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A rare entity in adults: bilateral hutch diverticulum with calculi.

Introduction

Bladder diverticulum is related to herniation through a weakness of the bladder muscular wall. (1) The great majority of bladder diverticulum is located at or near the ureterovesical junction in patients who are otherwise healthy. (2) They are classified as congenital, acquired, or iatrogenic. (3) CBDs are associated with a variety of genitourinary complications, such as infections and voiding dysfunction. (4) We report a very rare entity of bilateral congenital bladder diverticulum with calculi resulting from lower urinary tract symptoms (LUTS).

Case report

We present a case of a 42-year-old man suffering with LUTS with dysfunctional voiding. He had a mild right renal colic pain, difficulty in micturition, and frequent urinary tract infections (UTIs). His symptoms had worsened within last 2 months and he was then admitted to our clinic. After normal physical examination, urinalysis and urine culture tests were performed with routine complete blood count, creatinine, blood urea nitrogen (BUN), and prostate-specific antigen (PSA) measurements. Urinalysis showed severe UTI with nitrite positive and he had leukocytosis, and normal creatinine, BUN and PSA levels. Ceftriaxone 1 g intravenous (IV) daily started and was switched to meropenem 3 x 1 g IV daily when the urine culture showed extended spectrum beta-lactamase (ESBL) Escherichia coli growth. A plain abdominal radiography showed radiopaque stones in the bilateral diverticulum (Fig. 1, part A). He underwent an ultrasound examination of the urinary system, which revealed bilateral grade I and II hydronephrosis with bilateral ureteral dilatation and bilateral bladder diverticulum with 7 x 7cm at left inferior portion of the bladder and 1 x 2 cm at the right inferior portion with bladder calculi. Via ultrasound, the prostate measured 44 cc. An IV pyelography was performed to inspect the urinary tract. It revealed normal nephrogram and pyelogram phases, bilateral ureteral and renal dilatation with the bilateral bladder diverticulum and bladder stones in diverticulum (Fig. 1, part B). When the patient had a negative urine culture with antibiotics, the endoscopy was performed. Cystoscopy evaluation revealed a bilateral diverticulum near ureterovesical junction (Hutch diverticulum) and multiple calculi in the diverticulum (Fig. 1, part C). Cystolithotripsy for bladder calculi and non-surgical intervention for diverticulum was performed and patient's symptoms completely abated. At the 6-month follow-up visit, the patient had no abnormal LUTS and his urinary ultrasound was normal.

Discussion

Hutch diverticulum is a rare entity thought to be a congenital failure of normal muscle development around the ureteral orifice where Waldeyers heath anatomically covers the space between the intravesical ureter and muscular layer of bladder. (5) This diverticulum is usually solitary, occurs mostly in males, is located posteriorly and laterally to the ureteral orifice. A small amount of mucosa initially herniates through a congenital defect in the bladder musculature. Then the defect enlarges with voiding and finally the ureteral orifice is incorporated into the diverticulum. (6) There are very few reported cases and most of them are in children. Adult cases are rare. (7-8)

Patients with Hutch diverticulum can be asymptomatic or may have diverse symptoms due to obstruction or voiding dysfunction, urinary retention inside the diverticulum (urinary infections) or stone formation (as in the case we present here). (9) A review of the adult literature on Hutch diverticulum suggests that both conservative and surgical reconstruction depends on the symptoms and complications of the diverticulum. Indications for surgery are typically large diverticula with complications of incomplete emptying, including recurrent stone formation (5%-16%), recurrent UTIs (13%-73%), spontaneous rupture, and vesico-ureteral reflux mostly with children. (9-11)

In our case we decided on conservative management and followed up with our patient after endoscopic removal of the stone in the diverticulum and the opening of the diverticulum neck. At follow-up, the patient did not have LUTS, recurrent UTIs, or stone formation.

Conclusion

We report a very rare entity of bilateral CBD with calculi resulting from LUTS. CBDs are associated with a variety of genitourinary complications, such as infections and voiding dysfunction, which are the most frequent presentation forms. Most CBD are small and asymptomatic; they are managed conservatively with follow-up, although larger diverticula may present with significant urological symptoms and open or endoscopic diverticulectomy is recommended.

Caption: Fig. 1. A: Plain abdominal radiography showing radiopaque stones in the bladder (arrows). B: Intravenous pyelogram revealing bilateral bladder diverticulum with 7 x 7 cm at left inferior and 1 x 2 cm at right inferior portion (arrows). C: Endoscopic view of ureterovesical junction bladder diverticulum (arrows).

http://dx.doi.org/10.5489/cuaj.2327

Competing interests: The authors declare no competing financial or personal interests.

This paper has been peer-reviewed.

References

(1.) Boechat MI, Lebowitz RL. Diverticula of the bladder in children. Pediatr Radiol 1978; 7:22-8. http:// dx.doi.org/10.1007/BF00975333

(2.) Caldamone AA. Anomalies of the bladder and cloaca. In: Gillenwater JT, Grayhack JT, Howards SS, et al, editors. Adult and pediatric urology. 2nd ed. St Louis (Mo); Mosby-Year Book, Inc; 1991:2024-5.

(3.) Jenkins A. An adult case of bladder diverticula without urinary obstruction. Brit J Urol 1987; 6:102-4.

(4.) Evangelidis A, Castle EP, Ostlie DJ, et al. Surgical management of primary bladder diverticula in children. J Pediatr Surg 2005; 40:701-3. http://dx.doi.org/10.1016/j.jpedsurg.2005.01.003

(5.) Hernanz-Schulman M, Lebowitz RL. The elusiveness and importance of bladder diverticula in children. Pediatr Radiol 1995; 15:399-402. http://dx.doi.org/10.1007/BF02388360

(6.) Pace AM, Powell C. Congenital vesical diverticulum in a 38-year-old female. Int Urol Nephrol 2005; 37:4735. http://dx.doi.org/10.1007/s11255-004-8074-x

(7.) Palmero Marti JL, Ramirez Backhaus M, Alvarez Barrera A, et al. Hutch bladder diverticula: A very uncommon entity in adults. Arch Esp Urol 2012; 65:636-9.

(8.) Vite-Velazquez EJ, Venegas-Ocampo JJ, Robles-Scott MA, et al. Bilateral Hutch periureteral diverticulum without reflux in an adult patient. Rev Mex Urol 2009; 69:292-4.

(9.) Silay MS, Koh CJ. Management of the bladder and calyceal diverticulum: Options in the age of minimally invasive surgery. Urol Clin North Am 2015; 42:77-87. http://dx.doi.org/10.1016/j.ucl.2014.09.007

(10.) Heyns CF. Urinary tract infection associated with conditions causing urinary tract obstruction and stasis, excluding urolithiasis and neuropathic bladder. World J Urol 2012; 30:77-83. http://dx.doi. org/10.1007/s00345-01 1-0725-9

(11.) Cerwinka WH, Scherz HC, Kirsch AJ. Endoscopic treatment of vesicoureteral reflux associated with paraureteral diverticula in children. J Urol 2007; 178:1469-73. http://dx.doi.org/10.1016/j. juro.2007.05.168

Onur Telli, MD; Adil Gucal Guclu, MD; Perviz Haciyev, MD; Berk Burgu, MD; Cagatay Gogus, MD

Ankara University, School of Medicine, Department of Urology, Ankara, Turkey

Correspondence: Dr. Onur Telli, Ankara University School of Medicine, Department of Urology, Sihhiye/Ankara, Turkey; onurtelli@yahoo.com

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Article Details
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Title Annotation:CASE REPORT
Author:Telli, Onur; Guclu, Adil Gucal; Haciyev, Perviz; Burgu, Berk; Gogus, Cagatay
Publication:Canadian Urological Association Journal (CUAJ)
Article Type:Clinical report
Date:May 1, 2015
Words:1131
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