Pediatric Surgery for Bladder Anomalies Treatment & Management

• Bladder diverticula: If present, correct bladder outlet obstruction because many bladder diverticula resolve spontaneously after relief of obstruction. Congenital diverticula are usually removed surgically.
• Urachal sinus: These can be observed in the first 4-8 weeks of life.
• Urachal cyst: For small asymptomatic cysts that are discovered incidentally, observation with serial ultrasonography may be appropriate.
• Patent urachus: Observation may be undertaken in the first few months of life because some cases may resolve spontaneously. Persistence after 2 months warrants surgical correction. If bladder outlet obstruction is present, correct this first because this may be the cause of the persistent patency of the urachus.
• Vesicourachal diverticulum: Most patients do not require treatment.
• Bladder ears: No treatment is necessary because nearly all resolve spontaneously.
• Bladder agenesis: This condition requires urinary diversion and subsequent reconstruction (eg, continent urinary reservoir).
• Megacystitis: Clean intermittent catheterization may be considered in those patients with incomplete bladder emptying or frequent urinary tract infections. In children in whom clean intermittent catheterization is instituted, urodynamic studies should be obtained. See Surgical Care.
• Bladder duplication: Incomplete bladder duplication often does not require any treatment when the upper urinary tracts are normal and the bladder empties completely. If other associated anomalies are present, address them individually. See Surgical Care.
• Bladder septation: Depending upon the anatomy, no treatment may be appropriate, for example, with a small incomplete septation with normal upper tracts and complete bladder emptying.

• Bladder diverticula: Surgery is generally required when bladder diverticula cause obstruction, recurrent urinary tract infections, vesicoureteral reflux, or stone formation.^[15] Correct outlet obstruction first in patients with diverticula secondary to obstruction because some of these diverticula spontaneously resolve with relief of the obstruction. Surgical diverticulectomy for congenital diverticula may be approached extravesically or intravesically. The surgical approach varies depending on the size, location, associated anomalies (ie, vesicoureteral reflux), and surgeon's preferences. In very large paraureteral diverticula, take care to avoid injuring adjacent structures such as the ureter or vas deferens. In the presence of ureteral obstruction, renal function dictates management. If the associated kidney has little or no function, a nephrectomy with bladder diverticulectomy is performed. Perform diverticulectomy and ureteral reimplantation with adequate kidney function.
• Urachal sinus: Surgical correction involves complete removal of the urachus, from the umbilicus to the dome of the bladder. In an infant or child, this can be approached easily with a Pfannenstiel incision. In an infant, the distance from the dome of the bladder to the base of the umbilicus is very short. Complete removal eliminates any further problems. Plan surgical removal after adequate treatment of the infection because intraperitoneal structures may adhere to the urachus in the inflammatory process.^[16]
• Urachal cyst: After adequate treatment of infected urachal cyst, surgical removal of the entire urachus is warranted. A Pfannenstiel incision can be used in an infant or child. Again, in an infant, the distance from the dome of the bladder to the base of the umbilicus is very short. Complete removal eliminates any further problems.^{[17, 18]}
• Patent urachus: As with urachal cyst, complete removal using the described technique eliminates any further problems.
• Vesicourachal diverticulum: Surgical removal is reserved for large symptomatic diverticula causing recurrent urinary tract infections, stones, or poor emptying.
• Bladders ears: Surgery is unnecessary because nearly all resolve spontaneously.
• Bladder agenesis: Initial treatment is urinary diversion. Complex urinary reconstruction, such as the creation of a continent urinary reservoir, may be undertaken later in life.
• Megacystitis: The massive vesicoureteral reflux is corrected by ureteral reimplantation, which usually involves tapering the ureters at the time of reimplantation. Correction of the megacystitis by reduction cystoplasty often is not necessary. Correction of the reflux alone may be sufficient. If recurrent urinary tract infections or incomplete bladder emptying occur after ureteral reimplantation, reduction cystoplasty may be considered. In rare instances, a vesicostomy can be performed as a temporary measure in those children with megacystitis and severe vesicoureteral reflux until a more formal reconstruction can be performed.
• Bladder duplication: Complete bladder duplication has a much higher incidence of associated anomalies necessitating surgical correction such as fistulas between the urethra and adjacent structures. The variable anatomy of each case dictates the surgical approach.
• Bladder septation: Surgical treatment is dictated by each patient's anatomy. The goals are to relieve bladder and upper tract obstruction.

For all of the bladder anomalies, consultation with other professionals is dictated primarily by the presence of the associated anomalies. In situations of renal insufficiency with the various obstructive entities (eg, posterior urethral valves, neurogenic bladder), consultation with a nephrologist is advisable.

Generally, no dietary restrictions are needed for the various bladder anomalies. In cases of significant renal insufficiency, the nephrologist may impose certain dietary restrictions, such as limited protein intake.

No specific restrictions on activity are necessary.