機械手臂膀胱憩室切除手術:極罕見成人哈奇氏憩室案例報告及文獻回顧

楊哲學、林益聖、黃立華、歐宴泉、許兆畬、童敏哲

台中童綜合醫院 外科部 泌尿科

Robotic-Assisted Diverticulectomy of Urinary Bladder for Adult Hutch Diverticulum with Obstructive Uropathy: An Extremely Rare Case Report and Review of Literatures

Che-Hsueh Yang, Yi-Sheng Lin, Li-Hua Huang, Yen-Chuan Ou, Chao-Yu Hsu, Min-Che Tung

Division of Urology, Department of Surgery

Tungs' Taichung MetroHarbor Hospital, Taichung

Taiwan

Case: A 27-year-old man had been bothered by frequent urinary tract infection within the recent one year, and had not been through any congenital urinary tract medical histories ever. Under ultrasound of kidneys, right hydronephrosis was seen. Thereafter, intravenous pyelography was done, and a diverticulum could be observed seated superolateral to the right ureterovesical junction (UVJ), near right ureteral orifice, and contrast retention in that diverticulum was obviously evident. The computed tomography afterward revealed the diverticulum clearly seen with ostium included in the bladder diverticulum. Hutch diverticulum was thus diagnosed.

  Robotic-assisted diverticulectomy was scheduled and, before the surgery, right ureteroscopy was performed and right ureteral stent was placed inside across the diverticulum ostinum. Then, he was placed steep Trendelenburg position about 30 degrees. The camera was put right above the umbilicus and two 8 mm robotics ports were placed at both sides of the camera port, with 8 cm from each other on a radius of 17 cm to the pubic bone. A 12 mm assistant port was placed along the right axillary line and 2 cm above the anterior superior iliac crest.The approach was planned with transperitoneal way. At first, 300 milliliter saline was instilled to bulge the diverticulum out. Tracing laterally to the right seminal vesicle, the diverticulum was seen. After identified the diverticulum and right ureter, they were both carefully dissected. The transection was made on the diverticulum neck. In the end, the cutting defect on the right ureter was carefully sutured. The whole operation went on for 140 minutes, and blood loss was measured 20 milliliter.

  The incised Hutch diverticulum was about 3 cm in width and weighted 5 g. After discharge, we arranged ultrasound of bladder and kidneys and intravenous pyelography at follow-ups and relief of right hydronephrosis could be seen on image studies. Operative pathology showed focal squamous metaplasia. Intact bladder storage function and fully recovery of the right ureter were seen within one year after surgery.

Discussion: When the ureteral ostium is included in the bladder diverticulum, it is called Hutch diverticulum. Hypothesis describes that muscle development around the ureteral orifice, the site Waldeyer's sheath forms and goes into the bladder, failed. Thus, if the diverticulum exists, it will enlarge with voiding every single time. Hutch diverticulum is an extremely rare congenital disease not only in children, also adult. It is usually diagnosed at their first 10 years in childhood, majorly male and solitary, as a characteristic of congenital disease. The most symptoms and sign been told are frequent urinary tract infection, hydronephrosis, hematuria, and other abnormal urodynamics occasions. Onur Telli et al in 2015 reported a 45-year-old male with bilateral Hutch diverticulum and got calculi formed inside, thus he was presented majorly with mild right renal colic pain, difficulty in micturition, resembling the urinary tract stones, and recurrent urinary tract infection. This is the first case report regarding stone formation in Hutch diverticulum. Less than 3% occurrence overall was estimated worldwide, and less than 10 adult cases can be traced on the published literatures in the past 30 years at least. Malignant change is extremely rarely reported, only about less than 5% among patients.

  As for therapeutics modalities, both surgical and non-surgical are feasible based on reviewed literatures. Generally speaking, indications are dependent on the complications or recurrent diseases, such as recurrent urinary tract infection, recurrent calculi formation, diverticulum rupture, or vesicoureteral reflux, which under the most occasions is diagnosed among children. In our experiences, when surgery, robotics-assisted diverticulectomy acts as a safe and efficient method. The pros includes quick targeting the diverticulum neck, allowing sophisticated dissection between diverticulum and the ureter and the adjacent anatomies, and quality sealing of the ureter and bladder defects. These advantages allow robotics-assisted rival the open and laparoscopic way especially under the occasion of large size diverticulum. In this case we used saline instillation to bulge the diverticulum. In the other hand, Amanda Macejko et al. in 2008 reported a strategy of simultaneous illumination by cystoscope to locate the diverticulum, and perhaps as well provided a more straightforward method to identify the diverticulum in our case.