Giant bladder diverticulum in Ehlers-Danlos syndrome type I causing outflow obstruction

Three rare etiologies of urinary retention in pediatrics: A case series and review of the literature

Etiology of urinary retention in pediatric age differs significantly from adults and the elderly. Therefore, a comprehensive diagnosis is crucial before specific treatment. Every effort must be made to minimize invasive procedures as far as possible in children.

Unusual Combination of MEN-1 and the Contiguous Gene Deletion Syndrome of CAH and Ehlers-Danlos Syndrome (CAH-X)

The contiguous gene deletion syndrome of congenital adrenal hyperplasia and Ehlers-Danlos syndrome, named CAH-X, is a rare entity that occurs because of a deletion of a chromosomal area containing 2 neighboring genes, TNXB and CYP21A. Here, we describe a patient from a consanguineous family in which coincidentally MEN-1 syndrome is associated with CAH-X, causing particular challenges explaining the phenotypic features of the patient. A 33-year-old man with salt-wasting congenital adrenal hyperplasia and classic-like Ehlers-Danlos syndrome presented with an adrenal crisis with a history of recurrent hypoglycemia, abdominal pain, and vomiting. He was found to have primary hyperparathyroidism, hyperprolactinemia, and pancreatic neuroendocrine tumors, as well as primary hypogonadism, large adrenal myelolipomas, and low bone mineral density. A bladder diverticulum was incidentally found. Genetic analysis revealed a heterozygous previously well-described MEN1 mutation (c.784-9G > A), a homozygous complete deletion of CYP21A2 (c.1-?_1488+? del), as well as a large deletion of the neighboring TNXB gene (c.11381-?_11524+?). The deletion includes the complete CYP21A2 gene and exons 35 through 44 of the TNXB gene. CGH array found 12% homozygosity over the whole genome. This rare case illustrates a complex clinical scenario with some initial diagnostic challenges.

Urogenital and pelvic complications in the Ehlers-Danlos syndromes and associated hypermobility spectrum disorders: A scoping review

The Ehlers-Danlos syndromes (EDS) and associated hypermobility spectrum disorders (HSD) are a heterogenous group of connective tissue disorders associated with significant morbidity. The urogenital aspects of these disorders are understudied and there is little guidance on the prevalence, types, or outcomes of urogenital complications in EDS/HSD. Our objective was to perform a scoping review to characterize and synthesize the literature reporting urogenital and pelvic complications in EDS/HSD patients. We performed a systematic search of three databases (Medline, CINAHL, Embase) to January 2019. English language, full-text articles reporting on urogenital or pelvic complications in EDS/HSD were included. A total of 105 studies were included (62 case reports/series, 43 observational) involving patients with hypermobile (23%), vascular (20%), classical (12%) EDS, and HSD (24%). Some studies looked at multiple subtypes (11%) or did not report subtype (33%). Reported complications included urinary (41%), gynecological (36%), obstetrical (25%), renal (9%), and men's health problems (7%), with some studies reporting on multiple areas. Urinary and gynecological complications were most prevalent in patients with HSD, while a broad range of complications were reported in EDS. While further research is required, results suggest a higher index of suspicion for urogenital problems is probably warranted in this population.

Vesicoureteral reflux and the extracellular matrix connection

Primary vesicoureteral reflux (VUR) is a common pediatric condition due to a developmental defect in the ureterovesical junction. The prevalence of VUR among individuals with connective tissue disorders, as well as the importance of the ureter and bladder wall musculature for the anti-reflux mechanism, suggest that defects in the extracellular matrix (ECM) within the ureterovesical junction may result in VUR. This review will discuss the function of the smooth muscle and its supporting ECM microenvironment with respect to VUR, and explore the association of VUR with mutations in ECM-related genes.

Hutch diverticulum presenting as acute urinary retention in early life

There are only a few reports of recurrent acute urinary retention caused by obstruction from congenital paraureteral diverticulum. We review the literature and present a case of a 14-month-old boy with bilateral hutch diverticuli who had his first episode of acute urinary retention in the neonatal period caused by left-sided diverticulum. We emphasised the fact that hutch diverticulum should be considered as one of the possible differential diagnoses in a child presenting with acute urinary retention.

Giant vesical diverticulum: A rare cause of defecation disturbance

Vesical diverticula frequently result from bladder outlet obstructions. However, giant vesical diverticula which cause acute abdomen or intestinal obstruction are very rare. Our review of the English medical literature found 3 cases of bladder diverticula which caused gastrointestinal symptoms. Here, we present a 57-year-old man with a giant diverticulum of the urinary bladder who complained of abdominal pain, nausea and vomiting, constipation, no passage of gas or feces, and abdominal distension for 3 d. A 20 cm × 15 cm diverticulum was observed upon laparotomy. The colonic obstruction was secondary to external compression of the rectum against the sacrum by a distended vesical diverticulum. We performed a diverticulectomy and primary closure. Twelve months postoperatively, the patient had no difficulty with voiding or defecation.

Surgical techniques: robotic bladder diverticulectomy with the da Vinci-S surgical system

Bladder diverticulectomy is a surgical operation for symptomatic or large bladder diverticula. Typically, bladder diverticula are because of infravesical obstruction, although congenital diverticula can occur that may be large and symptomatic. The ability to excise the diverticulum completely, avoid important adjacent structures, and close the bladder defect in a watertight fashion are key fundamentals to this operation. Traditionally done via an open extravesical, intravesical, or combined approach, bladder diverticulectomy can now be done in a minimally invasive fashion. Both laparoscopic and robot-assisted methods have clear advantages over open surgery, including smaller incision, reduced pain, improved cosmesis, and reduced blood loss, with an equivalent functional result. Large bladder diverticula, particularly those involving the ureteric orifice which required ureteric reimplantation, were often considered beyond the scope of conventional laparoscopy. Recently, use of robotic technology as a means of facilitating laparoscopic excision of bladder diverticula has provided the ability to treat large and more complex diverticula. Advantages of the robotic approach are the finer precision and dexterity of the instruments coupled with three-dimensional imaging. Although there are several case reports describing pure laparoscopic diverticulectomy, as far as we are aware there are no published reports of robotic bladder diverticulectomy. This paper will outline a safe and reproducible surgical technique for performing robotic bladder diverticulectomy using the da Vinci-S surgical system.

Giant bladder diverticula causing bladder outlet obstruction in children

PURPOSE

Congenital giant diverticulum of the bladder is a consequence of deficiency in the detrusor musculature and has been reported in male infants as a rare cause of bladder outlet obstruction.

MATERIALS AND METHODS

A 10-year retrospective review revealed 4 patients (3 boys and 1 girl) with bladder outlet obstruction due to a giant bladder diverticulum. Prenatal and postnatal clinical and imaging records were reviewed.

RESULTS

Prenatal sonography was unremarkable in all patients. Three males (ages 4 months, 10 months and 3 years) had no medical history of voiding dysfunction, and 1 female (11 years) had the Ehlers-Danlos syndrome. While the girl presented with urinary tract infection, all patients presented with progressively decreasing urinary stream and urinary retention. Each patient underwent voiding cystourethrography (VCUG) and ultrasound. In each patient VCUG showed a giant (greater than 7 cm) bladder diverticulum that descended below the bladder neck and compressed the urethra during voiding. Vesicoureteral reflux was seen in 2 patients. Ultrasonography demonstrated moderate unilateral hydronephrosis in 2 patients. Bladder diverticulectomy was successfully performed in all patients, with ureteral reimplantation in 3.

CONCLUSIONS

A giant congenital bladder diverticulum, when noted on VCUG to descend below the bladder neck, may lead to bladder outlet obstruction. To our knowledge we report the first case of a female presenting with bladder outlet obstruction due to a giant bladder diverticulum. Children with connective tissue disorders may be predisposed to this disorder, which must be excluded, regardless of gender, in all patients presenting with voiding abnormalities. Surgical diverticulectomy, often with ureteral reimplantation, is the preferred treatment, with excellent long-term results.