). The reasons for these emergency department visits included hematuria (60%), dysuria with a negative urine culture (20%), and transient urinary retention (20%). Except for a clinically insignificant difference in PVR [study group PVR: 56 ml (IQR: 12, 94); control group PVR: 11 ml (IQR: 0, 54), P = 0.04], no significant differences in early or late postoperative complications were observed between the two groups, as presented in Fig. 1.
Figure 1.
A comparison of postoperative parameters between patients with and without bladder diverticulum who underwent HoLEP. ER, emergency room; HoLEP, holmium laser enucleation of the prostate.
In the group of 32 patients with BD, a strong positive linear correlation was found between BD size and the most recent PVR (Pearson coefficient = 0.58, P = 0.01). Twelve out of 32 patients (37.5%) experienced late postoperative urologic complications: persisting storage LUTS in five patients, persisting voiding LUTS in two patients, urethral stricture in one patient, and one or more of the following in the remaining 4 patients: UTI, hematuria and persisting storage LUTS. All complications were Clavien–Dindo grade ≤2. Patients who experienced these complications had larger prostate volumes and were significantly older. No significant difference in median BD size was observed between the patients who experienced complications and the 20 patients who did not (Table 3). In a median follow-up of 3.3 years (IQR: 2.5, 4.5), all patients were voiding with no clinically significant PVR and no patient required or was recommended for diverticulectomy.
Table 3.
Comparison of preoperative parameters in patients with bladder diverticula with and without late postoperative urologic complications
| With complications (n = 12) | Without complications (n = 20) | P | |
|---|---|---|---|
| Age, y, median (IQR) | 76 (72, 83) | 69 (66, 76) | 0.01 |
| Diverticulum size, median, mm (IQR). | 34 (22, 72) | 36 (25, 50) | 0.9 |
| PSA, ng/mL, median (IQR) | 3.5 (2.2, 6) | 4.2 (1.4, 6) | 0.9 |
| BMI, kg/m2, median (IQR) | 24.5 (22, 30) | 26.4 (24, 28) | 0.9 |
| Prostate volume, ml, median (IQR) | 120 (81, 145) | 91 (72, 99) | 0.08 |
| Comorbidities (diabetes, blood thinners, neurologic), n (%) | 9 (75) | 10 (50) | 0.3 |
| Indwelling catheter, n (%) | 4 (33) | 12 (60) | 0.1 |
| Positive urine culture, n (%) | 3 (25) | 8 (40) | 0.4 |
BMI, body mass index; IQR, interquartile range; PSA, prostate-specific antigen.
4. Discussion
The clinical significance of a BD is determined by factors such as its size, location, emptying ability, and impact on bladder function. This comparative study analyzed real-world data from patients who underwent HoLEP, with and without concurrent BD. Over a median follow-up period of 3.3 years, the majority of patients with BDs did not experience any BD-related complications. A small number of patients experienced complications, with a rate similar to that observed in HoLEP patients without BD.12
The management of the seemingly asymptomatic BD that is detected during LUTS evaluation is controversial with no agreed-upon cut-off size. Addressing the BOO while preserving these low-pressure pockets can negatively impact bladder contractility.13 Furthermore, preserving the BD, which carries an increased risk of rapidly progressing malignancy, necessitates lifelong periodic surveillance.14, 15, 16 With advancements in laparoscopic and robotic surgical techniques, the excision of BD has become less morbid, resulting in excellent outcomes. Some experts now advocate for a one-session procedure, combining minimally invasive diverticulectomy with BOO surgery.17,18 Conversely, successful treatment of BOO alone may improve bladder and BD emptying, potentially resolving BD-related symptoms and complications. Consequently, any additional procedure might be unnecessary.
To our knowledge, only one previous study, by Agarwal and Krambeck, investigated the effectiveness of HoLEP in patients with BOO and concurrent BD.19 Their study included a relatively large cohort (n = 51) but lacked a control group. Following HoLEP, patients experienced satisfactory relief of symptoms, with all patients voiding at a mean follow-up of 3 years. In their study, 6% (3/51) of patients required subsequent diverticulectomy. A comparative analysis of the three patients requiring diverticulectomy to the remaining 48 patients may provide insights into the prospective identification of candidates who may benefit from primary combined surgery. The three patients were younger (mean age: 55 vs. 71 years), with smaller preoperative prostate size (mean: 38 vs. 84 g), larger BD size (6.2 vs. 5.4 cm), higher rate of catheter-dependent retention (67% vs. 54%), and lower preoperative PSA level (mean: 1.2 vs. 8.3 ng/dl).
In the current study, no patient required diverticulectomy. However, some late postoperative urologic complications were observed, enabling a comparison between the subgroups of BD patients with and without complications. No statistically significant differences were found in prostate size, BD size, the rate of catheter-dependent urinary retention, or baseline PSA levels between these subgroups.
In contrast to the previous study, patients with BD who experienced complications in the current study were significantly older.20 It can be argued that the patient populations in both studies differed, as the mean prostate size was smaller (81 g vs. 103 g) and the mean BD size was larger (5.5 cm vs. 4.1 cm) in the previous study than in the current-study BD cohort.
It is generally acknowledged that a large BD with a small drainage neck, especially in young patients, should be considered a strong indication for intervention.4 Nonetheless, there is no consensus in literature regarding the specific BD size or the neck diameter that warrants intervention. A retrospective study by Iscaife et al analyzed the role of BD size as a risk factor for acute urinary retention (AUR) in the context of benign prostatic hyperplasia (BPH) patients who are candidates for combined surgery.21 A correlation was found between BD size and a history of AUR, with a BD diameter greater than 5.1 cm identified as a strong risk factor for AUR [odds ratio: 2.65 (1.20–5.85)]. Since all patients in their study underwent BPH surgery combined with diverticulectomy, conclusions regarding a safe size threshold for BD preservation cannot be drawn.
In addition to the lack of consensus regarding the optimal BD size, accurate measurement of BD is challenging due to their dynamic nature. Voiding cystourethrography (VCUG) is the gold standard for diagnosing BD, allowing for accurate measurements and evaluation of BD emptying during voiding. However, VCUG is not routinely performed as a preoperative imaging study for patients with LUTSs. In the current study, BD measurements were based on US, CT, or MRI, in addition to intraoperative cystoscopic assessment. In the study by Iscaife et al, measurements relied on contrast-enhanced CT, while Agarwal and Krambeck did not explicitly detail the preoperative imaging methods used. In the Agarwal and Krambeck cohort, two patients who required diverticulectomy underwent video urodynamic studies after HoLEP, revealing paradoxical enlargement of the BD during voiding. Considering the existing literature, it would be reasonable to recommend a dynamic imaging study, such as video urodynamic studies or VCUG, as part of the preoperative evaluation for HoLEP candidates at a high risk of BD-related complications. While defining clear-cut criteria for this high-risk group is not currently feasible based on the available literature, utilizing routine preoperative US to assess BD size and emptiness or enlargement during voiding may help identify patients who would benefit from more comprehensive investigations.
When preserving any BD, it's crucial to consider both the risk of malignancy and the necessary follow-up strategies for early detection. The accurate incidence of carcinoma arising within BD is difficult to determine, partly due to the unknown number of asymptomatic diverticula remaining undetected in the general population.22 In a clinically explored BD, the incidence varies widely, ranging from 1% to 33.3%.3,16 Of note, a significantly higher percentage of BD-associated carcinomas are high-grade ones and invasive.3,14 In both the current study and Agarwal and Krambeck's study, there were no reported cases of BD-associated carcinoma during a follow-up of approximately 3 years. Since routine cystoscopy or cytology was not included in the follow-up, the possibility of asymptomatic metaplasia or carcinoma within BD cannot be ruled out, underscoring the need for closer and longer-term surveillance.
This study has some limitations. First, there is lack of information regarding preoperative symptom scores and urodynamic data. However, all the patients included in this series were candidates for HoLEP surgery and were assessed based on their clinical baseline characteristics. In addition, to explore the net effect of preserving BD, a control group of HoLEP patients without BD was included.
Second, patients with BD who were not surgical candidates were not included in the analysis. This limitation precludes any definitive conclusions regarding the actual role of BD in the general population. Further prospective series are needed to accurately analyze the role of BD on the natural history of men with LUTSs.
5. Conclusion
HoLEP alone is an efficient treatment method for patients with outlet obstruction and concomitant BD. Preserving the diverticulum is not associated with a significantly higher rate of complications; thus, patients can avoid more invasive surgical intervention.
Ethics approval and consent to participate and consent for publication
Not applicable.
Data availability
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Contributors’ statement
Michael Frumer – conceptualization, data curation, project administration, methodology, formal analysis, writing - original draft.
Iyad Khamaisi, Guy Levenberg, Gherman Creiderman, Ron Gilad, Sagi A. Shpitzer, Tzach Aviv, Muhammad Krenawi, Shayel Bercovich, Nadav Dekel, Hadar Tamir, Tomer Hasdai, Yossi Ventura, Niv Segal, Hen Hendel, Liran Zieber-data curation, investigation, writing - review and editing.
Jack Baniel, David Lifshitz, Abd E. Darawsha, Yaron Ehrlich – conceptualization, writing - review and editing, supervision.
All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
The authors have no conflicts of interest relevant to this article to disclose.
Funding
No funding
Conflicts of interest
The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
Contributor Information
Michael Frumer, Email: mic1039@gmail.com.
Iyad Khamaisi, Email: eyad27.01@gmail.com.
Guy Levenberg, Email: Levenbergberg@gmail.com.
Gherman Creiderman, Email: creiderman_g@yahoo.com.
Ron Gilad, Email: roni789@gmail.com.
Sagi A. Shpitzer, Email: Sagi.shpitzer@gmail.com.
Tzach Aviv, Email: tzachaviv@gmail.com.
Muhammad Krenawi, Email: Krenawi1987@gmail.com.
Shayel Bercovich, Email: shayelb11@gmail.com.
Nadav Dekel, Email: nadavdekel@gmail.com.
Hadar Tamir, Email: hadar.tamir@gmail.com.
Tomer Hasdai, Email: 2208thasdai@gmail.com.
Yossi Ventura, Email: vinty23@gmail.com.
Niv Segal, Email: nivsegal5@gmail.com.
Hen Hendel, Email: henhendel@gmail.com.
Liran Zieber, Email: liranzib@gmail.com.
Jack Baniel, Email: jbaniel@clalit.org.il.
David Lifshitz, Email: davidlif@clalit.org.il.
Abd E. Darawsha, Email: a.darawsha@gmail.com.
Yaron Ehrlich, Email: yaronehrlich@gmail.com.
References
- 1.Kelalis P.P., McLean P. The treatment of diverticulum of the bladder. J Urol. 1967;98(3):349–352. doi: 10.1016/S0022-5347(17)62888-X. [DOI] [PubMed] [Google Scholar]
- 2.Gerridzen R.G., Futter N.G. Ten-year review of vesical diverticula. Urology. 1982;20(1):33–35. doi: 10.1016/0090-4295(82)90532-5. [DOI] [PubMed] [Google Scholar]
- 3.Kong M.X., Zhao X., Kheterpal E., Lee P., Taneja S., Lepor H., et al. Histopathologic and clinical features of vesical diverticula. Urology. 2013;82(1):142–147. doi: 10.1016/j.urology.2013.02.015. [DOI] [PubMed] [Google Scholar]
- 4.Powell C.R., Kreder K.J. Treatment of bladder diverticula, impaired detrusor contractility, and low bladder compliance. Urol Clin. 2009;36(4):511–vii. doi: 10.1016/j.ucl.2009.08.002. [DOI] [PubMed] [Google Scholar]
- 5.Burns E. Diverticula of the urinary bladder. Ann Surg. 1944;119(5):656–664. doi: 10.1097/00000658-194405000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Mićić S., Ilić V. Incidence of neoplasm in vesical diverticula. J Urol. 1983;129(4):734–735. doi: 10.1016/s0022-5347(17)52332-0. [DOI] [PubMed] [Google Scholar]
- 7.EAU Guidelines . March 2023. Presented at the EAU annual congress milan. ISBN 978-94-92671-19-6. [Google Scholar]
- 8.Franco J.V.A., Tesolin P., Jung J.H. Update on the management of benign prostatic hyperplasia and the role of minimally invasive procedures. Prostate Int. 2023;11(1):1–7. doi: 10.1016/j.prnil.2023.01.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Lim E.J., Castellani D., Somani B.K., Gökce M.I., Fong K.Y., Sancha F.G., et al. High-power holmium laser versus thulium fiber laser for endoscopic enucleation of the prostate in patients with glands larger than 80 ml: results from the Prostate Endoscopic EnucLeation study group. Prostate Int. 2024;12(1):40–45. doi: 10.1016/j.prnil.2023.12.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Moody J.A., Lingeman J.E. Holmium laser enucleation for prostate adenoma greater than 100 gm.: comparison to open prostatectomy. J Urol. 2001;165(2):459–462. doi: 10.1097/00005392-200102000-00025. [DOI] [PubMed] [Google Scholar]
- 11.Das A.K., Teplitsky S., Chandrasekar T., Perez T., Guo J., Leong J.Y., et al. Stress urinary incontinence post-holmium laser enucleation of the prostate: a single-surgeon experience. Int Braz J Urol. 2020;46(4):624–631. doi: 10.1590/S1677-5538.IBJU.2019.0411. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Lee H., So S., Cho M.C., Cho S.Y., Paick J.S., Oh S.J. Clinical outcomes of holmium laser enucleation of the prostate: a large prospective registry-based patient cohort study under regular follow-up protocol. Investig Clin Urol. 2024;65(4):361–367. doi: 10.4111/icu.20240080. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Adot Zurbano J.M., Salinas Casado J., Dambros M., Virseda Chamorro M., Ramírez Fernández J.C., Silmi Moyano A., et al. La urodinámica del diverticulo vesical en el varón adulto [Urodynamics of the bladder diverticulum in the adult male] Arch Esp Urol. 2005;58(7):641–649. doi: 10.4321/s0004-06142005000700008. [DOI] [PubMed] [Google Scholar]
- 14.Melekos M.D., Asbach H.W., Barbalias G.A. Vesical diverticula: etiology, diagnosis, tumorigenesis, and treatment. Analysis of 74 cases. Urology. 1987;30(5):453–457. doi: 10.1016/0090-4295(87)90378-5. [DOI] [PubMed] [Google Scholar]
- 15.Yu C.C., Huang J.K., Lee Y.H., Chen K.K., Chen M.T., Chang L.S. Intradiverticular tumors of the bladder: surgical implications--an eleven-year review. Eur Urol. 1993;24(2):190–196. doi: 10.1159/000474292. [DOI] [PubMed] [Google Scholar]
- 16.Baniel J., Vishna T. Primary transitional cell carcinoma in vesical diverticula. Urology. 1997;50(5):697–699. doi: 10.1016/S0090-4295(97)00319-1. [DOI] [PubMed] [Google Scholar]
- 17.Kang Q., Kang B., Yu Y., Yang B. Transurethral enucleation of the prostate combined with laparoscopic bladder diverticulectomy. Minim Invasive Ther Allied Technol. 2022;31(1):144–148. doi: 10.1080/13645706.2020.1768123. [DOI] [PubMed] [Google Scholar]
- 18.Elshal A.M., Eldemerdash Y., Mekkawy R., Taha D.E., Laymon M., El-Nahas A.R., et al. Prostate tissue retrieval after holmium laser enucleation of the prostate; assessment of non-morcellation approaches. Arab J Urol. 2016;14(2):147–155. doi: 10.1016/j.aju.2016.02.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Agarwal D.K., Krambeck A.E. Holmium laser enucleation of the prostate is an effective treatment in patients with concomitant bladder diverticula and outlet obstruction. World J Urol. 2018;36(1):87–90. doi: 10.1007/s00345-017-2114-5. [DOI] [PubMed] [Google Scholar]
- 20.Jeh S., Choi M., Kang C., Kim D., Choi J., Choi S., et al. The epidemiology of male lower urinary tract symptoms associated with benign prostatic hyperplasia: results of 20 years of Korean community care and surveys. Investig Clin Urol. 2024;65(1):69–76. doi: 10.4111/icu.20230249. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Iscaife A., Dos Anjos G., Barbosa C Neto, Nahas W.C., Srougi M., Antunes A.A. The role of bladder diverticula in the prevalence of acute urinary retention in patients with BPH who are candidates to surgery. Int Braz J Urol. 2018;44(4):765–770. doi: 10.1590/S1677-5538.IBJU.2017.0605. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Fellows F.J. The association between vesical carcinoma and diverticulum of the bladder. Eur Urol. 1978;4(3):185–186. doi: 10.1159/000473945. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.