A diagnostic conundrum: Is it a periurethral diverticulum/cyst or a bulking agent (Bulkamid)?

INTRODUCTION: Urethral bulking agents are commonly used to manage female stress urinary incontinence (SUI) as they have been suggested to be safe, efficacious, and a minimally invasive surgical option. Bulkamid is a newer bulking agent that has been introduced and promoted in the market for use. It is non-particulate in nature with high tissue biocompatibility, and consequently, it is difficult to differentiate between Bulkamid and a periurethral cyst on magnetic resonance imaging (MRI). This, therefore, presents a diagnostic dilemma. METHODS AND MATERIALS: Here we describe two cases with previous injections of Bulkamid referred to our Centre for management of a presumed periurethral diverticulum based on MRI findings. Both patients were reviewed and examined in outpatient clinics with MRI findings discussed at MDT, further imaging was required. RESULTS: We found that a limited noncontrast computed tomography (CT) pelvis, followed by a voiding cystometrogram (VCMG), and then a repeat limited noncontrast CT pelvis effectively differentiated between Bulkamid and these presumed periurethral diverticulae. The theory behind this was that during micturition, the contrast would pass through to the urethral diverticulum and appear as high-density (bright) material within the periurethral region (the pre-VCMG was required to prove that any high-density material was due to the contrast and not pre-existing high-contrast material). CONCLUSION: A CT scan done in conjunction with a VCMG is likely to be more effective in differentiating between Bulkamid and a true periurethral diverticulum than an MRI scan. Appropriate diagnostic evaluation of periurethral lesions can lead to time-saving and cost-effective patient management as this will bypass the need for unnecessary investigations and possible unwarranted surgical intervention.

The role of MRI in the diagnosis and management of tracheal diverticulum.

BACKGROUND: Multidetector CT is currently the best imaging method for detecting tracheal diverticulum (TD). Compared with CT, MRI is radiation-free and has higher resolution. However, the MRI characteristics of this disease have not been previously reported. The present retrospective study compared the MR and CT imaging features of TD, aiming to examine the role of MRI in TD diagnosis and management. METHODS: Imaging data were collected in 26 TD patients divided into two groups, including the uninfected and infected groups. The MR and CT imaging features (size/wall/channel) of uninfected patients were compared. The performances of MRI and CT in diagnosing and monitoring therapeutic efficacy in infected TD patients were comparatively assessed. RESULTS: The uninfected group comprised 25 cases with 25 lesions confirmed by CT, including 23 lesions (92%) detected by MRI, with an average diameter of 8.5 mm (range from 3 to 15 mm). Meanwhile, the average diameter was 7.8 mm as measured by CT (range from 2.8 mm to 14.7 mm). The lesion diameters of the two cases not detected by MRI were 2.3 mm and 2 mm. MRI detected walls of all the 23 lesions (23/23), while CT detected no wall (0/23). CT showed channels in 18 lesions (18/23) versus3 for MRI (3/23). The infected case presented with a paratracheal abscess; MRI clearly showed a relationship between the abscess and the trachea, while CT could not show the lesion source. MRI also sensitively showed the whole process of lesion absorption. CONCLUSIONS: MRI can be used as a supplementary method for TD diagnosis, providing information about the wall that cannot be obtained by CT. MRI is superior to CT in diagnosing infected TD cases presenting with a paratracheal abscess, and in monitoring therapeutic efficacy in these patients.

Calyceal Diverticula Disease: Diagnosis and Management Options in the Era of Non-Contrast CT Scan.

INTRODUCTION: Calyceal diverticula (CD) are traditionally diagnosed by contrast studies. However, non-contrast CT is the standard imaging modality for kidney stones. Therefore, we aimed to determine if the lack of contrast imaging affected outcomes of the management of symptomatic CD with stone. MATERIALS AND METHODS: This is a retrospective study of patients diagnosed with CD with intracalyceal stone from 2000 to 2017 analyzing demographics, clinical data, and success of different treatment options. The timing of CD diagnosis is correlated to the success of the first treatment. RESULTS: Forty-eight patients were found. CD was diagnosed prior to intervention in 20 (42%) cases and intraoperatively during flexible ureteroscopy in 17 (35%) and 11 (23%) cases were diagnosed after failed intervention, mainly ESWL. We found that the success rate of treatment was highly affected by the timing and modality of diagnosis. Preoperative diagnosis of CD was associated with 69% success rate of the first intervention. In contrast, there was a 0% success rate of first treatment if CD was not diagnosed with contrast imaging. Furthermore, univariate analysis showed no significant association between sociodemographics and clinical variables and success treatment (p > 0.05). CONCLUSIONS: The delay in diagnosing CD with stone contributes significantly to the success rate and the number of treatments.

The challenging diagnosis and treatment of duodenal diverticulum perforation: a report of two cases.

BACKGROUND: The duodenum is a common site for diverticulum formation. Most of the duodenal diverticula are asymptomatic, incidental findings. Perforation is a rare but potentially lethal complication of duodenal diverticular disease. Surgery remains the mainstay of treatment for perforated duodenal diverticula. In recent years, a few cases were successfully managed either conservatively or with endoscopy. CASE PRESENTATION: We present two cases of female patients treated in our department for duodenal diverticulum perforation. The first case was treated surgically with a diverticulectomy. The second case was managed conservatively with bowel rest and intravenous antibiotics. Both patients had an uncomplicated postoperative course and were discharged home. CONCLUSIONS: Both surgical and conservative treatments are viable options for a perforated duodenal diverticulum in selected patients. Patients with a contained duodenal diverticular perforation can be managed conservatively at the outset. Possibly, the introduction of a classification system for duodenal diverticulum perforation may help clinicians in making essential therapeutic decisions.

Small Bowel Diverticulosis: Pathogenesis, Clinical Management, and New Concepts.

PURPOSE OF REVIEW: Small bowel diverticulosis is a well-known clinical entity whose diagnosis and management has evolved in recent years. This review covers pathophysiology, incidence, and prevalence, and it also provides an update on modern diagnosis and management. Meckel's diverticula are covered elsewhere in this volume. RECENT FINDINGS: CT scan and MRI have largely supplanted barium follow-through for diagnosis. No intervention is needed in asymptomatic individuals. Endoscopic management is playing an increasing role for both bleeding and resection of intraduodenal diverticula, but surgical intervention remains the only definitive intervention for other complications like diverticulitis and small bowel obstruction. Small bowel diverticulosis is an uncommon condition which is associated with numerous possible complications. While endoscopy is playing an increasingly large role in management, surgical resection remains the treatment of choice for most complications. A high index of suspicion is needed in order to diagnose this entity.

Coronary sinus diverticulum: Importance, function, and treatment.

The importance of venous structure in the heart is usually overshadowed by that of the arterial system. Coronary sinus (CS) is a part of cardiac venous apparatus and connects left atria to the right atria. Other than having role in physiological contractions of both atria, it contributes substantially to cardiac electrical conduction system. Due to unique placement and connections of the CS, it has become growing interest in clinical cardiology. It is used in cardiac resynchronization therapy with biventricular pacing, left-sided catheter ablation of arrhythmias, and administration of retrograde cardioplegia in cardiac surgery. In some individuals, CS is presented with anatomical variants. CS diverticulum is a congenital outpouching that provides muscular connection between atria and ventricle. This connection provides a suitable substrate for occurrence of arrhythmias, which even results in life-threatening events such as sudden cardiac death. Early diagnosis leads to treatment with ablation techniques, which ultimately eliminates origins of arrhythmias.

Spinal subarachnoid diverticula in dogs: A review.

Spinal subarachnoid diverticula are fluid dilations of the subarachnoid space that can cause a compressive myelopathy in dogs. These diverticula are usually associated with high motion areas in the cervical and caudal thoracic spine. The definitive etiopathogenesis has not been determined but likely involves congenital or acquired causes. Pugs, French bulldogs, and Rottweilers are overrepresented breeds. Clinical signs typically include ataxia, paresis, and upper motor neuron urinary and/or fecal incontinence; pain is a less common feature. Diagnosis is based on advanced imaging, with magnetic resonance imaging now being favored given the additional detail of the spinal cord parenchyma that can be obtained. Outcomes are better with surgical intervention than with medical therapies, though there is a lack of long-term data. No superior surgical technique has been identified, and questions remain on the significance of addressing leptomeningeal adhesions at the time of surgery. Clinical signs can recur, though not always due to recurrence of diverticulum formation, and pugs may be less likely to have a successful long-term outcome.

Diverticule subarachnoïdien spinal chez des chiens : une revue. Les diverticules subarachnoïdiens spinaux sont des dilatations liquides de l'espace subarachnoïdien qui peuvent causer une myélopathie compressive chez les chiens. Ces diverticules sont généralement associés à des régions à motion élevée de la colonne vertébrale cervicale et caudale. L'étiopathogénie définitive n'a pas été déterminée mais implique fort probablement des causes congénitales ou acquises. Les carlins, bulldogs français et rottweiler sont des races sur-représentées. Les signes cliniques inclus typiquement de l'ataxie, de la parésie et un neurone moteur supérieur d'incontinence urinaire et/ou fécale; la douleur est une caractéristique moins fréquente. Le diagnostic est basé sur des analyses avancées d'imagerie, avec l'imagerie par résonnance magnétique maintenant favorisée étant donné les détails additionnels du parenchyme de la colonne vertébrale qui peuvent être obtenus. Les résultats sont meilleurs avec l'intervention chirurgicale qu'avec les thérapies médicales, bien qu'il y ait un manque de données à long terme. Aucune technique chirurgicale supérieure n'a été identifiée, et des questions persistent sur l'importance de s'attarder aux adhésions leptoméningées au moment de la chirurgie. Les signes cliniques peuvent réapparaitre, quoique pas toujours à cause de la récurrence de la formation des diverticules, et les carlins pourraient être moins enclin à avoir une issue favorable à long terme.(Traduit par Dr Serge Messier).

Distinct Clinical Factors in Hospitalized Patients with Diverticular Bleeding and Diverticulitis.

BACKGROUND/AIMS: It is unclear why colonic diverticular bleeding and diverticulitis rarely coexist. This study compared the characteristics of these conditions. METHODS: This single-center retrospective study examined 310 consecutive patients hospitalized with an episode of diverticular disease (cases) and outpatients without a diverticular episode (controls) from January 2012 to December 2015. We investigated distinct clinical factors in hospitalized patients with diverticular bleeding and diverticulitis. RESULTS: We identified 183 patients with 263 episodes of diverticular bleeding and 127 patients with 135 episodes of diverticulitis during the study period. Patients with diverticular bleeding were significantly older than those with diverticulitis (median age 76 vs. 56 years) and had more cardiovascular disease, hypertension, diabetes, cerebrovascular disease, chronic kidney disease, lipid disorder, or a poorer performance status. Significantly more diverticular bleeding patients were taking antiplatelet drugs, anticoagulant drugs, proton pump inhibitors, or laxative agents. Multivariate analysis revealed that an age > 65 years (OR 5.42), and antiplatelet agent use (OR 7.29) were more significant risk factors for diverticular bleeding than for diverticulitis. CONCLUSIONS: Elderly people using antiplatelet drugs may be more susceptible to diverticular bleeding than diverticulitis.

Giant urethral calculus in anterior urethral diverticulum: a case report.

BACKGROUND: In this case report, giant calculus in the urethral diverticulum was found through ureteroscopy investigation, the pneumatic lithotripsy combined with ultrasound lithotripsy (PLCUL) was successfully performed to break down this rare and giant urethral calculus in the diverticulum without open surgery. CASE PRESENTATION: A 82-year-old male presented to the urology department, complaining of frequent urination and dysuria. One giant, dark brown stone (6.5 × 6 × 5.5 cm) was revealed in the diverticulum of the anterior urethra using combination of local ultrasound, pelvic Computer Tomography (CT) and Magnetic Resonance Imaging (MRI). The stone was then successfully broken down via the PLCUL, and the emptied anterior urethral diverticulum was left untreated. In the 18 months' follow-up, no new calculus was found in urethral tract, anterior diverticula became gradually smaller, eventually disappeared. CONCLUSION: In the treatment of giant calculus in the urethral diverticulum, this case report provides an effective method of lithotripsy in the clinical trials.

Endoscopic papillary large balloon dilation with minor sphincterotomy for periampullary diverticular papilla.

Background To observe the outcome of endoscopic papillary large balloon dilation (EPLBD) with minor sphincterotomy (mEST) for periampullary diverticular papilla related to stone removal. Methods Patients with confirmed periampullary diverticulum (PAD) during stone removal from May 2016 to April 2018 were reviewed retrospectively. The Chi-square test with Yates correction or Fisher's exact test was used for the analysis of categorical data and a normality test was applied for continuous data. Results A total of 154 consecutive patients (89 males and 65 females, aged 51-87 years) with confirmed PAD during stone removal were included in the study. Cases were divided into the conventional EST group (n = 79) and the mEST plus EPLBD group (n = 75). The number of patients with an initial treatment success was greater in the EPLBD+mEST group compared with the EST group (96% vs 86.1%, p=0.03) and the procedure time for EPLBD+mEST was shorter than that for EST alone (46.1±13.7 min vs 53.3±11.6 min, p=0.01). The rate of complications in the EPLBD+mEST group was lower than in the EST group (17.3% vs 32.9%, p=0.04). When PAD was >15 mm, the initial success rate was higher (92.6% vs 73.9%, p=0.04) and the rate of overall complications was lower (14.8% vs 41.7%, p=0.03) in the EPLBD+mEST group than those in the EST group. Although, this was similar when PAD was <15 mm. Conclusion EPLBD+mEST might be safer and more effective than conventional EST alone for stone removal in the presence of PAD.

[Management of the bladder outlet obstruction associated with BPH in patients with special circumstances and/or complications]. / Prise en charge de l'obstacle sous vésical lié à une HBP chez les patients à terrain particulier et/ou ayant une complication.

INTRODUCTION: Medical or surgical treatment of lower urinary tract symptoms associated with the bladder obstruction due to BPH must take into account patient's comorbidities and tBPH complication. The objective is to review the different situations in order to optimize the treatment. METHODS: A review of the literature was conducted in English on the Pubmed website using the following keywords: BPH; diabetes; anticoagulants; antiplatelet agents; renal insufficiency; indwelling catheter; bladder calculus; urinary tract infection; hematuria; chronic bladder retention or diverticulum. The bibliographical sources cited in the European recommendations have been used. RESULTS: Some co-morbidities and complications may affect surgical outcomes: age is associated with increased anesthetic and surgical risks, diabetes with detrusor hypoactivity or overactivity that will not always be improved by surgery, chronic bladder retention with detrusor underactivity risk and anticoagulants and antiaggregants with an additional bleeding risk. Bladder stone should be treated with, in the majority of cases, BPH surgery. Bladder diverticulum is an indication of BPH surgery but not systematically associated with diverticulectomy. Persistent hematuria despite treatment with 5 alpha reductase inhibitor and repeated urinary tract infection are indications for surgery. CONCLUSION: The presence of co-morbidities or complication related to BPH leads to specifics of care that should not be ignored urologists. LEVEL OF EVIDENCE: 5 consensus d'experts.

Perivaginal benign masses: diagnosis and therapy in a series of 66 women.

PURPOSE: Benign perivaginal masses (PVM) are relatively rare. The aim of this study is, to create a higher awareness for these entities and to point out reliable diagnostics and an accurate treatment. METHODS: The medical records of the Department of Obstetrics and Gynecology Tuebingen were searched for number and type of urogynecological surgery in general, and a surgery, which took place particularly owing to benign PVM, over a period of 5 years. Diagnostics, treatment, histology and postoperative management were summarized and analyzed. Vaginal endometriosis manifestations were not considered. RESULTS: Between 2011 and 2015 a total number of 4.157 women underwent urogynecological surgery, 65 (1.6%) of these particularly because of benign PVM. The benign PVM in the patient cohort were composed as follows: urethral diverticula (UD), squamous epithelial inclusion cysts, periurethral cysts, Gartner's duct cysts, Müllerian cysts, pseudocysts, abscesses, epidermal inclusion cysts, angiofibromas, angiomyofibroblastomas, leiomyomas, solitary fibrous tumor and masses due to alloplastic materials. The PVM occurred singly or multiply. They were asymptomatic or accompanied by symptoms. Case history, clinical examination, pelvic floor sonography, urethrocystoscopy and MRI are essential tools for diagnostics. PVM simulated cystoceles and recto/enteroceles, were cause of an overactive bladder, dyspareunia, pain or were concomitants in women with stress urinary incontinence. The PVM were excised in 65 out of 66 cases, in one case an infected UD regressed completely under conservative antibiotic therapy. CONCLUSIONS: The awareness for benign PVM is helpful for their diagnostics and management. As secondary pathology, intradiverticular stones and malignancy have to be considered.

Two cases of perforated duodenal diverticulum successfully treated using conservative therapy.

We encountered two cases of perforated duodenal diverticulum successfully treated with conservative therapy. The first case involved a 72-year-old man who presented with abdominal pain and fever. An abdominal computed tomography revealed pneumoretroperitoneum. The second case involved a 90-year-old woman who presented with abdominal pain, vomiting, and fever. An abdominal computed tomography also revealed pneumoretroperitoneum and fluid collection. In both the cases, we initiated conservative therapy with parenteral nutrition and intravenous antibiotic therapy because the patients' general condition was good and the pneumoretroperitoneum was localized. Both patients were cured without serious complications and were discharged from the hospital 14 days after admission. Conservative treatment may be useful in the patients with early stage of perforated duodenal diverticulum and a good general condition without impending sepsis. However, in case of disease aggravation, careful observation and preparation for immediate surgical drainage are desired.

Management of Patients With Diverticulosis and Diverticular Disease: Consensus Statements From the 2nd International Symposium on Diverticular Disease.

The statements produced by the Chairmen of the 2nd International Symposium on Diverticular Disease, held in Rome on April 8th to 9th, 2016, are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease in patients with uncomplicated and complicated diverticular disease were reviewed by the Chairmen who proposed 41 statements graded according to level of evidence and strength of recommendation. Each topic was explored focusing on the more relevant clinical questions. The vote was conducted on a 6-point scale and consensus was defined a priori as 67% agreement of the participants. The voting group consisted of 80 physicians from 6 countries, and agreement with all statements was provided. Comments were added explaining some controversial areas.

Features and outcome of fetal cardiac aneurysms and diverticula: a single center experience in China.

OBJECTIVES: We aimed to describe the prenatal features and clinical outcome of fetal cardiac aneurysms (CA) and cardiac diverticula (CD). METHODS: Retrospective single center study reporting on antenatal findings and interventions and clinical outcome of fetuses with CA or CD are assessed in a ten year's period. RESULTS: Thirteen CA and 16 CD identified, mostly located at the cardiac apex. The average size of the CA was significantly larger than that of the CD (223.2 ± 84.4 vs 80.6 ± 57.9 mm(2) , respectively; p < 0.05). The bulge longitudinal strain, systolic strain rate, and diastolic strain rate in CA were significantly lower compared with CD (respectively, -12.9 ± 3.7 vs -20.0 ± 5.4% for strain and -1.3 ± 0.4 vs -2.0 ± 0.5 s(-1) for the systolic strain rate, 1.2 ± 0.4 vs 1.9 ± 0.4 s(-1) for the diastolic strain rate; all p < 0.05). CA coincided more frequently with arrhythmia and CD more frequently with pericardial effusion (p < 0.05). Adverse outcomes were more likely in children with CA [83.3% (5/6) vs 8.3% (1/12), respectively, p < 0.01]. CONCLUSION: Fetal cardiac aneurysms and diverticula are two distinct entities with different morphology and outcome. An isolated fetal CA has a less favourable outcome than fetal CD. © 2015 John Wiley & Sons, Ltd.

[A Case of Emphysematous Cystitis with Bladder Diverticulum].

Emphysematous cystitis (EC) is a rare form of acute complicated urinary tract infection (UTI). We report a case of EC with bladder diverticulum. A 77-year-old man who had a medical history of diabetes mellitus was admitted to our hospital with the chief complaint of macrohematuria and pneumaturia. Based on the findings of an abdominal computed tomography and cystoscopy, the diagnosis of EC and bladder diverticulum was made with its characteristic feature being gas within the bladder wall and lumen and a cystic lesion from the bladder. His condition improved immediately with a combination of bladder drainage and appropriate antibiotics. The cystography revealed a very large diverticulum causing incomplete bladder emptying and stagnation of urine. We considered diabetes mellitus and a large amount of residual urine after urination due to bladder diverticulum and neurogenic bladder as the possible causal factors of EC in this case.

Modern concepts in diverticular disease.

Over the last decade there has been a striking shift in our understanding of the epidemiology, pathology, and management of diverticular disease. Indeed, many of the guidelines published in the late nineties and early 2000s are now redundant. High-fiber diets, avoidance of nuts and seeds, antibiotic treatment for mild diverticulitis, elective resection after 2 attacks of diverticulitis, Hartmann's procedure (HP), and aggressive management of young patients are all open to question. The more we challenge our understanding of diverticulitis it becomes apparent how little we know about this disease entity. This review aims update the reader on current hypotheses and evidencebased modern management strategies in diverticular disease.

Adult left-ventricular diverticulum and patent ductus arteriosus misdiagnosed as coronary artery disease with infarct aneurysm: a case report.

BACKGROUND: Left-ventricular diverticulum (LD) associated with patent ductus arteriosus (PDA) is extremely rare. We have not found any previous reports of the coexistence of these two malformations. Such an association presenting with chest pain mimicking an infarct aneurysm with angina or a takotsubo cardiomyopathy with chest pain is difficult to differentiate clinically. Here, we discuss several diseases characterized by left-ventricular apical protrusion with chest pain to familiarize clinicians with the differential diagnosis of these diseases. CASE PRESENTATION: A 58-year-old woman was referred to our hospital because of complaints of chest pain and dyspnoea, mainly on exertion. An electrocardiograph on admission showed a q-wave in lead I, a Q-wave in lead aVL, and an abnormal T-wave in the limb leads and leads V4 to V6. A transthoracic echocardiograph revealed a PDA and a protrusion arising from the apex of the left ventricle. The diagnosis on admission was PDA and coronary artery disease with infarct aneurysm. To evaluate the source of the chest pain, further evaluations were performed. Coronary angiography showed no abnormal findings. Left ventriculography confirmed the presence of an apical contractile out-pouching. Based on these findings, we revised the diagnosis as LD associated with PDA. The patient underwent transcatheter occlusion of the PDA and was discharged 3 days later. Unexpectedly, transcatheter occlusion resolved the paroxysmal chest pain in this case. CONCLUSION: This is the first case report of LD combined with PDA. PDA should be considered in the list of differential diagnosis of chest pain. Several diseases characterized by left-ventricular apical protrusion with chest pain, such as LD, infarct aneurysm and takotsubo cardiomyopathy, can be misdiagnosed as one another. Therefore, it is important to familiarize clinicians with the differential diagnosis of these diseases.

Bladder pseudodiverticulum and debilitating dyspareunia: diagnostic and management dilemmas of a rare case.

Dyspareunia in a woman often lacks a well-defined cause with complex etiology. Similarly wide-mouthed nonobstructive bladder diverticula are mostly managed conservatively with no single etiology. Herein a rare case of dyspareunia and urinary symptoms is described, which started following a lower segment cesarean section (LSCS). Ultrasonography, micturating cystogram, and cystoscopy revealed a large wide-mouthed bladder diverticulum. After 3 years of failed and varied conservative therapy and management dilemmas, exploration was done for diverticulectomy which revealed a diagnostic surprise. A post-LSCS thick adhesive band was found between the uterus and anterior abdominal wall as a direct cause for both the bladder diverticulum and dyspareunia. Adhesions after LSCS may cause varied symptoms which may be difficult to diagnose and leave the patient refractory to conservative therapy. Laparoscopy or exploration may be useful in such cases.