Our study demonstrates that men with enlarged prostates and symptomatic large BD can be safely and effectively treated with the C-HoLEP–TUBD approach. The procedure was not only well-tolerated but also resulted in a significant reduction in diverticular size, with a mean decrease of 81.89 ± 15.09%. No patients had residual diverticula measuring more than 2 cm on postoperative imaging performed within 3 months. Furthermore, the absence of significant post-void residual (PVR) at 3-month follow-up indicated effective emptying of the residual diverticula.

The first transurethral treatment of bladder diverticula (BD) was described by Hartung and Flocks in 1943, highlighting that 75% of patients improved with treatment of bladder outlet obstruction (BOO) alone [17]. In 1977, Orandi et al. introduced transurethral fulguration of the bladder diverticulum (TUFD), achieving complete resolution in five of 17 patients and significant reduction in others [8]. That same year, Posta proposed resecting the diverticular neck, arguing it functioned like a sphincter, and advocated this method to reduce urinary stasis [9]. Vitale and Woodside later supported Posta’s approach, noting it was safe but cautioned against use in large tumors or near the ureter [18]. In 1984, Clayman et al. combined neck incision with mucosal fulguration in six patients, with near-complete resolution in all cases and minimal morbidity [19]. Yamaguchi et al. refined this in 1992, resecting the neck between the 4 and 8 o’clock positions for diverticula > 1.5 cm. In 26 patients, 84% had complete resolution and the rest had substantial volume reduction, with no residual urine or infections over two years. These developments established transurethral techniques as effective, lower-risk alternatives to open diverticulectomy [20].

After a two-decade hiatus, Pham et al. published a case report, and Pacella et al. presented a case series of 39 patients, reporting outcomes of combined TURP or TUIP with TUBD [10,11,12]. Pacella et al. from Italy modified Yamaguchi’s technique and instead of resecting the bladder diverticular neck from 4 to 8 o’clock, flattened the entire diverticular neck circumference with a rollerball electrode using plasma vaporization while treating diverticula > 4 cm. The authors considered the procedure successful in 76.9% patients with success defined as > 80% reduction in the size of diverticulum at 3- month follow-up imaging [6]. In the present study we noted a mean 82% decrease in diverticular size at 3 months follow up and none of the diverticula were > 2 cm in maximum dimension.

Over the past 2 decades there has been increasing application of laparoscopic and robotic assisted procedures for the treatment of BD [21, 22]. Some authors consider robotic simple prostatectomy in patients with large BD with the goal of addressing both pathologies concurrently and with the same approach [23]. Others have combined TURP with a laparoscopic or robotic approach [22, 24]. Important considerations of these methods are identifying the diverticular neck and preventing ureteral injury leading to reimplantation of the ureter in some rare cases [25, 26]. In a case series of 28 patient who underwent RABD without any procedure for BPO by 13 experienced urologists the average operating time was 106 min with a mean hospital stay of 2.67 days with 14% of the patients having grade II Clavien-Dindo complications. There was an 11% incidence of ureteral reimplantation in this case series [25]. A recent study RABD with TURP in 4 patients showed median operative time of 212 min with mean hospital stay of 4 days [24]. Our study reported a mean operative time of 217.16 ± 43.4 min and a hospital stay of 18 ± 0.81 h, including anesthesia time implying shorter operative time and hospital stay than laparoscopic or robotic approaches. Additionally, aside from prolonged catheterization, it does not impact recovery or increase complications post-HoLEP. RABD also remains a significantly more expensive option compared to transurethral techniques.

Histopathological evaluations of BD have demonstrated that bladder wall and connective tissue thickness is greatest in diverticula associated with BPO, compared to specimens with isolated BD or BPO [27]. The diverticular neck contains more connective tissue and thickened muscle, whereas the outer portion of the diverticulum comprises a thin mucosal wall with fibrosis and lacks muscularis propria. This structural deficiency results in the absence of contractile function and predisposes to urinary stasis [27]. The heat generated during transurethral cautery likely causes immediate mucosal destruction due to absence of muscle, resulting in visible intraoperative shrinkage of the BD (Fig. 1). Moreover, incision and resection of the diverticular neck facilitates effective drainage of residual diverticula, especially when combined with relief of BOO. We also observed a significant reduction in prostate-specific antigen (PSA) levels three months after HoLEP, with a mean nadir of 0.80 ± 0.9 ng/ml. This confirms complete adenomectomy suggests improved voiding dynamics, which likely enhances emptying of any remaining diverticulum—a phenomenon previously noted in other studies, including that by Agarwal et al. [11].

a, b Preoperative CT scan of case 4 showing BD of size 13.5 × 8.8 cm in coronal and sagittal plane respectively. c, d Intraoperative cystogram showing immediate reduction in maximal dimension of BD from baseline 13.5 to 7.2 cm immediately after TUBD. e, f Post-operative CT cystogram at 4 months showing complete obliteration of BD in coronal and sagittal plain respectively. g, h Preoperative CT pelvis of case 3 showing Mickey Mouse BD of size 8.1 (left) and 4.3 cm (right) and postoperative CT cystogram at 3 months showing complete obliteration of right sided BD and residual small left side BD of 2 cm. i, j MRI pelvis images of case 6 with (i) preoperative bladder diverticulum (BD) size 18.6 cm and 3 months follow up CT pelvis (j) showing reduction in diverticulum size to 3.6 cm

This study is limited by its retrospective nature and single-center, single-surgeon design with a small cohort. Additionally, it lacks a comparator arm evaluating open, laparoscopic, or robotic diverticulectomy and does not compare outcomes to a staged approach in which HoLEP is performed first, and BD is addressed later if needed. The follow-up period is also relatively short. Despite these limitations, this is the first reported experience demonstrating the safety and efficacy of C-HoLEP–TUBD, a technique that allows concurrent treatment of prostates of any size and associated BD, even in medically complex patients.