Technical Nuances of Robot-Assisted Laparoscopic Bladder Diverticular Surgery - Beyond the Abstract

Though simple in its definition – a protrusion out of the bladder wall – the pathogenesis of bladder diverticulum (BD) may be quite diverse ranging from congenital to chronic or benign to malignant. The management of BD may also be technically nuanced with a myriad of approaches dictated by clinical scenarios. As surgeons, we must learn to be versatile in our approach, honing in on pertinent clinical information. Just because you have a hammer, it does not mean everything you see is a nail.

In the largest, single-series, prospective review of robot-assisted laparoscopic bladder diverticular surgeries (RALBD),1 we found a median operative duration of 184 minutes in spite of 65% of patients undergoing concomitant urologic surgery. Statistically significant improvements in pre- and post-operative post-void residual and international prostate symptom scores (IPSS) were noted (p<0.05). When compared to open bladder diverticulectomy, the robotic approach heralded significantly less blood loss. Cancer control is also attainable with RALBD as highlighted in the manuscript with negative margins achieved in all patients.

What has become clear through our research is that one size does not fit all. The manuscript highlights different approaches dependent on patient pathology: extravesical approach, intravesical approach, trans-diverticular approach, and approach to intra-diverticular urothelial carcinoma. For instance, the extravesical approach is ideal with the diverticulum located at the dome or lateral wall while the transvesical approach is suitable for posterior or posterolateral diverticulum – i.e. when the diverticulum may be in close proximity to the ureter or ureteral orifice. For very large benign diverticulum, we employ the trans-diverticular approach given the ease of dissection and identification of the diverticular neck. When managing intra-diverticular carcinoma, sound oncologic principles must be adhered to. We previously reviewed our series of distal ureteral2 and mid-ureteral3 malignancies and found the same principles can be carried to intra-diverticular carcinoma surgery: meticulous dissection and minimal tissue manipulation to prevent downstream regional recurrence, safe handling of tissue specimen to avoid local cancer recurrence and implementation of proper and strict surveillance protocols.

Another distinct advantage of RALBD is the ease of performing concomitant procedures. In our cohort, 65% of patients underwent a concomitant procedure including radical prostatectomy, simple prostatectomy, lymph node dissection, and removal of vesicolithiasis. The additional procedures did not add any morbidity to the operation, thus establishing the safety and efficacy of this approach.

In conclusion, our research highlights the safety and efficacy of RALBD coupled with tips and tricks for the treating urologic surgeon. We hope the reader finds our manuscript helpful in managing patients with BD.

Written by: Ram A. Pathak, MD, Assistant Professor of Urology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, North Carolina; Shuo Liu, MD, FRACS, Resident of Urology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, North Carolina; Ashok K. Hemal, MD, Professor of Urology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, North Carolina


  1. Liu, Shuo, Ram A. Pathak, and Ashok K. Hemal. "Robot-assisted laparoscopic bladder diverticulectomy: adaptation of techniques for a variety of clinical presentations." Urology (2020).
  2. Singh, Iqbal, Karim Kader, and Ashok K. Hemal. "Robotic distal ureterectomy with reimplantation in malignancy: technical nuances." The Canadian Journal of Urology 16, no. 3 (2009): 4671-4676.
  3. McClain, Paul D., Patrick W. Mufarrij, and Ashok K. Hemal. "Robot-assisted reconstructive surgery for ureteral malignancy: analysis of efficacy and oncologic outcomes." Journal of endourology 26, no. 12 (2012): 1614-1617.
Read the Abstract