Now you see it, now you don't : the Hutch diverticulum.

Poster No.:

C-1591

Congress:

ECR 2014

Type:

Scientific Exhibit

Authors:

A. Charsoula, D. Katsiba, C. NALMPANTIDOU, A. Papadimitriou,

C. Kaitartzis, I. Torounidis, D. Rafailidis, M. Arvaniti; Thessaloniki/
GR

Keywords:

Congenital, Diverticula, Cystography / Uretrography, Fluoroscopy,

Urinary Tract / Bladder, Pediatric

DOI:

10.1594/ecr2014/C-1591

Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in
any way constitute or imply ECR's endorsement, sponsorship or recommendation of the
third party, information, product or service. ECR is not responsible for the content of
these pages and does not make any representations regarding the content or accuracy
of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold ECR harmless from and against any and all
claims, damages, costs, and expenses, including attorneys' fees, arising from or related
to your use of these pages.
Please note: Links to movies, ppt slideshows and any other multimedia files are not
available in the pdf version of presentations.
www.myESR.org

Page 1 of 25

Aims and objectives

Background
Bladder diverticula (BD) are generally classified as congenital, acquired, iatrogenic and
syndromic. The majority of bladder diverticula in children are congenital in origin and not
frequent with an incidence of 1.7%.
In 1961 John Hutch described a primary diverticulum in smooth-walled bladders not
associated with syndromes or bladder outlet obstruction. The 'Hutch diverticulum' refers
to a primary diverticulum at or near the ureterovesical junction (UVJ) with its orifice located
above the ureteral orifice that is found in children who are otherwise normal. In general
there is a male predominance for BD, which is thought to be related to the higher voiding
pressures in males both in utero and shortly after birth.

Page 2 of 25

Page 3 of 25

Fig. 12: The 'Hutch diverticulum' refers to a primary diverticulum at or near the
ureterovesical junction (UVJ) with its orifice located above the ureteral orifice that is
found in children who are otherwise normal.
References: Juskiewenski S, Vaysse P, Moscovici J, de Graeve P, Guitard J. The
ureterovesical junction. Anat Clin. 1984;5(4):251-9.
The paraureteral diverticula develop at the site where the Waldeyer's sheath covers
the space between the intravesical ureter and the muscular layer of bladder. This
anatomic site of the bladder is rather vulnerable and any congenital defect of the
detrusor muscle (including embryological weakness in the detrusor muscle, hypoplasia
of the muscularis, absence of the muscularis or a non-functional detrusor muscle) can
result in the herniation of the bladder mucosa and the formation of a diverticulum
even in the absence of vesical outlet obstruction. The above explains the common
association between congenital diverticula and the ureteral orifice (90% of congenital
bladder diverticula are located in close proximity to the UVJ, while the remaining 10%
occur in posterolateral locations).
Hutch was also the first to associate paraureteral diverticula with vesicoureteral reflux
(VUR) because of the alteration of the ureterovesical anatomic relationship and many
authors since then have also well documented this association in various papers.

Aims and objectives

The purpose of this report is to present the paraureteral Hutch diverticulum. Our study
concentrates on:
1.
2.
3.
4.

the findings of this congenital diverticulum in voiding

cystourethrography (VCUG)
the difficulties to visualize it because of its dynamic nature,
how to ensure its demonstration in fluoroscopic studies and
its association with vesicoureteral reflux (VUR).

Images for this section:

Page 4 of 25

Page 5 of 25

Fig. 12: The 'Hutch diverticulum' refers to a primary diverticulum at or near the
ureterovesical junction (UVJ) with its orifice located above the ureteral orifice that is found
in children who are otherwise normal.

Page 6 of 25

Methods and materials

VCUG examinations performed fluoroscopically in children in our department during a 3year period were retrospectively reviewed for Hutch diverticula.
The indications for the VCUG examinations were urinary tract infection mainly and
dysfunctional voiding in a few only cases.
In infants and very small children we usually perform 2 cycles of VCUG. Cyclic VCUG is
also used in toilet trained children whenever deemed necessary.
One boy additionally underwent an IVP examination, referred to our department by the
pediatric surgeon.

Results
Our results in brief are shown on Table1.

Table 1: 8 children were found to have 9 congenital paraureteral diverticula. Bilateral

diverticula were found in 1 boy. The majority of the children were boys (7 boys, 1 girl).
Children's ages varied from 2 months to 8 years. In 3 children BD were visible in filling

Page 7 of 25

phase of VCUG and in all children in the voiding phase. In 6 children ipsilateral VUR
was found.
References: Radiology - Thessaloniki/GR
Radiologic morphology of Hutch diverticula in fluoroscopic studies was not different from
other types of bladder diverticula that are found either in adults or children: they appeared
as oval or round, sharply marginated focal outpouchings of the bladder wall filled with
contrast material.

Page 8 of 25

Fig. 1: Bladder diverticula in fluoroscopic studies appear as oval or round, sharply

marginated focal outpouchings of the bladder wall filled with contrast material.
References: Radiology - Thessaloniki/GR

Page 9 of 25

However, depiction of Hutch diverticula in VCUG studies was challenging because

of certain characteristics that are specific only to these kind of congenital diverticula.
Analytically:

all were located near or at the ureterovesical junction.

They were found cephalad and lateral to the ureteral orifice. In cases of ipsilateral VUR
extrinsic narrowing of the ipsilateral ureter was observed ("notch sign").
Fig. 2 on page 14

they appeared intermittently.

Specifically in our specimen, all diverticula were visible in the voiding phase of the VCUG
and only 3 were also suspected in the filling phase. Fig. 3 on page 15 Fig. 4 on page
16
Hutch diverticula are dynamic abnormalities of the bladder that typically appear during
micturition, when intravesical pressures increases.
We have to point out, about the 3 cases in our study in which Hutch diverticula emerged
during the filling phase of the VCUG, that:
- in the case of the 2-year-old boy the diverticulum was rather large Fig. 7 on page 18
Fig. 8 on page 19
- in the case of the 7-year-old boy wide bladder neck anomaly was also present. Fig. 10
on page 20

their size was not constant

Diverticula in 4 children gradually increased significantly in size during micturition and in

one case there were fluctuations in size during voiding.
The dynamic character of paraureteral diverticula is also reflected in this changeability of
their size especially during voiding. The size of the diverticulum depends on the degree
of eversion of the bladder wall and can vary through the filling-voiding cycle of VCUG
and between examinations.
Fig. 4 on page 16
Fig. 7 on page 18
Fig. 8 on page 19

Page 10 of 25

Fig. 9 on page 19
Fig. 11 on page 20

there was need for specific views of the bladder for their depiction.

In the 3 children mentioned above with diverticula present in the filling phase of the VCUG,
the full bladder face views of the filling phase revealed none. There was need for oblique
(or profile) views of the bladder for their depiction.
The above can be explained when considering the anatomic position of the diverticulum:
it is located near or at the UVJ, which lies retrovesically and thus is hidden in frontal views
of the bladder of a VCUG. This is especially true for full bladder views, when bladder
is filled with dense contrast material. Best views for the depiction of the UVJ and the
retrovesical portion of the ureter are the oblique ones (right oblique for the left VUJ and left
oblique for the right VUJ) and secondly the profile ones. In this way and especially when
the ipsilateral ureter is delineated because of VUR, the diverticulum can be thoroughly
evaluated.
Fig. 3 on page 15
Fig. 7 on page 18
Fig. 8 on page 19
Fig. 10 on page 20
In 6 children post void views showed better the diverticula even in face bladder views.
Much attention should be made to view the bladder just after voiding. As mentioned
above, Hutch diverticula appear during micturition and are at their largest at the end of
micturition. Thus they still remain visible, filled with contrast next to an empty bladder on
post void views, especially diverticula with a narrow neck that empty poorly and belated
compared to the bladder.
Fig. 3 on page 15
Fig. 4 on page 16
Fig. 5 on page 16
Fig. 6 on page 18
Fig. 7 on page 18
Fig. 8 on page 19

Page 11 of 25

Fig. 11 on page 20

there was associated VUR

Six children had ipsilateral VUR of various degrees and of both phases of the VCUG (1
child with grade I, 3 children with grade III, 2 children with grade IV - 3 children in the
filling phase and 3 children in the voiding phase).
Fig. 3 on page 15
Fig. 4 on page 16
Fig. 5 on page 16
Fig. 9 on page 19
Fig. 10 on page 20
Fig. 11 on page 20
Reflux that is secondary to a Hutch diverticulum is as dynamic as the diverticulum itself
and will appear intermittently just like the diverticulum. The relationship between the
orifices of the diverticulum and the ureter is not static and determines the presence of
VUR. When the ureter opens on the diverticulum's rim and the bladder is completely
distended the ureteral orifice is incorporated transiently into the bladder diverticulum.
When the ureter enters the diverticulum directly the ureteral orifice is incorporated
permanently into the bladder diverticulum. Both cases render the antireflux ureterovesical
mechanism incompetent and lead to secondary VUR.
Images for this section:

Page 12 of 25

Table 1: 8 children were found to have 9 congenital paraureteral diverticula. Bilateral

diverticula were found in 1 boy. The majority of the children were boys (7 boys, 1 girl).
Children's ages varied from 2 months to 8 years. In 3 children BD were visible in filling
phase of VCUG and in all children in the voiding phase. In 6 children ipsilateral VUR
was found.

Page 13 of 25

Fig. 1: Bladder diverticula in fluoroscopic studies appear as oval or round, sharply

marginated focal outpouchings of the bladder wall filled with contrast material.

Page 14 of 25

Fig. 2: Hutch diverticula were found cephalad and lateral to the ureteral orifice. In cases of
ipsilateral VUR extrinsic narrowing of the ipsilateral ureter was observed.(white arrow:BD,
yellow arrow:ureter).

Page 15 of 25

Fig. 3: (a)Barely visible saccule on the left side of the bladder of a 2-month-old boy in the
face view in the middle of the filling phase of the VCUG. (b)The lesion "disappears" in
face view when bladder is fully distended, "hiding" behind the densely opacified overlying
bladder. (a-d)Bilateral VUR is shown in the filling phase (grade III on ipsilateral to the
diverticulum side). (c+d)Both the diverticulum and the left ureter are better visualised
either in the right oblique view (best view for assessing the left UVJ) or in the post void
view (when the bladder is no longer an obstacle).

Fig. 4: (a) 4-month-old boy with right grade III VUR during the filling phase of 1st cycle
of VCUG shows a smooth-walled bladder. (b+c) The boy is turned to right lateral side
for the voiding phase. At the beginning of voiding, a small saccule appears near the UVJ
that gradually becomes larger during micturition. (d-f) During the 2nd cycle of VCUG, left
oblique images were chosen during filling and voiding, so as to better evaluate the right
UVJ. The bladder has a completely smooth contour during the filling phase (d) and the
paraureteral diverticulum appears only during voiding, becoming more apparent at the
end of voiding(e-f).

Page 16 of 25

Page 17 of 25

Fig. 5: (a-b) III grade left VUR in a 10-month-old girl on the 1st cycle of VCUG. A suspicion
about a diverticulum on the left side on face views during voiding (a), becomes a certainty
when the bladder is almost empty (b). The diverticulum has a paraureteral position. (c-d)
During a 2nd cycle no diverticulum is visualized when the bladder is fully distended even
with the girl turned obliquely right (c). During voiding the Hutch diverticulum reappears
in a paraureteral position (d).

Fig. 6: VCUG of a 13-month-old boy. (a-b)No lesion is detected during the filling phase,
either on face (a) or right lateral views. (c-d)During voiding though, a small diverticulum
appears at the site of the left UVJ that is better appreciated on a post void face view.
No VUR was detected.

Page 18 of 25

Fig. 7: VCUG of a 2-year-old boy. (a-c)During the mid-filling phase an abnormal contour
of the right side of the bladder is noticed and a left oblique view is taken that shows a large
right-sided Hutch diverticulum (c). The full bladder face view (b) that had preceded gave a
false negative result (the diverticulum was "hidden" by the densely opacified bladder). (dg)During voiding the diverticulum increases gradually in size significally. Large diverticula,
especially when they have a narrow neck, empty slowly and later than the bladder, thus
they are still large and visible on early post void views(f) and may refill the bladder with
opacified urine on delayed post void views(g).

Fig. 8: (a-c)IVP of previous 2-year-old boy. Because no VUR was detected and in order
to answer the pediatric surgeon's question "is the ureteral orifice incorporated in the
diverticulum or just below it?", the boy underwent an IVP and fluoroscopic left oblique
views were taken while the boy was asked to try to micturate. The ipsilateral ureter was
imaged with a normal orifice just below the diverticulum but was compressed by it. The
diverticulum fluctuated in size, becoming larger every time the boy was trying to urinate
(b-c).

Fig. 9: (a-b) A boy 4,5 years old with IV grade VUR on the right side during the
filling phase of VCUG and no paraureteral diverticulum on oblique full bladder views.
Page 19 of 25

(c-d)During micturition a left Hutch diverticulum emerged that gradually enlarged and
grade I VUR was found ipsilateraly. VUR in this child was not only associated with the
Hutch diverticulum because of concomitant stenosis of the anterior urethra (double white
arrows). (e)On face view the BD is obscured by the full bladder.

Fig. 10: 7-year-old boy. (a-c) 1st VCUG: Grade IV VUR on the left side and a paraureteral
diverticulum ipsilateraly depicted during the filling phase on a right oblique view. A wide
bladder neck was a constant finding throughout the examination (green arrow). The
examination was not completed because the boy was unable to empty his bladder on
the examination table. No diverticulum was depicted in the oblique images (b-c) although
the boy was trying to urinate. (d-i) 2nd VCUG 6 months later : IV grade VUR was found
bilaterally(e) and the left paraureteral Hutch diverticulum was depicted by the left UVJ in
the early filling phase on face views(d). There was no change concerning the bladder neck
deformity(green arrow). Once more, voiding was difficult. The size of the diverticulum
varied during the phases of the VCUG: during the filling phase the diverticulum is large(d),
at the beginning of voiding is small(h) and during voiding it increases again in size(i).

Page 20 of 25

Fig. 11: 8-year-old boy (a-c) Left IV grade VUR in the voiding phase. During micturition a
Hutch diverticulum was found on the same side. (c) A post void en face view was taken,
on which the left Hutch diverticulum was better depicted filled with contrast material next
to the empty bladder and a small right diverticulum was found.

Page 21 of 25

Conclusion
Congenital paraureteral diverticula are rare but since they are associated with VUR it is
important to diagnose them.
VCUG under fluoroscopic control is the most reliable modality for their detection. Their
demonstration though is a diagnostic challenge for the radiologist, because:

They appear intermittently usually only during voiding, when intravesical

pressures maximize.

Their location near the UVJ is usually "hidden" in standard frontal views
obscured by an opaque full bladder.

They usually enlarge during voiding becoming more apparent at post void
films, even in face projections, especially when they are narrow-necked.

They are associated with secondary VUR because they alter, either
transiently or permanently, the normal slanted insertion of the ureter in the
bladder. Fig. 13 on page 23

Thus VCUG, especially in children with high grade VUR, should be performed with careful
technique and attention to details such as:

bladder should be completely empty before filling phase of the examination

starts (diverticula may contain non-opaque urine rendering them undetected
during the examination).

all phases should be fluoroscopically monitored and especially voiding

because paraureteral diverticula typically appear during high pressure
micturition. Diverticula may have emptied into the bladder by the time the
next film is taken, when static VCUG is used.

oblique and lateral views should be obtained to visualize the ureterovesical

junction, near the trigone where Hutch diverticula are located.

post void views immediately after bladder emptying should be taken

because Hutch diverticula that enlarge during voiding become more
apparent in these views.

delayed post void views may be taken when needed to evaluate narrownecked diverticula that empty later than the bladder. These diverticula may
explain aberrant micturition in these cases.

Page 22 of 25

Even if recent studies claim that the evolution of VUR is independent of the presence of
a Hutch diverticulum, the mere presence of such a diverticulum in a child is an indication
for cystoscopy, follow up examinations and potentially surgical treatment.
Images for this section:

Fig. 13: The relationship between the orifices of the diverticulum and the ureter is not
static and determines the presence of VUR. When the ureter opens on the diverticulum's
rim and the bladder is completely distended the ureteral orifice is incorporated transiently
into the bladder diverticulum. When the ureter enters the diverticulum directly the ureteral
orifice is incorporated permanently into the bladder diverticulum. Both cases render the
antireflux ureterovesical mechanism incompetent and lead to secondary VUR.

Page 23 of 25

Personal information
Radiology Department of "G.Gennimatas" Hospital of Thessaloniki, GREECE
M. Arvaniti
D. Katsiba
D. Rafailidis
I. Torounidis
A. Charsoula
C. Kaitartzis
C. Nalmpantidou
A. Papadimitriou
e-mail address:
annahars@ath.forthnet.gr
mail address:
"G.Gennimatas" Hospital of Thessaloniki
Radiology Department
41 Ethnikis Aminis St.
54635
Thessaloniki
GREECE

References
1.

2.

3.

Singh BP, Nagathan DS, Sankhwar S, Yadav R. Hutch diverticulum

presenting as acute urinary retention in early life. BMJ Case Rep. 2013 Sep
7;2013.
Evangelidis A, Castle EP, Ostlie DJ, Snyder CL, Gatti JM, Murphy JP.
Surgical management of primary bladder diverticula in children. J Pediatr
Surg. 2005 Apr;40(4):701-3.
Hutch JA (1961) Saccule formation at the ureterovesical junction in smoothwalled bladders. J Urol 86: 390.
Page 24 of 25

4.
5.
6.
7.
8.
9.
10.
11.
12.

13.
14.

15.
16.

17.

18.

Juskiewenski S, Vaysse P, Moscovici J, de Graeve P, Guitard J. The

ureterovesical junction. Anat Clin. 1984;5(4):251-9.
Psutka SP, Cendron M. Bladder diverticula in children. J Pediatr Urol. 2013
Apr;9(2):129-38.
Mackellar A, Stephens FD. Vesical diverticula in children. Aust N Z J Surg
1960;30:20e31.
Barrett DM, Malek RS, Kelalis PP. Observations on vesical diverticulum in
childhood. J Urol 1976;116(2):234e6.
King, Allen NH, AtwelI JD (1980) The paraureteric diverticulum in Childhood.
Br J Urol 52:264-268
Bauer SB, Retik AB. Bladder diverticula in infants and children. Urology.
1974 Jun;3(6):712-5.
Bellinger MF, Gross GW, Boal DK. Bladder diverticulum associated with
ureteral obstruction. Pediatr Radiol. 1985;15(3):207-8.
Boechat MI, Lebowitz RL. Diverticula of the bladder in children. Pediatr
Radiol. 1978 Apr 10;7(1):22-8.
Aydogdu O, Burgu B, Soygur T. Predictors of surgical outcome in children
with vesicoureteral reflux associated with paraureteral diverticula. Urology.
2010 Jul;76(1):209-14.
Hernanz-Schulman M, Lebowitz RL. The elusiveness and importance of
bladder diverticula in children. Pediatr Radiol. 1985;15(6):399-402.
Berrocal T, Lpez-Pereira P, Arjonilla A, Gutirrez J. Anomalies of the
distal ureter, bladder, and urethra in children: embryologic, radiologic, and
pathologic features. Radiographics. 2002 Sep-Oct;22(5):1139-64.
Juskiewenski S, Vaysse P, Moscovici J, de Graeve P, Guitard J. The
ureterovesical junction. Anat Clin. 1984;5(4):251-9.
Khemakhem R, Ghorbel S, Jlidi S, Nouira F, Louati H, Douira W, Chennoufi
F, Bellagha I, Chaouachi B. Management of congenital bladder diverticulum
in children: A report of seven cases. Afr J Paediatr Surg. 2013 AprJun;10(2):160-3.
Rowell AC, Sangster GP, Caraway JD, Walker PW, Elmajian DA, Heldmann
MG. Genitourinary imaging: part 1, congenital urinary anomalies and their
management. AJR Am J Roentgenol. 2012 Nov;199(5):W545-53.
Lebowitz RL, Avni FE. Misleading appearances in pediatric uroradiology.
Pediatr Radiol. 1980 Sep;10(1):15-31.

Page 25 of 25