Diverticulocystoplasty with Bilateral Ureteric Reimplantation: Management in a Rare Case of Combined Congenital Large Paraureteric Diverticulum with Bilateral Obstructive Megaureter

Abstract

A large congenital paraureteric diverticulum has not been reported earlier in combination with bilateral obstructed megaureter. We present one such case in an adolescent male with decreased bladder capacity and renal failure. A single sitting surgical procedure included diverticulocystoplasty with bilateral ureteric reimplantation. The left ureter was implanted into the diverticular wall, which was used as a patch to augment the bladder. Reimplantation into the wall of the diverticulum has also not been reported earlier.Keywords Primary obstructive megaureter . Paraureteric bladder diverticulum . Diverticulocystoplasty . Augmentation Case ReportA 14-year-old boy presented with pain in flanks, frequency (8-12 times/day), and pyuria for 1.5 years. There was no urgency, incontinence, straining, or thinning of stream of urine. There was no neurological disease or recurrent infections in childhood. Urinary routine and culture confirmed infection, while blood investigations showed renal failure (urea 54.2 mg%, creatinine 2.2 mg%). External genitalia and spine were normal. Ultrasonography showed a large bladder diverticulum with bilateral marked hydroureteronephrosis. An indwelling urethral catheter was kept suspecting bladder outlet obstruction or vesicoureteric reflux with UTI and uremia. However, there was no improvement in serial blood urea/creatinine values and the catheter was subsequently removed. Meanwhile after treating infection, further evaluation with voiding cystourethrogram (Fig. 1) showed a narrow-necked large primary bladder diverticulum (PBD). The bladder capacity was low (total infused volume 150 cc, inclusive of diverticulum). MR urography (Fig. 1) confirmed the findings and also suggested coexisting bilateral primary obstructive megaureter (POM). Diuretic renal nuclear scan showed differential function of 55 % (right) and 45 % (left). Total GFR was 25 ml/minute with body weight of 43 kg. Consent was taken for cystoscopy and surgical exploration under anesthesia.Cystoscopy showed normal urethra and bladder, 160 cc total capacity, nonidentifiable ureteric orifices, and a narrow diverticulum opening at site of the left ureteric orifice. Diverticuloscopy was unremarkable. A midline infraumbilical extraperitoneal approach was used for exploration. PBD was identified and both ureters were dissected. The long rattailed end-of-left ureter was confirmed to be opening alongside the neck of PBD. The PBD had reasonable detrusor backing in its wall (Fig. 2). Decision was then made to use it for augmentation. Its neck was thus separated from the bladder while inferior and lateral attachments were left undisturbed to maintain blood supply. It was opened longitudinally extending both superiorly and inferiorly from its neck to form a patch. The bladder was also opened longitudinally extending upward in a curvilinear fashion starting from the site of opening of PBD. Bilateral excision/tailoring and reimplantation of ureters were done over 7 F feeding tubes. The left ureter was reimplanted into the diverticul...