The posterior urethral valve can cause a variety of problems to the urinary tract. In this child, the compliance of the bladder was poor, and there was a large diverticulum in the bladder, right obstructive megaureter, and left grade IV vesicoureteric reflux.
In this complex scenario, there are several options of reconstruction to answer all the issues.
The options in this child were:
- 1. Ileocystoplasty with reimplantation of the right ureter; diverticulectomy with reimplantation of the left ureter.
- 2. Ureterocystoplasty using the right lower ureter with right to left transureteroureterostomy with diverticulectomy and management of left ureteric reflux later.
- 3. Diverticulocystoplasty with right ureteric reimplantation with detrusorrhaphy for the left ureter.
The first option of using bowel loop to augment the bladder of a child can cause long-term problems. Following the other option of ureterocystoplasty with transureteroureterostomy, the transureteroureterostomy may compromise the right renal unit due to obstruction, or reflux from the already refluxing left unit. It may rarely compromise the left renal unit also due to obstruction. In this child, because a large diverticulum was present, we considered the third option of using the diverticulum for augmentation.3
The incidence of congenital bladder diverticula in children is 1.7%.5
Congenital diverticula are usually single. Though the primary diverticula are characteristically described as arising at the ureterovesical junction, sometimes, secondary diverticula can arise at this site.5,6
Low compliance bladder with or without detrusor overactivity due to PUV may be associated with diverticulum (secondary diverticulum). In such cases, the diverticulum represents the pop off mechanism for reducing the bladder pressure.
In this child, the right ureter was obstructed due to primary obstructive megaureter. The left ureter was refluxing. Though the patient had 2 pop-off mechanisms in the operation (diverticulum and refluxing left ureter), he still had low compliance bladder. Hence, diverticulocystoplasty3,7
was considered to augment the low-compliance bladder in this child ()
. However because the right ureter was entering the neck of the diverticulum, it necessitated ureteric reimplantation.
Clip art showing the diverticulocystoplasty.
Management of low-compliance bladder by laparoscopic diverticulocystoplasty has been described in adults.8
The present article is the first case report of such a procedure in a child. Postoperative urodynamic study showed improvement in compliance. Renal function on the right side improved, and there was no obstruction on isotope renogram. The histopathology of the diverticulum showed muscle fiber suggesting primary diverticulum. Laparoscopic reconstruction has the benefit of better visualization, cosmesis, and a shorter hospital stay.9