DIVERTICULUM OF THE MALE URINARY BLADDER

BY J. CHRISTOPHER O'DAY, M.D.

HONOLULU, HAWAII

THE initial cause of sacculated or diverticulated bladders is, perhaps

with some few exceptions, congenital; traceable to some embryologic disparity; a disparity so likely to be compromised by any degree of deformity
from a mere sacculation to the most pronounced exstrophy even hypospadia
an(l anaspadias, that the resulting problems have, on many occasions, tried
and baffled the judgment of the most adroit of genito-urinary surgeons.
Obstruction, whether partial or complete, has, by many observers, been
regardled as an important etiologic factor, yet, and while it must be admitted
that such an obstruction to the bladder's outlet is a cause in the bringing
forth of this deformity, it must not be forgotten that it is merely a relative
one. Nor should it prevent the fullest inquiry when it must be ever in mind
that the question of a ratio is ever present-the ratio that correlates that
great number of occltu(led urethre where divertictila or saccule do not obtain,
and the much smaller number where they do. Here, may the question of
"why ?" be interjecte(l. Why are saccule and diverticula the exception, then,
instead of the rule when this comparison is made to parallel these two sets of
reckonings ?
There are those of our genito-urinary surgeons who, having felt the truth
of this, concluded that urethral obstructions, whether of prostatic or cicatricial
origin, are mere factors. Never a cause.
The normal bladder may be distended to a remarkable degree without entailing the slightest risk of provoking either saccules or diverticula. Let it be
put in this way, namely: The actual cause of sacculation or diverticulatioii
within the wall of the male urinary bladder is congenital but is impotent unless
urethral obstruction, partial or complete, distentioni and compression be
present as contributing factors.
To determine how much of the truth might be coupled with the foregoing
supposition, a number of bladders, secured from slaughtered pigs, were subjected to the following rather crude tests. When extreme distention was
induced by either water or air, the mucosa, at no point, showed a tendency
to herniate. Nor did it when severe compression was subsequently applied.
But when a portion of the bladder's wall had been gently teased away from
its underlying mucous lining, and the maneuver repeated, no sign of pouting
appeared until the compression was applied, and then, and almost immediately,
the mucosa began to bulge through the denuded area, and a diverticulum,
in the making, was emphatically demonstrated.
There are those among our physiologists who teach that the normal act of
urinating depends more on compression from the intestines than it does on the
1061

J. CHRISTOPHER O'DAY

contractility of the bladder's muscular coat. If this is true, the fact that the
bladder has a muscular coat, moots the question. However, that cannot be
discussed here. But whatever the truth of it may be, compression, up to
some unknown degree, seems to be the determining factor in forcing the
mucous membrane to herniate into an extravesical sac. It must not, however,
be forgotten that unless ectopia of the muscular fasciculi be present, neither
the obstruction, distention nor compression can give rise to the deformity.
To elucidate the primary or congenital cause of these diverticula, it will

FIG. I.-(a) Small sacculations; the fasciculi are not displaced to a degree capable of pouting the
bladder's mucosa into a diverticulunm (b) Large sacculations. Here are the openings that lead
to a sac only. Diverticulitis is not to be expected where so many large sacculations are present. It
may occur, but the fasciculi are usually discouragingly arranged. (c) Typical opening into divert:culum. Note the fibrous ring. (d) Section of diverticulum.

be necessary to briefly review the embryologic development of the genitourinary tract. In doing this, we will find something to puzzle over when,
through speculative curiosity, we would like to find out the time that the
kidneys begin the first secretion of urine.
Of course, this question is irrelative. Perhaps it should have been omitted,
yet it is an emphasis on that which is of paramount interest, for it becomes
apparent that unless the allantois had opened into the ventral cloaca in time to
save itself from becoming distended by the urine from the newly functioning
1062

DIVERTICULUM URINARY BLADDER

kidneys, a disparity of that portion of its structure, destined to be the muscular

coat of the developing bladder, would result in a chaotic dispersion of the
subsequently developed muscular fasciculi, and thus force into the bladder
wall areas of potential diverticula. If the allantois is granted its communication with the ventral cloaca before the distention has caused an irreparable
condition, no more than an illy marked trabeculation may be the ultimate
result. Otherwise, should some embryologic irregularity prevent a timely
communication, and the distention finally end in rupture, an exstrophy would
be the likely result. Between these two extremes, may be conjectured the
various congenital bladders with which we have to deal, and in which is to
be found the reasons why the best of us are often at our wits' end, for we
are dealing with defects that are not always amenable to good surgery because
of the flabbiness of the tissues with which the repair has to be made; a flabbiness that had its origin in or during the embryologic distention. Pouching
of the bladder wall is a condition that in no way should have its etiology
confused with that of the diverticula or sacculation. Pouching may come to
any normally developed bladder through the presence of a calculus, the removal of which, followed by proper drainage, is all that is required to restore
the pouched portion of the bladder's wall to its normal contour.
Experience has given us a fear of sodium bromide when used as a diagnostic adjunct to r6ntgenology. It was the only medium used through which
we had two severely fatal burns. I know of no statistics on this particular
point, but having had no such sequela following the use of the milder salts
of silver, we had given up the bromide salt entirely. When possible, the
cystoscope is the diagnostic instrument of choice rather than the X-ray.
What has been outlined in the foregoing is meant as a mere sketch of
the conditions through which all surgical approach has to be made. In a
word, it gives to us the key to the greatest success attainable, for it emphasizes the importance of restoring to the urethra the fullest patency, even
to the removal of the prostate when its urethral tunnel is found to be narrowed, and this without regard to the size of the gland itself.
Immediate surgery in all these cases is, as a rule, contraindicated. Suprapubic drainage must be the prerequisite of all that is hoped to be accomplished.
It also gives immediate relief to the distressing tenesmus-vesicae. While this
drainage is going on, the urethra may be sounded and rendered patent. If
its prostatic portion is found to be menacingly narrow, prostatectomy is to be
postponed until the bladder has been suprapubicly opened for the removal of
the diverticulum. Not a few methods of coping, surgically, with bladder
diverticula have been described. It probably matters but little what method
may be the one of choice so long as good results are obtained, but the method
that calls for the sac's inversion, in our experience, proved too cumbersome.
It also sacrifices tissues that will be greatly needed in obliterating the space
that the sac had previously occupied. Stuffing the diverticulum with gauze
lacks surgical appeal because of the danger of tearing the bladder wall while
delivering the sac. The opening into these sacs is encircled with a fibrous
1063

J. CHRISTOPHER O'DAY

ring. This ring must be removed else union will be thwarted. The incision
should be an elliptical one, its long axes directed to the securing of the best
working facilities. It includes the entire fibrous ring with the mouth and end
of the sac. With this accomplished, the freed portion is grasped with light
forceps and gentle traction is continued into the bladder while a gauzecapped finger gently pushes back whatever tissue may be adherent. If the
opening thus made in the wall of the bladder is large enough to admit a finger
without the likelihood of tearing, the fibrous ring may be severed by a snip

FIG. 2.-(a) Elliptical incision preliminary to dissection of the diverticulum. (b) Ellipse with
opening into sac being drawn into bladder while a gauze-capped finger pushes back all adhering tissue.
(c) Ring incised to admit finger. (d) Once the sac is made free a finger within facilitates the
dissecting.

of the scissors and the further dissecting of the sac facilitated by inserting
a finger within it. Throughout the time it may require to complete the removal of the sac and the subsequent closure of the opening, sopping with
sponges will take care of the urine that is coming in from the ureters.
The ease with which the water-shed closure of the opening may be effectedl
will, of course, depend very much upon what portion of the bladder wall is
involved. If high, and easily reached from the suprapubic incision, little dif-

ficulty need be expected. \V;hen, however, it is low, and the diverticulum

1064

DIVERTICULUM URINARY BLADDER

has been in a posterior position, the closure should be effected from within
the bladder, for extensive separation from surrounding tissues is liable to
invite sloughing. The method we have followed is not difficult, yet, it may,
at the first try, seem so. Number 0 0 chromic gut is the ideal suture material, but it should be softened and rendered pliable in warm water, and by
gauze-friction before using. Otherwise it will be too harsh. For the suturing, a small, full-curved, non-cutting intestinal needle is ideal. The stitch
may be begun at either angle of the ellipse according to the convenience of
the operator. Inverting the edges of the wound, the needle is made to pick
up, right side first, two or more bites of the inverted edge, working the
needle away from the free edge while doing so. It is then passed across
to the left side of the incision and the maneuver repeated with the exception

Co"~~~~~~~~
.411~~~~

Ar~~~~

FIG. 3.-a, b, and c shows technic of a modification of Murphy's (the late John B.) water-shed
suture. This stitch closes the bladder wound without appearing within the viscus. This avoids leaving
any foreign substance to precipitate crystallization of the urinary salts.

that on this side the needle is made to work toward the free edge. The
suture from this point on is zigzagged toward the opposite angle which,
when reached, is given a horizontal direction as in the first application, then
zigzagging back, crossing the others to make a series of X's, similar to the
lacing of a shoe, until the place of beginning has been reached. The two
free ends of the suture are permitted to protrude from between the edges
of the wound while a pterygium hook draws the lacing taut. Finally, traction
on the ends will approximate the edges in to an appositional or water-shed
welt.
The suture may then be tied, the ends cut, and the knot induced between
the edges and forced into an extravesical position.
1065