Surgical Technique

With the patient in general anesthesia a cystoscope is introduced in the bladder, which is distended with saline at his/her maximum capacity. The diverticulum's ostium and its relationship with the ureters are evaluated. Under ultrasound and endoscopic control three spinal needles are introduced in the bladder and then substituted with three Enteca 5 mm trocars, with a self-retaining balloon (Fig. 1). Combination of ultrasound and endoscopic control will ensure the appropriate placement of the three trocars avoiding perforation of the peritoneal cavity. The trocar, which will be used for the 0° 5 mm optic is introduced on the abdominal midline and the remaining two on the opposite side of the diverticulum with the axis forming a 90° angle. The use of the Entec trocars, with a self-retaining balloon, allows to fix the bladder dome to the abdominal wall thus avoiding the possibility of losing the bladder in case a deflation occurs (Fig. 2). Care must be taken during this delicate maneuver because if a hole in the bladder is accidentally caused the whole procedure cannot be performed. In fact the bladder cannot be distended anymore and the trocars cannot be introduced.

Water is then substituted with air, laparoscopic forceps and a hook are introduced in the trocars, and the diverticulum orifice is circumscribed. The cleavage plan between mucosa and the fibrous layer is easily developed using a monopolar hook (Fig. 2). Once completely released from the reactive capsule, the intact diverticulum is recovered from the bladder through a transurethral 24 Ch sheath of a resectoscope and a biopsy forceps.

A small 8 French Redon drainage is introduced in the bladder through one of the trocars. At the same time, through an extravesical separate stab wound, a Kelly clamp is introduced in the residual cavity. Using a forceps, introduced through the other trocar, the drainage is positioned in the residual cavity and extracted with the Kelly clamp.

The defect in the bladder wall is sutured with two running sutures, Vicryl 3-0 for the muscle and Vicryl 5-0 for the mucosa. Using a half sheath of a Korth cannula, introduced on a guidewire through the trocars these are substituted with three Foley catheters 14 Ch.

In case of a small prostate a transurethral resection of the prostate is performed in the same setting thanks to the drainage of the three Foley catheters. If the prostate is large the transurethral resection of the prostate is postponed for one week. The suprapubic

6 mm pon Midway between umbilicus ä xipl lüic

6 mm pon Midway between umbilicus ä xipl lüic

FIGURE 1 ■ Pointed troxar with a self-retaining balloon and stopper.

FIGURE 2 ■ Trocars in place fixing the bladder dome to the abdominal wall.

FIGURE 1 ■ Pointed troxar with a self-retaining balloon and stopper.

aIncision Medical, Brisbane, Australia.

Foley catheters and drainage are removed after 48 hours and urethral catheter 24 hours later. Patients are dismissed the day after.

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