Abstract
•	This case report presents the complex surgical management of a 72-year-old male experiencing severe lower urinary tract symptoms due to an enlarged prostate and bilateral bladder diverticula, which resulted from prostatic enlargement. Uniquely, both ureters inserted into the diverticula on each side.
•	The patient's medical history included diabetes mellitus and hypertension, and he presented with gross hematuria and clot retention. Initial interventions involved bladder wash and clot evacuation.
•	Subsequent CT imaging unveiled substantial bladder diverticula and significant prostate enlargement, each contributing to severe urinary tract obstruction. Notably, the diverticula featured atypical ureteral insertions necessitating bilateral ureter reimplantation after diverticulectomy.
•	The performed procedures included an open prostatectomy, bladder diverticulectomy of both diverticula, and bilateral ureteral reimplantation. These interventions were crucial for managing the prostate-induced bladder outlet obstruction and the rare anatomical presentation of the ureteral insertions into the diverticula.
•	This report highlights the challenges and complex surgical strategies required to manage a very rare urological condition, offering insights into the decision-making and technical nuances essential for achieving favorable outcomes in similarly intricate scenarios.

Bladder diverticula, frequently associated with benign prostatic hyperplasia (BPH), are pouch-like evaginations of the bladder wall that can lead to significant complications (8) . This case illustrates the intricate relationship between bladder diverticula and BPH, highlighting the necessity for a comprehensive understanding of these conditions for effective management .

Bladder diverticula can be categorized into two main types: congenital and acquired. Congenital diverticula are often linked to conditions such as posterior urethral valves or neurogenic bladder, while acquired diverticula typically arise from bladder outlet obstruction, often due to BPH [8].

The size of bladder diverticula plays a critical role in the risk of acute urinary retention (AUR) among patients with BPH. Research indicates that diverticula larger than 5.15 cm significantly heighten the likelihood of AUR, with a sensitivity of 73% and specificity of 72% [9, 10]. In this case, the presence of a large diverticulum measuring 9 x 6 cm likely contributed to the patient's symptoms.

Additionally, bladder diverticula can lead to urinary stasis, stone formation, recurrent urinary tract infections, and even malignancies [8, 10]. The large diverticula observed in this patient could also compress pelvic veins, raising the risk of deep vein thrombosis and pulmonary embolism [11].

Surgical intervention is often necessary for managing bladder diverticula in the context of BPH. This case involved an open prostatectomy and bladder diverticulectomy, along with bilateral ureteral reimplantation due to the diverticula's involvement with the ureters. 

While minimally invasive techniques, such as transurethral laser enucleation of the prostate combined with laparoscopic diverticulectomy, are effective in many cases [12], 
in our case, Minimally invasive techniques    , such as     robot-assisted or laparoscopic diverticulectomy    , were considered but deemed     less suitable     due to the     patient’s anatomical complexity     and     large diverticula size

•	This case underscores the complex interrelations between bladder diverticula and significant prostate enlargement, illustrating the unique scenario of ureteral insertions into these diverticula. The successful management through combined prostatectomy, diverticulectomy, and ureteral reimplantation accentuates the importance of a personalized approach, meticulous intraoperative decision-making, and thorough postoperative care. This report adds valuable insights into managing similar complex urological cases, emphasizing the necessity for individualized treatment plans and interdisciplinary collaboration to achieve optimal outcomes.

Case report

As above

1.	Favorito, L. (2018).   Bladder diverticula & acute urinary retention in BPH  . Int Braz J Urol, 44, 662-663. [https://doi.org/10.1590/S1677-5538.IBJU.2018.04.01](https://doi.org/10.1590/S1677-5538.IBJU.2018.04.01)
2.	Iscaife, A., Anjos, G., Barbosa, C., Nahas, W., Srougi, M., & Antunes, A. (2018).   The role of bladder diverticula in acute urinary retention in BPH patients  . Int Braz J Urol, 44, 765-770. [https://doi.org/10.1590/S1677-5538.IBJU.2017.0605](https://doi.org/10.1590/S1677-5538.IBJU.2017.0605)
3.	Kang, Q., Kang, B., Yu, Y., & Yang, B. (2020).   Transurethral enucleation of the prostate combined with laparoscopic bladder diverticulectomy  . Minim Invasive Ther Allied Technol, 31, 144-148. [https://doi.org/10.1080/13645706.2020.1768123](https://doi.org/10.1080/13645706.2020.1768123)