V8-05: Concomitant Holmium Laser Enucleation of the Prostate (HoLEP) and Laparoscopic Robot-Assisted Bladder Diverticulectomy for Treatment of a Large Bladder Tumor

Video

Introductions and Objectives
Bladder diverticula may be congenital or acquired. Acquired diverticula are often secondary to elevated intravesical pressure related to bladder outlet obstruction (BOO) and benign prostate hyperplasia (BPH). Bladder tumors occur in bladder diverticula in 1-13% of cases and can be a therapeutic dilemma. Historically, bladder tumors in diverticula have presented at more advanced stages necessitating aggressive surgical extirpation. Recently, partial cystectomy with bladder diverticulectomy has been performed with comparable disease-free survival. Here we describe a patient with long standing BOO and BPH who additionally has a large bladder diverticulum containing a substantial bladder tumor. Video of concomitant HoLEP and laparoscopic robot-assisted bladder diverticulectomy is demonstrated.

Methods
A 67 year old male was referred for evaluation of gross hematuria and lower urinary tract symptoms. His initial AUA symptom score was 22. Cystoscopy demonstrated an enlarged prostate with intravesical extension, diffuse trabeculations and a large bladder diverticula located cephalad and lateral to the left ureteral orifice. A large localized bladder tumor was visualized emanating from the diverticula. A CT scan confirmed these findings. Bladder biopsies were performed showing high-grade pTa urothelial carcinoma. Surgical management to treat both BPH and bladder tumor was planned.

Results
HoLEP was completed without complication and minimal blood loss. Enucleation time was 45 minutes. A 5 French localizing ureteral stent was placed to help identify the left ureter during the diverticulectomy. The robot was then docked for the diverticulectomy. A standard left pelvic lymph node dissection was performed. The bladder was closed in two layers and the specimens were obtained. A drain and a foley catheter were left at the conclusion of the procedure. Total operative time was 201 minutes. Final pathology was pT1 high grade urothelial carcinoma with 0/4 lymph nodes positive. Induction BCG was completed in the post-operative period. After 1 year of follow-up, the patient remains free of recurrence. Most recent AUA symptom score is now 5 with a bother score of 0.

Conclusions
Concomitant HoLEP and robotic-assisted laparoscopic bladder diverticulectomy is a safe and feasible operation for men with BPH and a large bladder tumor within a diverticulum. Early oncologic outcomes are encouraging. Larger cohorts and longer follow up are needed to confirm initial findings.

Funding: none