Conservative management of suspected bladder rupture after augmentation enterocystoplasty

Long-term risks of childhood surgery

INTRODUCTION

Several patients, who underwent major reconstruction under the care of an experienced pediatric urologist are now, as adults, several years later, appearing with long term problems and complications. This consensus process was undertaken to give an overview of long term consequences (and their management) of urological childhood surgery.

MATERIAL AND METHODS

Several known urologists with experience in life-long follow up and revisional surgery of patients with congenital conditions were asked to review literature and comment based on their experience about several complications of childhood surgery.

RESULTS

Renal impairment, metabolic consequences, bladder stones, Vit B 12 deficiency and recurrent infections are often encountered. Also recurrent ureteric strictures and difficulties with catheterizable channel (both obstruction and incontinence) can be challenging to manage. Specific attention is needed regarding female sexuality and pregnancy. Both the development of malignancies in reconstructed bladders as secondary malignancies need to be taken into account during follow up.

CONCLUSION

Follow up of patients with rare congenital conditions is highly specialized and revisional surgery can be challenging. Therefore, follow up needs to be organized in specialized centers.

Bladder augmentation from an insider's perspective: a review of the literature on microcirculatory studies

Augmentation cystoplasty is an exemplary multiorgan intervention in urology which is particularly associated with microvascular damage. Our aim was to review the available intravital imaging techniques and data obtained from clinical and experimental microcirculatory studies involving the most important donor organs applied in bladder augmentation. Although numerous direct or indirect methods are available to assess the condition of microvessels the implementation of microcirculatory diagnostic methods in humans is still challenging and the assessment of organ microcirculation in the operating theatre has limitations. Nevertheless, preclinical studies generally report good internal validity and although prospective human protocols with reduced variability are needed, a possible positive impact of microcirculatory diagnostics on the clinical outcomes of urologic surgery can be anticipated.

Successful conservative management of a spontaneous intraperitoneal rupture of bladder diverticulum in a critical patient: A case report. A CARE-compliant article

RATIONALE

A spontaneous rupture of the bladder diverticulum in an adult patient is extremely rare. The recommended treatment is surgery. However, some cases can be successfully treated with urinary catheterization, antibiotics, and/or percutaneous peritoneal drainage. In this case report, a spontaneous rupture of the bladder diverticulum was successfully treated non-surgically because it was deemed too risky for surgical intervention, such as non-ST segment elevation myocardial infarction (NSTEMI).

PATIENT CONCERNS

A 76-year-old man presented with abdominal pain, distention, diarrhea, and oliguria for 3 days and hypotension for 1 day with no history of trauma. The patient showed direct and rebound tenderness in the lower abdomen. Computed tomography revealed an intraperitoneal bladder rupture associated with the bladder diverticula. Electrocardiography, echocardiography, and elevated cardiac enzyme suggested NSTEMI.

DIAGNOSES

A spontaneous rupture of the bladder diverticulum, NSTEMI, and suspected sepsis due to gastroenteritis or urinary infection.

INTERVENTIONS

The patient was treated conservatively with urinary catheterization and antibiotics for a bladder rupture and an infection. Percutaneous transluminal coronary angioplasty was performed for NSTEMI.

OUTCOMES

The patient fully recovered without complications on hospitalization day 13.

LESSONS

Conservative management might be an alternative for a spontaneous intraperitoneal bladder rupture in some cases. However, close observation is required, and surgical intervention is the first option for a spontaneous intraperitoneal rupture of the bladder diverticulum.

Diagnosis of Perforated Enterocystoplasty

In the operation of enterocystoplasty, now widely practised, segments of bowel are used to augment or replace the urinary bladder. An occasional complication is perforation, and this may present in non-specialist settings. We investigated the management of spontaneous perforations among 264 patients with enterocystoplasty followed by one surgeon for 2-18 years. Patients’ charts were examined for data on presentation, diagnosis and treatment.

10 patients had thirteen perforations; data were available for nine perforations in 9 patients. Mean time from enterocystoplasty to perforation was 45 months. Presentation was shoulder pain in 1 and abdominal pain (with or without fever) in 8. Perforation was diagnosed without delay in 3, but the initial diagnosis was urinary tract infection in 4 and small-bowel obstruction in 2. Ultrasound was the most useful investigation being diagnostic in 6 of 7 cases; contrast cystography showed a leak in only 2 of the 6 patients in whom it was performed. Treatment was successful in 8 cases (surgery 6; percutaneous drainage 2); 1 patient, who remained undiagnosed, was treated medically and died.

Patients with enterocystoplasty need to be educated about this potentially lethal complication, so that they can alert non-specialist clinicians to what may have happened. In any patient with enterocystoplasty who reports abdominal pain or shoulder pain, perforation has to be ruled out.

Bladder perforation after augmentation cystoplasty: Determining the best management option

INTRODUCTION

Delayed bladder perforation is a well-described complication after augmentation cystoplasty. Although the frequency, risk factors, and diagnostic challenges are well documented, discussions regarding management strategies are sparse.

OBJECTIVE

We evaluated our experience of managing augmented bladder perforation to interrogate the hypothesis that non-operative management can be used effectively.

STUDY DESIGN

We retrospectively evaluated the management of 10 patients with augmented bladder perforations over a 16-year period (Jan 2000-Jan 2016). Patients who demonstrated clinical deterioration, severe peritonitis, or extensive extravasation on imaging underwent exploratory laparotomy and primary closure. Clinically stable patients with minimal extravasation were managed non-operatively with maximal bladder drainage, and those with loculated fluid collections in feasible locations for drainage underwent an image-guided percutaneous drain placement.

RESULTS

Underlying diagnoses included four patients with myelomeningocele, three with sacral agenesis, two with spinal cord injuries, and one with bladder exstrophy. Three of the four patients with myelomeningocele had concomitant ventriculoperitoneal shunts. Six patients had continent catheterizable channel creation and two patients had bladder neck reconstructions during the original operation. Four patients were managed with exploratory laparotomy and primary closure. Among the six patients managed non-operatively, three underwent image-guided drain placement in addition to maximal bladder drainage. Four patients developed re-perforation. Two of the four surgically managed patients developed re-perforation. Two of the three patients managed only with maximal bladder drainage developed re-operation. None of the patients managed non-operatively with drain placement suffered from re-perforation. Four perforation episodes were alcohol-related, two occurred after high-impact sporting activity, and two patients reported non-compliant catheterization.

DISCUSSION

Non-operative management with maximal bladder drainage and selective image-guided drain placement can be successfully deployed in clinically stable patients with limited extravasation. Ensuring low intraluminal detrusor pressures and empty bladder with maximal drainage is critical for spontaneous sealing of the perforation site. Exploratory laparotomy and primary closure remains our approach for those presenting with clinical deterioration or significant extravasation on imaging. The majority of our perforations and re-perforation episodes seemed to stem from preventable behavioral risk factors.

CONCLUSIONS

Our findings support the hypothesis that non-operative management with maximal bladder drainage and image-guided drain placement can be effective in stable patients with limited extravasation.

An unusual cause of abdominal distension: intraperitoneal bladder perforation secondary to intermittent self-catheterisation

We report a strikingly unusual case of traumatic intraperitoneal perforation of an augmented bladder from clean intermittent self-catheterisation (CISC), which presented a unique diagnostic challenge. This case describes a 48-year-old T1 level paraplegic, who had undergone clamshell ileocystoplasty for detrusor overactivity, presenting with abdominal distension, vomiting and diarrhoea. Initial investigations were suggestive of disseminated peritoneal malignancy with ascitic fluid collections, but the ascitic fluid was found to be intraperitoneal urine from a perforation of the urinary bladder. This was associated with an inflammatory response in the surrounding structures causing an appearance of colonic thickening and omental disease. Although the diagnostic process was complex due to this patient's medical history, the treatment plan initiated was non-operative, with insertion of an indwelling urinary catheter and radiologically guided drainage of pelvic and abdominal collections. Overdistension perforations of augmented urinary bladders have been reported, but few have described perforation from CISC.

Bladder perforation in augmentation cystoplasty during urodynamic investigation: a case report and review of the literature

BACKGROUND

Spontaneous bladder rupture is a known complication of augmentation cystoplasty. We report the second case of bladder rupture during filling cystometry many years after bladder augmentation and the first case occurring in a patient with an autoaugmentation cystoplasty. In addition, the management and outcome for a bladder perforation in an autoaugmentation cystoplasty will be discussed.

CASE

A 20-year-old male with a history of an L4 myelomeningocele underwent an autoaugmentation cystoplasty for neurogenic bladder dysfunction and decreased bladder wall compliance five years previously. He self catheterized four times daily. During filling cystometry, detrusor pressure increased to 60 cm H(2)O with 300 mL filling. Detrusor pressure then rapidly decreased to 20 cm H(2)O without evidence of external leakage. The infusion was immediately stopped and X-ray showed intraperitoneal leakage of contrast material. Serial abdominal examination demonstrated worsening abdominal distension. Exploratory laparotomy revealed a 2 cm perforation within the autoaugment portion of the bladder.

CONCLUSION

An autoaugmentation cystoplasty improves bladder compliance and capacity with the use of native urothelial tissue. Although perforation after autoaugmentation has not been previously reported, caution must be used during urodynamic evaluation in patients with decreased bladder wall compliance and augmentation cystoplasty.

Bladder augmentation: Complications in the pediatric population

Bladder augmentation is an invaluable tool for the pediatric urologist, for both the protection of the upper urinary tract and attainment of urinary continence. However, it remains a major surgical undertaking with significant morbidity. This review examines the incidence and pathophysiology of some of the most common and serious complications, which include surgical complications, such as malignancy, bowel obstruction, and bladder perforation, and medical complications including urinary tract infections and gastrointestinal dysfunction. We review the most current and pertinent literature to provide a comprehensive and practical overview of complications from bladder augmentation in the pediatric population.

[Recurrent neobladder rupture: conservative management]

PURPOSE

To present a case of recurrent neobladder rupture treated in a conservative fashion. To review the articles on conservative management of cases like this one published from 1985.

RESULTS

Nineteen articles have been published since 1985 on spontaneous neobladder rupture, 4 of which describe the possibility of a successful conservative management, provided that the patients are carefully selected.

CONCLUSIONS

Faced to abdominal pain in patients with neobladder, it is essential to suspect spontaneous perforation and, if possible, to confirm such suspicions by means of cystography or CT. An exploratory laparotomy may be necessary in many instances, sometimes due to lack of a diagnosis and sometimes because the patient's status rules out any other procedure, but in selected and precisely diagnosed cases a conservative management can be resolvent.

Post-augmentation bladder perforation during urodynamic investigation

AIMS

To report for the first time bladder rupture during filling cystometry many years after bladder augmentation.

METHODS

A 17-year-old girl with T10 meningomyelocele had received an ileocystoplasty, continent catheterizable stoma, and bladder neck sling for neurogenic bladder dysfunction and intractable incontinence 8 years previously. She was continent with clean intermittent self-catheterization four times per day. Yearly urodynamics showed a bladder capacity of up to 700 ml with good compliance and low bladder pressures. In March 2006, filling cystometry was performed.

RESULTS

Bladder pressure was normal until 400 ml, after which it increased due to lower compliance. At 620 ml filling, the detrusor pressure was 52 cm H2O, and the patient complained suddenly of abdominal discomfort and bilateral shoulder pain, and the infusion was stopped. A catheter was placed and cystography showed intraperitoneal leakage along the left lateral bladder aspect and at the Mitrofanoff insertion site on the bladder dome. The perforations were closed via a midline incision and a ventriculoperitoneal shunt had to be exteriorized. There were no post-operative complications and a control cystogram revealed no leakage.

CONCLUSIONS

Augmentation ileocystoplasty has been used extensively in order to increase bladder capacity and decrease intravesical pressure. Although spontaneous or traumatic perforation of the augmented bladder has been described previously, it was never reported in correlation with urodynamic investigation. Extreme caution is warranted in the face of decreased compliance during filling cystometry in these patients, even though urodynamics showed good bladder compliance and low bladder pressures many years after ileocystoplasty.

Management of delayed bladder augmentation perforation

BACKGROUND

A 17-year-old male, with a history of bladder augmentation enterocystoplasty 7 years earlier, presented with nausea, emesis and acute abdomen.

INVESTIGATIONS

Physical examination, blood and urine culture, and abdominal and pelvic CT cystography.

DIAGNOSIS

Acute abdomen from perforation of bladder augmentation.

MANAGEMENT

Support and stabilization, bladder decompression, and broad-spectrum intravenous antibiotics, followed by immediate exploratory laparotomy with repair of enterocystoplasty and peritoneal lavage.

[Spontaneous urinary bladder perforation after pediatric cystoplasty]

OBJECTIVE

The spontaneous cystoplasty perforation is a serious and potentially fatal problem if a delay in diagnosis and treatment occurs. We pretend: 1) to look for prevention analyzing the risk factors, 2) to identify the main data of diagnostic suspicion and 3) to evaluate the result of the treatments done.

MATERIAL AND METHODS

Out of 30 children with cystoplasty 5 of them have presented 8 perforations (16,6%). Several influential factors, the symptoms, the treatments and the evolution are reviewed.

RESULTS

The average time between cystoplasty and the perforation was 8,2 years. A urethral resistance that allows continence, and an insufficient intermittent catheterization, have been the main risk factors. In the 8 episodes there were abdominal pain and distension. The ultrasonography showed intraperitoneal extravasation in 5 episodes, multiple peritoneal cysts in one, and suggestive image of appendicular plastron in another one. The cystography showed intraperitoneal extravasation only in 3 cases. The initial management was conservative in the 7 episodes diagnosed before surgery, and 3 had a good evolution (42,8%); the other 4 needed surgery with good evolution in all cases. Two of 5 patients (40%) presented 3 relapses in an average time of 5 years. The survival is 100%.

CONCLUSIONS

16,6% of patients with cystoplasty of this series had one or more episodes of spontaneous bladder perforation. The more significant risk factors are a high urethral resistance and an inadequate intermittent catheterization. The patients with cystoplasty, and their families, must know this complication, their risk factors and symptoms to prevent it, or to facilitate an early diagnosis.

Nonoperative treatment of isolated posttraumatic intraperitoneal bladder rupture in children-is it justified?

PURPOSE

Open surgical repair has been the standard treatment for intraperitoneal bladder rupture. We sought to explore the possibility of nonoperative treatment of isolated intraperitoneal bladder rupture in children.

MATERIALS AND METHODS

Eight children (4 girls and 4 boys) with a mean age of 6.3 +/- 4.6 years (range 1 to 13) presented with isolated posttraumatic intraperitoneal bladder rupture between 1993 and 2003. Retrograde cystogram was performed in all cases. Diagnosis was confirmed by aspiration and chemical analysis of the free intraperitoneal fluid in patients with an equivocal cystogram. Four patients who presented early in the series (group 1) were treated with the classic open repair, whereas the last 4 patients (group 2) were treated nonoperatively with adequate bladder drainage and percutaneous intraperitoneal tube drain. The mechanisms of injury, clinical presentation, management, complication, hospital stay and duration of catheterization were reviewed in both groups.

RESULTS

Six patients had a history of a direct blow to the full bladder, while 2 presented following a motor vehicle accident. All patients presented with vomiting and abdominal distention, and 5 had mild gross hematuria without associated clots or hemodynamic instability. One patient in group 1 had early urinary leakage and wound sepsis, and was treated conservatively. All patients in group 2 demonstrated significant improvement in general condition within a few hours of the bladder and peritoneal drainage. Intraperitoneal tube drains were removed at 1 to 4 days. There were no post-intervention complications in group 2 and surgical treatment was never required. Mean indwelling catheter duration was 9.3 +/- 7.9 and 11.8 +/- 2.6 days (p = 0.24), and mean hospital stay was 10.5 +/- 8.4 and 7.3 +/- 3.9 days (p = 0.56) in groups 1 and 2, respectively.

CONCLUSIONS

Nonoperative treatment is a justified initial approach for isolated intraperitoneal bladder rupture in children. Indications for surgical intervention include improper bladder drainage, unduly prolonged urinary drainage through the peritoneal drain and/or lack of clinical improvement.

Rupture and perforation of urinary reservoirs made from bowel

A review of the literature involving the rupture or perforation of urinary reservoirs made from the bowel indicates that this complication is perhaps not as rare as commonly perceived. It is a severe complication for which a high index of suspicion needs to be maintained. Physicians attending to patients with such urinary reconstructions should be aware that the diagnosis is often difficult to confirm without resorting to exploratory laparotomy and in particular that a negative cystogram can be misleading. A practical suggestion to help alert these physicians to the possibility of a ruptured urinary reconstruction is that such patients should carry a medical card stating the type of reservoir they have along with their special circumstances. From the reported experiences, it is, however, clear that in carefully selected cases and with vigilant monitoring, some patients may be managed non-operatively.

Diagnosis of perforated enterocystoplasty

In the operation of enterocystoplasty, now widely practised, segments of bowel are used to augment or replace the urinary bladder. An occasional complication is perforation, and this may present in non-specialist settings. We investigated the management of spontaneous perforations among 264 patients with enterocystoplasty followed by one surgeon for 2-18 years. Patients' charts were examined for data on presentation, diagnosis and treatment. 10 patients had thirteen perforations; data were available for nine perforations in 9 patients. Mean time from enterocystoplasty to perforation was 45 months. Presentation was shoulder pain in 1 and abdominal pain (with or without fever) in 8. Perforation was diagnosed without delay in 3, but the initial diagnosis was urinary tract infection in 4 and small-bowel obstruction in 2. Ultrasound was the most useful investigation being diagnostic in 6 of 7 cases; contrast cystography showed a leak in only 2 of the 6 patients in whom it was performed. Treatment was successful in 8 cases (surgery 6; percutaneous drainage 2); 1 patient, who remained undiagnosed, was treated medically and died. Patients with enterocystoplasty need to be educated about this potentially lethal complication, so that they can alert non-specialist clinicians to what may have happened. In any patient with enterocystoplasty who reports abdominal pain or shoulder pain, perforation has to be ruled out.

Surgical management of the neuropathic bladder

In a simplified view, the "normal" bladder, through a multifaceted neuromuscular event, allows the basic functions of urinary storage and emptying. More specifically, the urinary bladder accommodates increasing urinary volume with little to no increase in vesicular pressure while maintaining continence. The normal act of emptying integrates the relaxation of the urinary sphincters (external and internal) with the subsequent bladder contraction to void to completion when full. There are a multitude of conditions, both congenital and acquired, that can affect the bladder's ability to perform these functions in a smooth and coordinated fashion. The most common causes of pediatric bladder dysfunction necessitating surgical intervention are those associated with spina bifida/myelodysplasia, posterior urethral valves, and bladder exstrophy. Over the last 2 decades, the evolution of complex reconstruction for lower urinary tract dysfunction has resulted in an improved quality of life for children afflicted with upper urinary tract changes or incontinence despite maximum utilization of nonoperative therapies. Because each patient represents a unique therapeutic entity, an individualized approach to each child is recommended.

Advances in bladder augmentation

Over the past 20 years, rapid advances have been made in bladder augmentation due to the introduction of clean intermittent catheterization, the use of intestinal segments interposed into the urinary tract, and the development of tissue expansion. The particular augmentation method selected from the multiple methods currently available is an individualized process that takes into account both patient factors and potential complications. Exciting new techniques, such as tissue engineering, may change the face of lower urinary tract reconstruction.

Acute abdominal symptoms and signs in children and young adults with spina bifida: ten years' experience

BACKGROUND/PURPOSE

Diagnosis and management of the acute abdomen in patients with spina bifida (SB) can be problematic. There are at least 4 clinical factors that can predispose to the development of acute abdominal symptoms and signs, and patients with a thoracic level lesion can have a partially insensate abdomen. The authors analyzed their accumulated experience to determine the annual incidence of acute abdominal signs and symptoms in children and young adults with spina bifida, the differential diagnosis, the operative management, and the outcome. The pertinent literature was reviewed.

METHODS

Cases were ascertained during a 10-year period at 1 institution and reviewed retrospectively.

RESULTS

Twenty-two episodes of acute abdominal symptoms and signs in 19 children and young adults with SB were ascertained over 10 years at 1 institution, for an annual incidence of 0.74%. More patients had a thoracic level lesion (n = 12; 60%) than in the clinic population as a whole (27%; P =.04), but the gender distribution was similar (58% girls), as was the prevalence of ventriculoperitoneal shunts (VPS; 95%). The median age was 13 years (range, 1 year to 26 years). Hospitalization was necessary for 19 (86%) of the 22 episodes. The duration of symptoms before diagnosis was a median of 3 days (range, 1 to 14 days). Most patients (82%) presented with abdominal pain. Fever was present in 27%, shock in 23%, and peritoneal signs in 23%. There were 14 different final diagnoses, 10 (71%) of which were associated with a predisposing factor. Of the 22 episodes, 18 (82%) could be attributed to an underlying factor: (1) neurogenic bladder (9; 41%); (2) neurogenic bowel (3; 14%); (3) VPS (4; 18%); (4) complications from previous surgery (2; 9%). Thirteen patients (59%) underwent a total of 20 surgical procedures of 12 different kinds. Despite awareness of the complexities involved, 3 patients (14%) died: 1 from complications resulting from bladder perforation; 1 from urosepsis and shock; and 1 from peritonitis caused by VPS infection.

CONCLUSION

The differential diagnosis of the acute abdomen in patients with SB is broad, conditions requiring surgery are frequently diagnosed, and the mortality rate is substantial, despite aggressive management.

Bladder neck reconstruction in children

Bladder neck reconstruction in children is a challenging undertaking. Goals must be established for each patient, either continence or dryness. Knowledge of the various types of bladder neck reconstructive procedures and what they are designed to do is important when considering bladder neck reconstruction. A detailed description of urethral lengthening, reimplantation, and other bladder neck reconstructive procedures is presented.

Spontaneous bladder perforation in paraplegia as a late complication of augmentation enterocystoplasty: case report

The management of spinal cord injured (SCI) patients with small capacity, noncompliant bladders has focused on the preservation of renal function and social continence. When conservative management is unsuccessful, surgical intervention may prove beneficial. Augmentation enterocystoplasty is a reliable method of achieving increased bladder capacity while decreasing intravesical filling pressure. Spontaneous bladder rupture is a rare complication of augmentation enterocystoplasty. Because the urine is often colonized with bacteria, bladder rupture may result in chemical and bacterial peritonitis, which is associated with a 25% mortality rate. SCI patients may not present with the classic signs of an acute abdomen. Early diagnosis is critical so that aggressive management may be instituted. The case of late spontaneous perforation of an augmentation enterocystoplasty in a 33-year-old man with T7 complete paraplegia is presented, and the literature discussing the etiology, diagnosis, management, and prevention of augmented bladder perforation is reviewed.

Comparison of bladder rupture pressure after intestinal bladder augmentation (ileocystoplasty) and myomyotomy (autoaugmentation)

OBJECTIVES

To compare the risk of bladder rupture of bladder augmentation using ileocystoplasty versus that of autoaugmentation with myomyotomy in a rat model.

METHODS

Bladder rupture pressure and volume of three groups of female Sprague-Dawley rats were determined by cystometry. The first group of 11 rats had undergone ileocystoplasty using a detubularized 1 -cm segment of ileum. A second group of 9 rats had undergone autoaugmentation with myomyotomy. One month after surgery the animals were studied cystometrically to determine the bladder rupture pressure, then killed. A third group, consisting of 10 nonoperated rats, was studied and served as controls.

RESULTS

Nonoperated, control rat bladders were able to sustain 154 +/- 43 mm Hg pressure and 2.5 +/- 2.0 mL volume prior to bladder rupture. Conventional ileocystoplasty was noted to increase bladder capacity to 4.0 +/- 1.9 mL, but decrease rupture pressure to 111 +/- 49 mm Hg. Myomyotomy resulted in a mean bladder rupture volume of 1.2 +/- 0.4 mL, with a rupture pressure of 101 +/- 13 mm Hg. The rupture pressure after myomyotomy is significantly lower than that of the native bladder (P < 0.001), whereas the rupture volume after myomyotomy is significantly lower than either after the ileocystoplasty or with the native bladder (P < 0.001). Bladder rupture occurred at the augmented ileal bladder dome in 7 of 11 ileocystoplasty animals and at the anastomotic suture line in 4 animals. Bladder rupture occurred at the area of bladder diverticulum in all 9 myomyotomy animals. Among controls, no specific site pattern of bladder rupture was noted.

CONCLUSIONS

Bladder augmentation with myomyotomy increases vulnerability to urinary extravasation, evidenced by a significantly reduced rupture pressure and bladder volume at rupture when compared to the native bladder.

Laplace's law and the risks and prevention of bladder rupture after enterocystoplasty and bladder autoaugmentation

The purpose of this study was to utilize a rat model of bladder augmentation to determine the effect on bladder rupture pressure and volume of bladders augmented using myomyotomy autoaugmentation, intestinal patch ileocystoplasty alone, and a combination of ileocystoplasty and detrusor-myoplasty techniques. Four groups of female rats were studied: 1) sham animals served as controls, 2) ileocystoplasty, 3) autoaugmentation using a myomyotomy technique, and 4) ileocystoplasty reinforced with a rectus muscle flap to envelop the augmented bladder (detrusormyoplasty). One month after surgery bladder rupture pressure and volume were determined by cystometry. Sham control rats manifested bladder rupture at a mean pressure of 154 +/- 43 mmHg and mean volume of 2.5 +/- 2.0 ml. Myomyotomy animals demonstrated a diminished mean rupture pressure and rupture volume (101 +/- 13 mmHg and 1.2 +/- 0.4 ml, respectively) compared to control (both P < 0.05). Ileocystoplasty animals demonstrated bladder rupture at a significantly higher volume of 4.0 +/- 1.9 ml than either myomyotomy or control animals (P < 0.05), although rupture pressure of 111 +/- 49 mmHg did not differ significantly from control values (P = 0.55). The combination of ileocystoplasty and detrusor-myoplasty yielded a statistically significant increase in rupture pressure (262 +/- 108 mmHg) than the other three groups (P < 0.05). Rupture volume in this group of animals did not differ significantly from animals with ileocystoplasty but without detrusormyoplasty (P = 0.46). Bladder autoaugmentation results in a significantly reduced rupture pressure and volume than noted in the native bladder. Although ileocystoplasty significantly increases bladder capacity, the risk of urinary extravasation is also increased with this technique. The combination of ileocystoplasty and detrusor-myoplasty affords not only an increase in bladder capacity, but also significantly increases rupture pressure and thereby decreases the risk of bladder rupture after bladder augmentation.