Intestinocystoplasty in combination with clean intermittent catheterization in the management of vesical dysfunction

Bladder augmentation: experience with 129 children and young adults

From 1977 to 1989 bladder augmentation was performed in 56 male and 73 female patients from 1 to 35 years old (average age 12.7 years). In 59 cases augmentation was performed as part of an undiversion operation. Indications for augmentation included neurogenic bladder, severely scarred bladder from prior operations, noncompliant bladder after previous treatment of severe urethral valves, small bladder in former exstrophy patients, epispadias with a small bladder, cloacal exstrophy, and small, noncompliant bladder after therapy for cancer, trauma, cloaca and miscellaneous conditions. We used 145 bowel segments, since 16 patients had 2 bowel segments. Segments included cecum in 65 cases, sigmoid in 46, small bowel in 24, stomach in 4 and left colon in 1. The most common complication was stones. Detubularized bowel for augmentation of small noncompliant bladders allows functional reconstruction in a wide range of urological disorders that were formerly treated by diversion. Reconstruction is possible in many previously diverted patients if bladder augmentation is used.

Augmentation enterocystoplasty for the management of voiding dysfunction in spinal cord injury patients

A total of 12 spinal cord injury adults underwent augmentation enterocystoplasty for treatment of a high pressure neurogenic bladder. These patients suffered from urinary incontinence, recurrent urinary tract infection, upper tract deterioration and severe autonomic dysreflexia. A sigmoid colon segment fashioned into a cup-patch was used in 11 patients and detubularized cecum was used in 1. The artificial urinary sphincter was implanted in 3 patients at augmentation enterocystoplasty and in 1 after enterocystoplasty. After a mean followup of 15 months all patients were continent on clean intermittent self-catheterization, the upper tract had remained stable or had improved and the symptoms of autonomic dysreflexia had disappeared. A third of the patients are on maintenance antibiotic therapy to control bacteriuria.

Renal transplantation into the reconstructed bladder

In our experience with 821 renal transplants performed between 1974 and October 1987 we used the native or reconstructed bladder of the patient in all but 2 instances. Seven patients have undergone enterocystoplasty and subsequent renal transplantation, while 1 underwent bladder augmentation after transplantation. Of these 8 patients 4 have functioning grafts 6 months to 7 years after transplant or reconstruction. Renal transplantation coupled with enterocystoplasty in properly selected patients has acceptable morbidity and should be considered as an alternative to other forms of urinary diversion in allograft recipients.

Perforation of the augmented bladder in patients undergoing clean intermittent catheterization

During urological reconstructive surgery small or large bowel is used to increase bladder capacity or to create a urinary reservoir. In most patients clean intermittent catheterization is necessary for urinary drainage. We report on 4 patients with a sigmoid cystoplasty who perform clean intermittent catheterization and who have experienced a serious long-term complication, urinary reservoir perforation, which was fatal in 1. Two were adolescent girls with myelodysplasia and 2 were prepubertal boys with bladder exstrophy. One patient experienced 2 separate reservoir perforations. Rupture occurred 15 to 48 months (mean 30.2 months) after reconstruction. Diagnosis was made by a static cystogram, which demonstrated extravasation in 2 of 4 patients, and ultrasound. In 2 patients the cystogram was normal. Management included intravenous antibiotics and open abscess drainage in all patients. In patients who have undergone augmentation cystoplasty or continent diversion and in whom abdominal pain and distension develop reservoir perforation should be considered in the differential diagnosis.

Urinary tract reconstruction in children

The successful introduction of clean intermittent catheterization and increased awareness of urinary tract physiology and urodynamics have been the basis for recent major advances in urinary tract reconstructive surgery. Surgical techniques are now available to manage anatomical and functional deficiencies of any isolated or combined components of the urinary tract. The high incidence of unsatisfactory long-term results with ileal conduit diversion has led to increased popularity in urinary tract undiversion and greater utilization of reconstructive principles. As with any new surgical field of endeavour, new operative techniques are appearing at a rapid rate. In particular, there has been a recent proliferation of surgical procedures that provide a continent, low pressure, catheterizable reservoir for urine storage. Most children with major urinary tract deficiencies can now be offered socially and cosmetically unobtrusive surgical solutions without jeopardizing renal function.

Urethral replacement with ureter

Proximal or total urethral replacement was performed in 8 patients using distal ureter. This was accomplished by basing the ureteral segment solely on a vascular pedicle arising from the internal iliac artery. Diagnoses included classical bladder exstrophy in 4 patients, cloacal exstrophy in 3 and an imperforate anus with hypoplasia of the bladder neck and urethra in 1. Continence was achieved by a tunneled submucosal reimplantation into either the bladder (4 cases), gastric reservoir (2) or colonic reservoir (2). Although an isolated distal segment of ureter was used in each case, all segments have remained viable. With limited followup (5 to 44 months) continence with either normal voiding or intermittent catheterization has been achieved in 7 of the 8 patients. A distal ureteral segment should be considered potentially useful in the construction or reconstruction of the proximal (male) or total (female) urethra in patients with congenital urethral malformations.

Ileocecal bladder augmentation in myelodysplasia

We discuss 14 children and adolescents with myelodysplasia who underwent bladder augmentation with the ileocecal segment. The bowel was not detubularized nor was the ileocecal valve intussuscepted. Urodynamic evaluation was performed before and after the procedure in 13 patients with a followup of 1 to 8 years. Postoperative capacity and compliance were normal but cecal contractions occurred in 8 patients despite adequate doses of anticholinergics. Reflux was demonstrated at capacity with a cecal contraction in 4 patients but upper tract dilatation and infection were not clinical problems. Three patients required reoperation for complications owing to ureteroileal stenosis and/or urinary tract calculi. Although the clinical results were satisfactory, detubularized segments of bowel with intussuscepted afferent loop valves to prevent reflux may resolve these problems in the future.

Pediatric urinary diversion and undiversion

Many things have changed in our management of the urinary tract of children and young adults. Important contributions from many sources have resulted in the refinement of therapy and the progression from diversion to undiversion and reconstruction. Primary urinary diversion is now uncommon. Patients with exstrophy, for example, are treated with primary bladder closure as newborns, and newborns with valves often are treated with primary valve ablation. Children with neurogenic bladder dysfunction resulting from myelodysplasia are rarely diverted, but are started at an early age with ICC. It is hoped that in future the contents of this article on diversion techniques and undiversion will be of historical interest, however. Note: The editors also have found the use of the Mitrofanoff procedure, utilizing a nonrefluxing tunnel and a catheterizable stoma made out of the ureter or appendix, to be a very valuable addition to the reconstructive surgeon's armamentarium. We also feel that use of detubularized bowel for either bladder augmentation or replacement provides more efficient storage capability. Occasional reports of extremely significant diarrhea after removal of the ileocecal segment from the intestinal tract have been reported in children with myelodysplasia.

Intestinocystoplasty and total bladder replacement in children and young adults: followup in 129 cases

A review of 129 consecutive young patients (average age 13.4 years) who underwent intestinocystoplasty or total bladder replacement during a 6 1/2-year period at our institution is presented. The most common diagnosis was myelodysplasia and the average followup was 44 months. The clinical and urodynamic aspects of 4 types of intestinocystoplasty (ileocecal, tubular sigmoid, sigmoid patch and ileal patch) are presented. All 4 operations resulted in a significant increase in bladder volume, with a decrease in filling pressure and, thus, improved vesical compliance. In combination with clean intermittent catheterization renal function was maintained or improved in 91 per cent and urinary continence was achieved in 82 per cent of the patients. Hyperchloremic acidosis requiring therapy was noted only in patients with pre-existing renal insufficiency, although mild hyperchloremia after cystoplasty was seen with all 4 types of cystoplasty. There were no operative mortalities. Significant surgical complications occurred in 36 per cent of the patients, the most common of which was vesicoureteral reflux in the ileocecal cystoplasty. Mass unit peristaltic contractions occurred in 34 per cent of the tubular-shaped bowel segments compared to only 10 per cent of the patch segments. These peristaltic contractions contributed to the greater postoperative morbidity noted in the tubular large bowel cystoplasties. The over-all success rate for intestinocystoplasty in this series was 84 per cent. Intestinocystoplasty is an effective procedure when used to increase the compliance of the lower urinary tract. In combination with clean intermittent catheterization it can be applied successfully to patients with neurogenic bladder dysfunction. Large and small bowel seem to have similar clinical and urodynamic properties. The type of intestinal segment used for intestinocystoplasty seems to be of less importance than the size and configuration. Large bowel in its native tubular configuration should be avoided.