V11-01: NOTES-assisted laparoscopic transvesical bladder diverticulectomy

Video

Introductions and Objectives
Several techniques have been described for management of acquired retentive bladder diverticula. These include endoscopic fulguration for small diverticula and open or Laparoscopic surgery for larger ones. An elegant minimally invasive technique has been described by Pansadoro et al. using transvesical approach. Recently, Transvesical Laparo-Endoscopic Single-port Surgery (T-LESS) has been attempted successfully by Roslan et al._x000D_ We present a novel approach for management of retentive bladder diverticula using NOTES-assisted laparoscopic transvesical approach in which the urethra offers an extra access to the diverticula.

Methods
We present a 63 years old male patient with 3 retentive bladder diverticula causing recurrent UTI. Patient was placed in lithotomy position. Diagnostic cystoscopy was performed to assess the location of diverticula. In bladder filled with saline, we inserted the optic 10mm special self-retentive trocar with special internal balloon into the bladder at midline, followed by insertion of 2 working 5 mm trocars in a flat triangular pattern on both sides. A mucosal circumferential incision at the mouth of diverticulum using monopolar scissors, followed by grasping the diverticular mucosa alone. By means of blunt and sharp dissection, stripping of mucosa from the surrounding detrusor muscle till it’s excised completely. Finally, we close the bladder detrusor muscle after ensuring good hemostasis. We used the urethra as a natural orifice gateway for insertion of traction instrument, extraction of the excised diverticular mucosa and insertion of needle holder for closure of the bladder detrusor.

Results
The surgery was uneventful. Operative time was 179 minutes. Blood loss was minimal (>50 mL). Retrograde cystography performed 10th day postoperative showed smooth bladder outlines with no leak of dye. The introduction of the needle holder through the urethral natural orifice –NOTES- added the advantage of better direction of the needle holder for suturing of bladder wall, being parallel to the trigone & posterolateral walls. This renders such step easier rather than suturing the bladder wall through the transvesical laparoscopic ports.

Conclusions
Transvesical laparoscopic bladder diverticulectomy is a promising procedure with good outcome. Using the urethra (NOTES-assisted) as an extra access to the bladder facilitates diverticular traction and bladder suturing without the need for extra ports. This technique can also be applied together with the novel T-LESS approach.

Funding: none