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Veeratterapillay R, Thorpe AC, Harding C. Augmentation cystoplasty: Contemporary indications, techniques and complications. Indian J Urol 2013; 29:322-7. [PMID: 24235795 PMCID: PMC3822349 DOI: 10.4103/0970-1591.120114] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Augmentation cystoplasty (AC) has traditionally been used in the treatment of the low capacity, poorly compliant or refractory overactive bladder (OAB). The use of intravesical botulinum toxin and sacral neuromodulation in detrusor overactivity has reduced the number of AC performed for this indication. However, AC remains important in the pediatric and renal transplant setting and still remains a viable option for refractory OAB. Advances in surgical technique have seen the development of both laparoscopic and robotic augmentation cystoplasty. A variety of intestinal segments can be used although ileocystoplasty remains the most common performed procedure. Early complications include thromboembolism and mortality, whereas long-term problems include metabolic disturbance, bacteriuria, urinary tract stones, incontinence, perforation, the need for intermittent self-catheterization and carcinoma. This article examines the contemporary indications, published results and possible future directions for augmentation cystoplasty.
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Jacobsen NEB. Overcoming the Stigma of Complications of Continent Cutaneous Diversion. Bladder Cancer 2009. [DOI: 10.1007/978-1-59745-417-9_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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3
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Ascaso Til H, Segarra Tomás J, De la Torre Holguera P, Monllau Font V, Palou Redorta J, Villavicencio Mavrich H. [Recurrent neobladder rupture: conservative management]. Actas Urol Esp 2007; 31:279-84. [PMID: 17658158 DOI: 10.1016/s0210-4806(07)73635-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- H Ascaso Til
- Servicio de Urología, Fundació Puigvert, Barcelona.
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Martínez del Castillo ML, Miguélez Lago C, García Mérida M, Galiano Duro E, García Soldevila N, Valls Moreno E. [Spontaneous urinary bladder perforation after pediatric cystoplasty]. Actas Urol Esp 2005; 29:869-78. [PMID: 16353773 DOI: 10.1016/s0210-4806(05)73358-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- M L Martínez del Castillo
- Cirugia Pediátrica, Hospital Materno-Infantil, del Hospital Regional Universitario Carlos Haya, Málaga
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Singh S, Choong S. Rupture and perforation of urinary reservoirs made from bowel. World J Urol 2004; 22:222-6. [PMID: 15309492 DOI: 10.1007/s00345-004-0439-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2004] [Accepted: 05/28/2004] [Indexed: 10/26/2022] Open
Abstract
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.
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Affiliation(s)
- Sadmeet Singh
- The Institute of Urology and Nephrology, University College London, 48 Riding House Street, London W1W 7EY, UK
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DeFoor W, Tackett L, Minevich E, Wacksman J, Sheldon C. Risk factors for spontaneous bladder perforation after augmentation cystoplasty. Urology 2003; 62:737-41. [PMID: 14550454 DOI: 10.1016/s0090-4295(03)00678-2] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To present our experience with the use of stomach, ileum, and colon for augmentation cystoplasty to examine the incidence of, and risk factors for, spontaneous perforation. Spontaneous bladder perforation is a potentially life-threatening complication of augmentation cystoplasty with a reported incidence of up to 13%. METHODS A retrospective review of medical records from 1988 to 2001 identified 107 children (57 males and 50 females) who underwent augmentation cystoplasty at our institution. The etiology for bladder dysfunction included myelomeningocele, VATER (vertebral defects, imperforate anus, tracheoesophageal fistula, radial and renal dysplasia) syndrome, bladder and cloacal exstrophy, posterior urethral valves, and pelvic malignancy. Thirteen patients also had end-stage renal disease. RESULTS The median follow-up was 7.4 years. Gastrocystoplasty was performed in 50 children (47%), ileocystoplasty in 37 (35%), colocystoplasty in 18 (17%), and gastric-ileal composite neobladder in 2 (2%). Augmentation cystoplasty procedures were performed using a standard technique that included a two-layer anastomosis. Additional procedures at the time of reconstruction included Mitrofanoff neourethra in 66 patients (62%) and bladder neck repair in 44 (41%). Postoperatively, most patients started a strict incremental catheterization regimen. The overall incidence of bladder perforation was 5%, with one traumatic (1%) and four spontaneous (4%) perforations. All patients recovered uneventfully after exploratory laparotomy. CONCLUSIONS We believe that the relatively low incidence of spontaneous bladder perforation encountered in this series may be explained by the large number of patients with gastrocystoplasty, as well as our strict adherence to a postoperative incremental catheterization program.
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Affiliation(s)
- William DeFoor
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA
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INTRAVITAL MICROSCOPIC ASSESSMENT OF PRESSURE INDUCED MICROCIRCULATORY CHANGES AFTER ENTEROCYSTOPLASTY IN RATS. J Urol 2001. [DOI: 10.1097/00005392-200104000-00069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bajory Z, Szabó A, Pajor LÁ, Tiszlavicz LÁ, Boros M. INTRAVITAL MICROSCOPIC ASSESSMENT OF PRESSURE INDUCED MICROCIRCULATORY CHANGES AFTER ENTEROCYSTOPLASTY IN RATS. J Urol 2001. [DOI: 10.1016/s0022-5347(05)66513-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- ZoltÁn Bajory
- From the Department of Urology and Institutes of Surgical Research and Pathology, University of Szeged, Szent-Györgyi Albert Medical and Pharmaceutical Center, Szeged, Hungary
| | - Andrea Szabó
- From the Department of Urology and Institutes of Surgical Research and Pathology, University of Szeged, Szent-Györgyi Albert Medical and Pharmaceutical Center, Szeged, Hungary
| | - LÁszlÓ Pajor
- From the Department of Urology and Institutes of Surgical Research and Pathology, University of Szeged, Szent-Györgyi Albert Medical and Pharmaceutical Center, Szeged, Hungary
| | - LÁszlÓ Tiszlavicz
- From the Department of Urology and Institutes of Surgical Research and Pathology, University of Szeged, Szent-Györgyi Albert Medical and Pharmaceutical Center, Szeged, Hungary
| | - MihÁly Boros
- From the Department of Urology and Institutes of Surgical Research and Pathology, University of Szeged, Szent-Györgyi Albert Medical and Pharmaceutical Center, Szeged, Hungary
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Barroso U, Jednak R, Fleming P, Barthold JS, González R. Bladder calculi in children who perform clean intermittent catheterization. BJU Int 2000; 85:879-84. [PMID: 10792170 DOI: 10.1046/j.1464-410x.2000.00625.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the role of clean intermittent catheterization (CIC) as a possible predisposing risk factor for bladder calculi, assessing risk factors in patients with and without bladder augmentation, and to evaluate management options for bladder calculi in these patients. PATIENTS AND METHODS The records of 403 patients who were using a regimen of CIC between January 1981 and March 1998 were reviewed to identify those forming bladder calculi; stones were diagnosed in 28 patients. The patients were categorized as: group 1, patients with no bladder augmentation who catheterized urethrally (227, group 1a) or via a Mitrofanoff conduit (18, group 1b); group 2, patients with augmented bladders who catheterized urethrally (100, group 2a) or via a Mitrofanoff conduit (58, group 2b). The incidence of bladder calculi in each group was determined and compared statistically where applicable. The success of the treatment options for stone management was reviewed. RESULTS Bladder calculi developed in 5% of patients in group 1a, 8% in group 2a, 11% in group 1b, and 10% in group 2b; the incidence of calculi was not significantly different among the groups. Of these patients, 18 (64%) were asymptomatic at the time of diagnosis and significant bacteriuria was found in 23 (88%). Difficulty in catheterizing either the Mitrofanoff conduit or the native urethra was reported in 14 (50%) of these patients. Calculi were more often solitary (71%) and typically composed of struvite or apatite. Calculi were managed by open cystolithotomy in 15 patients (54%) and endoscopically in 13 (46%). Stones recurred in nine patients (32%) after treatment, comprising four of six patients treated endoscopically with electrohydraulic lithotripsy and in five of 15 after open cystolithotomy. The mean interval to recurrence was 22.8 months. CONCLUSION These results suggest that patients on a regimen of CIC are at risk of developing bladder calculi but the incidence of calculi is not influenced by bladder augmentation. The presence of a Mitrofanoff conduit was associated with a slightly increased incidence of calculus formation. Open cystolithotomy was associated with a lower stone recurrence rate but there were too few patients to draw definitive conclusions.
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Affiliation(s)
- U Barroso
- Department of Paediatric Urology, Children's Hospital of Michigan and Wayne State University School of Medicine, Detroit, Michigan, USA
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Månsson W, Bakke A, Bergman B, Brekkan E, Jonsson O, Kihl B, Nurmi M, Pedersen J, Schultz A, Sørensen B, Urnes T, Wolf H. Perforation of continent urinary reservoirs. Scandinavian experience. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 1997; 31:529-32. [PMID: 9458509 DOI: 10.3109/00365599709030656] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In a questionnaire survey of urological departments in Sweden, Denmark, Finland and Norway, 20 episodes of perforation of continent urinary pouches were found to have occurred in 18 patients, representing an incidence of 1.5%. This complication occurred with ileal as well as colonic segments, without predilection. In one case there was perforation of an appendiceal outlet. Noticeable findings were (a) a long delay (median 10h) to treatment and (b) that investigational procedures such as enterocystography and enterocystoscopy were not commonly employed. Treatment of this potentially lethal complication was by oversewing the perforation, and there were no subsequent major complications. This complication should be strongly suspected if a patient with continent urinary reconstruction presents with acute abdominal pain.
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Affiliation(s)
- W Månsson
- Department of Urology, University Hospital, Lund Sweden
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Rivas DA, Chancellor MB, Huang B, Epple A, Figueroa TE. Comparison of bladder rupture pressure after intestinal bladder augmentation (ileocystoplasty) and myomyotomy (autoaugmentation). Urology 1996; 48:40-6. [PMID: 8693650 DOI: 10.1016/s0090-4295(96)00096-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- D A Rivas
- Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Chancellor MB, Rivas DA, Bourgeois IM. Laplace's law and the risks and prevention of bladder rupture after enterocystoplasty and bladder autoaugmentation. Neurourol Urodyn 1996; 15:223-33. [PMID: 8732989 DOI: 10.1002/(sici)1520-6777(1996)15:3<223::aid-nau7>3.0.co;2-h] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- M B Chancellor
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Slaton JW, Kropp KA. Conservative management of suspected bladder rupture after augmentation enterocystoplasty. J Urol 1994; 152:713-5. [PMID: 8022002 DOI: 10.1016/s0022-5347(17)32688-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Bladder rupture after augmentation enterocystoplasty is a potentially life-threatening condition. We reviewed our experience with 13 patients who presented to our institution with 15 episodes of sudden onset of abdominal pain and rebound tenderness, and were diagnosed on clinical grounds to have peritonitis secondary to a suspected bladder augmentation rupture. (Three patients had had similar episodes treated previously elsewhere with abdominal exploration and repair of an augmentation rupture.) These episodes were initially managed with hospitalization, bladder drainage with an indwelling catheter, intravenous antibiotics and serial abdominal examinations. Cystogram and/or computerized tomography was diagnostic in only 3 of 7 cases in which it was performed. In 13 of 15 instances signs and symptoms of peritonitis quickly resolved, and intermittent catheterization was resumed after a mean of 12 days. In the remaining 2 patients delayed surgical repair of a bladder rupture was done in 1, and exploration and repair of an incarcerated internal hernia were done in 1. Although prompt abdominal exploration is the gold standard for suspected bladder augmentation rupture, treatment of peritonitis as bladder rupture in patients with a bladder augmentation by nonoperative techniques was successful in 87% of episodes.
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Affiliation(s)
- J W Slaton
- Department of Urology, Medical College of Ohio, Toledo 43699
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Couillard DR, Vapnek JM, Rentzepis MJ, Stone AR. Fatal perforation of augmentation cystoplasty in an adult. Urology 1993; 42:585-8. [PMID: 8236605 DOI: 10.1016/0090-4295(93)90283-g] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This is a case report of a fatal spontaneous perforation of an augmentation enterocystoplasty in a twenty-nine-year-old T12 paraplegic, thirteen months post augmentation and placement of artificial urinary sphincter. A review of the literature involving 41 episodes in 31 patients is provided with a discussion concerning presentation, etiology, and management.
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Affiliation(s)
- D R Couillard
- Department of Urology, University of California, Davis, Sacramento
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Selzman AA, Elder JS, Mapstone TB. UROLOGIC CONSEQUENCES OF MYELODYSPLASIA AND OTHER CONGENITAL ABNORMALITIES OF THE SPINAL CORD. Urol Clin North Am 1993. [DOI: 10.1016/s0094-0143(21)00510-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Gastrocystoplasty was performed in 29 female and 14 male patients 1 to 23 years old (average age 11 years). Urodynamic studies were completed in 20 patients preoperatively and within 6 months postoperatively. When postoperative studies were compared with the preoperative evaluation, it was noted that overall capacity increased an average of 220% (range 20 to 750%). Compliance also improved dramatically postoperatively. Bladder pressures increased from a mean volume of 34% of capacity preoperatively to 73% of the post-augment capacity. The average maximum filling pressure decreased by 32%, from 57 to 39 cm. water. Uninhibited contractions resolved completely in 6 of 10 patients who had them preoperatively. No one had uninhibited contractions postoperatively. Cyclical contractions of the stomach segment not exceeding 50 cm. water developed in 6 patients. The gastric patch seems to be an adequate source for improving the dynamics of a poorly functioning detrusor muscle in most patients. When a diamond-shaped patch of stomach is harvested and added to the bladder a spherical configuration is created, enhancing the storage properties. This result is in sharp contrast to other bowel segments, which must be detubularized to produce a suitable reservoir. The long-term effects of gastric augmentation remain to be determined.
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Affiliation(s)
- A Atala
- Division of Urology, Children's Hospital, Boston, Massachusetts
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Bauer SB, Hendren WH, Kozakewich H, Maloney S, Colodny AH, Mandell J, Retik AB. Perforation of the augmented bladder. J Urol 1992; 148:699-703. [PMID: 1640550 DOI: 10.1016/s0022-5347(17)36698-3] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In 12 of 264 children treated with enterocystoplasty 15 spontaneous perforations occurred. Of the 12 children 9 had myelodysplasia. All segments of the gastrointestinal tract were used for the augmentation and most were detubularized. Surgery to increase bladder outlet resistance was done in 8 cases. At the time of each perforation 9 children had sterile cultures, however, 3 died of overwhelming sepsis. Presenting signs included abdominal pain in 8 cases, septic shock in 4 cases and shoulder pain in 4 older myelodysplastic children with diaphragmatic irritation from escaping urine. Cystography demonstrated a leak in 10 of 11 cases. Urodynamic studies revealed good compliance with low maximum filling pressure in 8 of 10 children. Hyperreflexia was noted in only 5 cases and outlet resistance greater than 85 cm. water was demonstrated in 5. Histological analysis showed changes in the bowel wall consistent with ischemia but suture granulomas were present in areas adjacent to the perforation site or thinned areas in biopsy or autopsy specimens. In addition to the theory that overdistention may cause enterocystoplasty perforation, current detubularization techniques may produce areas of relative ischemia, which become accentuated when the augmented bladder is distended beyond a reasonable volume.
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Affiliation(s)
- S B Bauer
- Department of Surgery, Children's Hospital, Boston, Massachusetts
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