Robot-assisted bladder diverticulectomy – video

Overview

Objective: To present the technique of robot-assisted diverticulectomy (RADE) in a video. File: Between 2011 and 2020, we performed 35 laparoscopic diverticulectomies, 15 of which were combined with photoselective vaporization of the prostate using a green laser (PVP). From 2021 to October 2025, we performed 16 RADE procedures. RADE technique: Supine position, lower limbs abducted. We begin with cystoscopy using a flexible (supine position) or rigid cystoscope –⁠ previously in the lithotomy position, in the last four cases already in the final position. The ureter on the side of the diverticulum is probed with a ureteral catheter. Capnoperitoneum is created with a Veres needle at a pressure of 12 mmHg. Four 8mm robotic ports and one 12mm assistant port are inserted at the level of the navel. The patient is tilted into a 30° Trendelenburg position. The Da Vinci Xi system is docked. The peritoneum is opened with scissors or a SynchroSeal™ sealing device, and the diverticulum is gradually dissected on an artificially filled bladder. Care must be taken in the area adjacent to the ureter. The bladder neck is interrupted and the defect in the bladder is closed in two layers with V-Loc™ 90 3-0. The bladder is filled to verify watertightness. The peritoneal defect is closed with V-Loc™ 90. The specimen is extracted and the defects after the ports are closed, usually without a drain. On the sixth to seventh postoperative day, the urinary catheter is removed after cystography. Results: RADE: Average age 65.1 ± 7 (52.4–72.4) years, body mass index 28.3±3.5 (21.9–33.6) kg/sqm, average procedure time (14 RADE without additional procedures) 111 ± 37 (50–182) minutes. One case had diverticulum duplex, one triplex (182 minutes). In five cases, transurethral resection of the prostate (TURP) was performed in the first stage, holmium laser enucleation of the prostate (HoLEP) in six cases, transurethral incision of the prostate (TUIP) once, simultaneous radical prostatectomy once (135 minutes) and twice without desobstructive surgery (one of which had a urothelial tumor in the diverticulum). One case was combined with nephroureterectomy (first in the lateral position for nephrectomy, then rotation to the supine position –⁠ 206 minutes). One case of partial ureter transection was treated with suture –⁠ long-term follow-up without stenosis. No postoperative complications were observed. Conclusion: RADE via transperitoneal extravesical approach is now our preferred option of diverticulectomy. We perform the desobstructive procedure in the first stage, mainly TURP or, more recently, HoLEP. Another possible option for the future is a combination of RADE and adenoma enucleation.

Keywords:

bladder diverticulum – laparoscopy – robot – diverticulectomy