Technical Pearls in Robotic Diverticulectomy for Carcinoma Confined to a Bladder Diverticulum

Urothelial carcinoma isolated to a bladder diverticulum is a rare entity comprising 1% of all bladder tumors. Chronic inflammation from urinary stasis within the diverticulum may be one unique risk factor for carcinogenesis in such cases. For disease isolated to a diverticulum, National Comprehensive Cancer Network guidelines endorse partial cystectomy/diverticulectomy with or without adjuvant intravesical therapy. We present a case of robotic diverticulectomy and pelvic lymph node dissection, highlighting reproducible steps and practical pearls for performing an oncologically sound resection. A 73-year-old male presented with intermittent gross hematuria, dysuria, and obstructive urinary symptoms. Work-up demonstrated high-grade urothelial carcinoma isolated to a bladder diverticulum, with negative bladder biopsies throughout the rest of the bladder and no evidence of metastatic disease. He was recommended and elected treatment with robotic diverticulectomy and pelvic lymph node dissection. Intraoperatively, a council-tip catheter was placed into the diverticulum cystoscopically. The balloon was inflated and secured to mild traction to occlude the diverticular neck, permitting intradiverticular indocyanine green (ICG) instillation to aid with intraoperative identification using Firefly. Key steps were: 1) Early ureterolysis, 2) Circumferential dissection of diverticulum, 3) Laparoscopic stapling across neck of diverticulum, 4) Staple line exclusion and excision as final margin, 5) Pelvic lymph node dissection. The case was completed without complications. The patient was discharged home on post-operative-day (POD) #1 and had an unremarkable recovery. Final pathology showed extensive carcinoma in situ with keratinizing squamous, glandular, and urothelial differentiation with negative margins (pTisN0). After cystogram on POD#14 showed no leak, the patient underwent a successful voiding trial. He started tamsulosin for chronic obstructive urinary symptoms with subjective improvement in urinary symptoms. Intravesical induction BCG was initiated six weeks after surgery. In this video, we demonstrate several technical pearls to optimize oncologic resection during robotic diverticulectomy for treatment of bladder cancer. These include cystoscopy-guided catheter placement with balloon occlusion of the diverticular neck, followed by ICG instillation and Firefly use to optimize visualization and identification of the diverticulum; early ureterolysis to mobilize the ureter off the diverticulum and protect for inadvertent injury during resection; use of a robotic or laparoscopic stapler to divide the diverticular neck without spillage or intraluminal entry; and suture exclusion of the staple line from the bladder lumen followed by resection as a final margin.