Delayed bladder rupture after augmentation enterocystoplasty

Management of tuberculous-contracted bladder with bilateral duplex collecting system: a case report with modified robotic urinary tract reconstructive surgery

Tuberculous bladder contracture with a bilateral duplicated collecting system is rare. According to anatomic variation, the surgical treatment strategy is highly individualized. We illustrate our robotic technique of urinary tract reconstruction. A 19-year-old girl with a history of pulmonary tuberculosis (TB) as a young child presented with a complaint of increasing frequency of micturition, nocturia, urgency, and urge incontinence starting at the age of 17. Clinical and imaging examinations demonstrated tuberculous contracted bladder with a bilateral duplex collecting system. The patient underwent a robot-assisted Institute of Urology Peking University (IUPU) orthotopic ileal neobladder reconstruction. This is a modified urinary tract reconstructive method, including resection of the end of the duplex ureters and diseased contracted bladder with preservation of the proximal urethra and bladder neck, ileal harvesting and IUPU strategy to reconstruct an ileal neobladder, uretero-ileal anastomosis and neobladder-bladder neck anastomosis. The patient remained symptom-free without recurrence of TB and had improved renal function during the one-year follow-up after surgery. Thus, our robot-assisted IUPU orthotopic ileal neobladder reconstruction method is an effective approach for this benign case. It can effectively increase bladder capacity, reduce intravesical pressure, and improve symptoms such as urination frequency and urgency.

Neurogenic bladder - concepts and treatment recommendations

Introduction:

Bladder and urinary sphincter malfunctioning that results from some change in the central and/or peripheral nervous system is defined as neurogenic bladder. The urinary tract symptoms that can be related to its filling, emptying, or both have a significant impact on the quality of life of individuals. The present review was based on the document prepared for the public health system in Brazil as a treatment guidelines proposal.

Material and Methods:

Survey questions were structured as per PICO (Population, Intervention, Control, and Outcome). Search strategies were defined and performed in the MEDLINE/Pubmed, Embase, Epistemonikos and Google Scholar databases. The selection of articles followed the evidence hierarchy concept; evidence body was identified, and the quantitative study data were extracted. The quality of evidence and grade of recommendation were qualitatively assessed according to GRADE (Grading of Recommendations, Assessment, Development and Evaluations).

Results:

A total of 2.707 articles were identified, with 49 of them being selected to compose the basis for this review. Neurogenic bladder treatments were classified according to their focus on filling or emptying symptoms and sub- classified in pharmacological and surgical treatments.

Conclusion:

Treatment guidelines are important tools for the public health system to promote the best practice when treating neurogenic bladder patients.

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.

Outcomes of seromuscular bladder augmentation versus standard ileocystoplasty: A single institution experience over 14 years

INTRODUCTION

Ileocystoplasty is the standard technique used for bladder augmentation, and has been used widely for decades. However, it is known to be associated with complications such as stone formation, mucus production, metabolic acidosis, urinary tract infections, intestinal obstruction, and a long-term risk of bladder cancer. Seromuscular bladder augmentation (SMBA) is an alternative to the standard ileocystoplasty, and has been associated with a lower incidence of bladder stones. Few reports have been published on intermediate outcomes of SMBA. Herein, we report long-term outcomes of SMBA from a single institution compared with standard ileocystoplasty.

METHODS

After Institutional Review Board approval, a retrospective chart review of all patients who underwent bladder augmentation at our institution over a 14-year period was performed. The status of patients after SMBA (10 patients) was compared according to age, sex, and diagnosis with patients who underwent traditional ileocystoplasty (30 patients). Parameters such as demographic information, pre- and postoperative bladder capacity as assessed by urodynamic studies, urinary tract infections (UTIs), bladder calculi, incontinence, need for secondary surgical procedures, and spontaneous bladder perforation were compared in the two groups. All the patients were on a clean intermittent catheterization (CIC) regimen.

RESULTS

Over the study period, 10 patients underwent SMBA and 30 patients (according to age, sex, and diagnosis) underwent standard ileocystoplasty; the average age at surgery was 10.3 and 10 years respectively, with a mean follow up of 6.7 years in the SMBA group and 6 years in the ileocystoplasty group. There were no statistically significant differences in the rate of UTIs, urinary incontinence, subsequent surgery, or spontaneous bladder perforation. The mean bladder capacity increased significantly for both groups as assessed by pre- and postoperative urodynamic studies, although the difference in the rate of bladder calculi between the two groups (0 [0%] vs. 8 [27%], p = 0.06) did not reach statistical significance (Table).

CONCLUSIONS

SMBA is safe and efficacious and may result in a lower rate of stone formation than standard ileocystoscopy. SMBA should be considered as a viable alternative to standard ileocystoplasty.

Continent urinary diversion in childhood: complications of alcohol abuse developing in adulthood

PURPOSE

We reviewed the urological sequelae of alcohol abuse in patients following enterocystoplasty in childhood.

MATERIALS AND METHODS

We reviewed our patient registry of 385 enteric bladder augmentations. We evaluated patients providing information regarding social habits. Patients were defined as abusing alcohol if they consumed more than 2 alcoholic beverages daily and were compared to a control group consuming 0 to 2 alcoholic beverages daily.

RESULTS

A total of 203 patients met inclusion criteria. Of the patients 24 (12%) admitted a history of alcohol abuse, of whom 5 (21%) sustained a total of 10 bladder ruptures, all related to alcohol consumption. All 5 patients presented in a delayed fashion, at more than 12 hours to 5 days following rupture. Despite immediate exploration and repair, 3 separate cardiac resuscitations were performed in 2 patients, of whom 1 died. One patient underwent conversion to an ileal conduit for repeated bladder ruptures (4 episodes) and failure to remain sober following 2 rehabilitation treatments. Three patients maintained long-term sobriety (5 to 9 years) after rehabilitation treatments.

CONCLUSIONS

The incidence of alcohol abuse in patients following enterocystoplasty is 12% (24 of 203) and is not different from the reported lifetime risk of 12% to 18% seen in the United States population. Due to the severe consequences of alcohol abuse in patients with enterocystoplasty, we preoperatively instruct all patients that they will have to limit alcohol consumption following the operation and screen via a social history on subsequent followup visits. If a history of alcohol abuse is noted, immediate consultation for rehabilitation is provided.

Clinical and radiological findings following continent urinary diversion with colonic segment in dog

In order to assess clinico-radiological findings of urinary diversion, five adult healthy mongrel dogs of both sexes weighing between 25-40 kg and average age of 1.5 years, underwent continent urinary diversion surgery. In this approach fifteen centimeters of the descending colon with preservation of its mesenteric vessels was resected and this segment longitudinally was opened and flushed with an aqueous solution of povidin iodine 0.1% and the remaining colon re-anastomosed by seromuscular sutures. Then two ends of transected ureters were drawn into the resected colon by mosquito hemostatic forceps and simple interrupted sutures were placed between the ureter and the colonic mucosa for uretero-colonic anastomosis. The uretero-colonic part in a cap form transplanted to partially cystectomized bladder with one layer of cushing pattern suture. All animals survived after the operation. Clinically, all dogs were dull and depressed and passed blood tinged urine for first few postoperative days. There was pollakiuria in all of animals distinctly, but urinary incontinence was not observed. At the first few postoperative days, anorexia, nausea and vomiting were seen in three dogs. In all animals, polydipsia were seen and continued until the end of study. Intravenous urograms showed hydronephrosis and upper urinary tracts dilatation in all animals at 25th day but there were signs of improvement at 45th day distinctly. Unilateral ureteral obstruction was observed in two dogs. In regards to clinico-radiological findings can be concluded that this operation has some distinct sequela that some of them may be seen in radiographic assessments.

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 Bladder Perforations: A Report of 500 Augmentations in Children and Analysis of Risk

PURPOSE

The spontaneous perforation of an augmented bladder is an uncommon but serious complication. To our knowledge our institution has the largest reported series of bladder augmentations. We examined our data to determine the incidence of spontaneous bladder perforation and to delineate associated risk factors.

MATERIALS AND METHODS

We performed a retrospective chart review of 500 bladder augmentation procedures performed during the preceding 25 years with a minimum followup of 2 years.

RESULTS

Spontaneous perforations occurred in 43 patients (8.6%), for a total of 54 events. The calculated risk was 0.0066 perforations per augmentation-year at risk. Approximately a third of the cases had perforated within 2 years of surgery, a third between 2 and 6 years postoperatively, and a third at more than 6 years after augmentation. Patients who underwent augmentation between 1997 and 2003 had a higher rate of perforation within 2 years of surgery than those operated on between 1978 and 1987. Increased risk of perforation was observed with the use of sigmoid colon and bladder neck surgery. A decreased risk was associated with the presence of a continent catheterizable channel.

CONCLUSIONS

We believe that this large and comprehensive series gives valuable insight into this serious complication. The delineation of these potential risk factors serves as a guide for further discussion and investigation.

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.

Risk factors for spontaneous bladder perforation after augmentation cystoplasty

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.

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.

Enterocystoplasty

Despite the problems of augmentation cystoplasty, on balance it has been a much better form of management of the lower urinary tract in patients with bladder neuropathy or high pressure detrusor contractions than the alternatives of rectal diversion, indwelling catheter or external urinary diversion. The metabolic consequences do not seem to interfere with general health in the medium term. The risk of perforation appears to be present with other forms of augmentation cystoplasty or bladder replacement. However, the results are far from perfect and the ideal technique will be one that: removes the need for intraperitoneal surgery and prevents the risk of intestinal adhesions; stops the development of intestinal mucus and stone formation; prevents the metabolic complications and potential bony complications during adolescence; at the same time improves the patient's resistance to UTI; maintains the same degree of long-term, good, low-pressure urine storage and the consequent improvement and stability of the upper urinary tract.

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.

Spontaneous late rupture of orthotopic detubularized ileal neobladders: report of five cases

OBJECTIVES

To report five spontaneous ruptures in 4 patients. Spontaneous late rupture of orthotopic ileal bladder replacements is a rare complication of continent urinary diversion.

METHODS

Four recurrence-free patients aged 36 to 68 years experienced apparently spontaneous rupture of continent orthotopic ileal bladder replacement 3 months to 3 years after curative radical cystectomy and urinary diversion for invasive bladder cancer. Ileal bladder rupture occurred twice in 1 patient with an interval of 9 months.

RESULTS

All 4 patients had had a good result from their diversion procedure and had reported complete day and nighttime continence before the spontaneous rupture. The spontaneous rupture was evidently caused by overdistension of the ileal neobladder in four of five instances. In addition to overdistension, a second factor such as minor blunt abdominal trauma or urethral occlusion was identifiable in two instances. The rupture occurred in the right upper corner of the ileal bladder in four of five instances and led to acute and severe abdominal pain. Cystography was done in three instances, but was diagnostic in only 2 cases. The histologic examination of the excised bladder wall margins revealed nonspecific inflammatory changes in 3 cases. Open surgical drainage and repair was successfully undertaken in all cases.

CONCLUSIONS

The circumstances of the cases described suggest that late spontaneous rupture of an orthotopic ileal bladder replacement is not related to the surgical technique but rather to factors of patient compliance and medical management.

Cyclophosphamide-induced hemorrhagic cystitis in rats that underwent colocystoplasty: experimental study

PURPOSE

Cyclophosphamide and its derivatives induce hemorrhagic cystitis. A substantial number of patients receive bladder augmentation or replacements using bowel. If patients who have undergone colocystoplasty need treatment with cyclophosphamide before or after the operation, does hemorrhagic cystitis develop? We evaluated the histological changes produced in the colon wall and bladder related to cyclophosphamide and its derivatives in rats that underwent colocystoplasty.

MATERIALS AND METHODS

Sprague-Dawley rats of each sex were grouped according to whether they received a single 200 mg./kg. dose of cyclophosphamide, underwent colocystoplasty, underwent each technique or served as controls. The technique of colocystoplasty was the same in all groups. Results were analyzed according to previously reported criteria, by the gross appearance of the bladder and colon segment used for colocystoplasty, and by histological changes.

RESULTS

Two weeks after surgery colocystoplasty had not resulted in secondary changes in the implanted colon segment or original bladder, while there were only nonspecific changes of an inflammatory type in the anastomotic area. After cyclophosphamide administration the animals lost considerable weight and in the bladder area we observed hemorrhagic cystitis that was greater in males than in females, and greater in isolated bladder than when the bladder was sutured to the colon segment. In the colon there was no inflammation or hemorrhage damage of the hemorrhagic cystitis type in the bladder. A total of 12 days after colocystoplasty there were no secondary histological changes except in the anastomotic area. A single 200 mg./kg. dose of cyclophosphamide caused substantial weight loss and hemorrhagic cystitis. Cystitis was quantitatively greater in males than in females and greater in isolated bladder than in bladder anastomosed to the colon.

CONCLUSIONS

Administering a single dose of cyclophosphamide did not result in lesions in the colon segment used for colocystoplasty analogous to those of the bladder, such as hemorrhagic cystitis.

A new, unique and simple method for ureteral implantation in kidney recipients with small, defunctionalized bladders

BACKGROUND

Major, almost insurmountable, deterrents exist to the use of the small capacity, defunctionalized, nonneurogenic urinary bladder in renal transplantation, namely, the technical difficulty in performing a satisfactory ureteral implantation with conventional methods and the potential secondary problems with high grade ureteral reflux and obstruction. Alternatives are less than ideal and include transplantation into a bowel-augmented urinary bladder with intermittent self-catheterization, ileal conduit urinary diversion, or avoidance of transplantation and relegating the patient to life-long dialysis.

METHODS

Eight consecutive patients (ages 13 months to 29 years) with small, defunctionalized urinary bladders underwent a new method of intravesical implantation of the transplant ureter. The mean capacity of these bladders was 18.5+/-13.1 ml (range 6 to 45 ml), with the bladders defunctionalized for a mean 81.6+/-24.3% of the patients' total lifetime. The technique involved placement of the transplant ureter into a shallow, mucosa-denuded, rectangular trough extending from a superiorly placed ureteral hiatus distally to the trigone. We hypothesized that the mucosal margins on the two lateral aspects of the rectangular trough would grow over the anterior surface of the ureter until they met the advancing mucosal edges from the contralateral side to form a natural neosubmucosal tunnel.

RESULTS

Posttransplantation cystoscopic examination demonstrated bladder mucosal regeneration and growth over the ureter, confirming the spontaneous development of a good length neosubmucosal tunnel. All patients demonstrated no evidence of ureteral reflux or ureteral obstruction, whereas an immediate prior cohort of four consecutive patients with bladder capacities < or =30 ml showed that three of four had ureteral reflux (P=0.02) and four of four developed hydronephrosis (P=0.002). All urinary bladders in the present cohort enlarged to expected normal or nearnormal capacities. Serum creatinines were stable throughout the entire follow-up period, with the exception of one patient who had rejection episodes. Two patients had urinary tract infections posttransplantation, but there were no episodes of acute pyelonephritis.

CONCLUSIONS

This novel technique for ureteral implantation successfully capitalizes on the regenerative potential of the bladder mucosa, resulting in a physiological, anatomically natural, and very effective neosubmucosal tunnel. It appears to guarantee success against both ureteral reflux and obstruction, no matter how small the urinary bladder, and offers no hindrance to enlarging the bladder to near normal capacity posttransplantation. The implantation technique is simple and safe, and its use should eliminate the reluctance to use these bladders. Moreover, this procedure offers a major incentive for the successful rehabilitation of small, defunctionalized, nonneurogenic bladders after kidney transplantation.

Clinical and urodynamic evaluation after ureterocystoplasty with different amounts of tissue

PURPOSE

Ureter is one of the best tissues for bladder augmentation. The amount of ureteral segment available is extremely variable among patients. We compared results in patients who underwent ureterocystoplasty with 2 ureters, 1 complete ureter or a distal segment only after transureteroureterostomy.

MATERIALS AND METHODS

During a 6-year period we performed 32 ureterocystoplasties at 2 pediatric centers in Argentina (16) and Chile (16). Median patient age at surgery was 9 years (range 4 months to 20 years). Clinical presentation included urinary infection, hydronephrosis, incontinence and undiversion. The diagnosis was neurogenic bladder in 20 cases, infravesical obstruction in 7, massive reflux in 3 and ureterocele in 2. All patients had poor bladder compliance and vesicoureteral reflux. We used different options to augment the bladder, including 2 ureters in 5 patients, bilateral nephrectomy in 3, a complete duplex system in 1 and a bilateral partial ureter in 1 (group 1); a complete ureter in 14 (group 2), and a distal segment of ureter with transureteroureterostomy in 13 (group 3). When transureteroureterostomy was performed, a suprapubic tube remained indwelling for 2 weeks and a Double-J stent was placed for 1 month. Median followup was 16 months (range 4 months to 6 years). Clinical and radiological evaluations, including ultrasound, cystography, urodynamics, renal scan and renal function measurement, were done 4 months postoperatively and twice yearly thereafter as needed.

RESULTS

We noted no significant difference in bladder capacity when 1 or 2 ureters were used. Median increase in bladder capacity in groups 1 and 2 was 375% (range 80 to 800). All patients who received a complete segment of ureter had clinical improvement, decreased hydronephrosis and resolution of reflux with improved bladder compliance. When a partial segment of ureter was used median capacity increased 230% (range 40 to 400) with clinical improvement in 12 patients (92.3%). Compliance improved, which led to longer intervals between clean intermittent catheterizations. No patient has needed repeat augmentation to date.

CONCLUSIONS

There is a difference in median increased bladder capacity when a segment of distal ureter is used to augment the bladder versus 1 or 2 whole ureters. However, the use of distal ureter still represents a safe alternative for augmenting the bladder and simultaneously resolving massive reflux. Ureterocystoplasty is an excellent choice for increasing bladder capacity and improving bladder compliance despite the different amounts of tissue available.

Clinical and urodynamic evaluation after ureterocystoplasty with different amounts of tissue

PURPOSE

Ureter is one of the best tissues for bladder augmentation. The amount of ureteral segment available is extremely variable among patients. We compared results in patients who underwent ureterocystoplasty with 2 ureters, 1 complete ureter or a distal segment only after transureteroureterostomy.

MATERIALS AND METHODS

During a 6-year period we performed 32 ureterocystoplasties at 2 pediatric centers in Argentina (16) and Chile (16). Median patient age at surgery was 9 years (range 4 months to 20 years). Clinical presentation included urinary infection, hydronephrosis, incontinence and undiversion. The diagnosis was neurogenic bladder in 20 cases, infravesical obstruction in 7, massive reflux in 3 and ureterocele in 2. All patients had poor bladder compliance and vesicoureteral reflux. We used different options to augment the bladder, including 2 ureters in 5 patients, bilateral nephrectomy in 3, a complete duplex system in 1 and a bilateral partial ureter in 1 (group 1); a complete ureter in 14 (group 2), and a distal segment of ureter with transureteroureterostomy in 13 (group 3). When transureteroureterostomy was performed, a suprapubic tube remained indwelling for 2 weeks and a Double-J stent was placed for 1 month. Median followup was 16 months (range 4 months to 6 years). Clinical and radiological evaluations, including ultrasound, cystography, urodynamics, renal scan and renal function measurement, were done 4 months postoperatively and twice yearly thereafter as needed.

RESULTS

We noted no significant difference in bladder capacity when 1 or 2 ureters were used. Median increase in bladder capacity in groups 1 and 2 was 375% (range 80 to 800). All patients who received a complete segment of ureter had clinical improvement, decreased hydronephrosis and resolution of reflux with improved bladder compliance. When a partial segment of ureter was used median capacity increased 230% (range 40 to 400) with clinical improvement in 12 patients (92.3%). Compliance improved, which led to longer intervals between clean intermittent catheterizations. No patient has needed repeat augmentation to date.

CONCLUSIONS

There is a difference in median increased bladder capacity when a segment of distal ureter is used to augment the bladder versus 1 or 2 whole ureters. However, the use of distal ureter still represents a safe alternative for augmenting the bladder and simultaneously resolving massive reflux. Ureterocystoplasty is an excellent choice for increasing bladder capacity and improving bladder compliance despite the different amounts of tissue available.

Bladder autoaugmentation in myelodysplastic children

OBJECTIVE

To present the long-term results of bladder autoaugmentation in myelodysplastic children with low compliance neurogenic bladders who failed attempts at medical management, including clean intermittent catheterization (CIC) and pharmacological bladder relaxation.

PATIENTS AND METHODS

Twenty-one patients with a neurogenic bladder after myelomeningocele operations (mean age 9.5 years, range 3-16) underwent autoaugmentation; 12 children were paraplegic and hydrocephalic, and were treated by insertion of a ventriculoperitoneal valve. All patients had low-compliance neurogenic bladders confirmed urodynamically. Ten patients had vesico-ureteric reflux (VUR) and eight had dilated upper urinary tracts with no reflux. All patients had been treated pre-operatively using CIC and anticholinergic agents, with no success.

RESULTS

Of 21 children treated surgically, 17 were assessed urodynamically and examined to determine the condition of the upper and lower urinary tract. The follow-up ranged from 3 months to 8 years (mean 6 years). In 13 patients the bladder capacity increased by approximately 60 mL and in 14 the intravesical pressure decreased by approximately 65 cmH2O. Fourteen children were continent using CIC (from 3- to 4-hourly); in the six patients with VUR the reflux resolved in two, decreased in two and remained unchanged in two. Of eight patients with dilated upper tracts but no reflux, seven improved. There was no improvement in bladder capacity in four patients and no reduction in intravesical pressure in three. Two patients underwent enterocystoplasty (one ileocystoplasty and one colocystoplasty) with good results. Two children needed anticholinergic agents after autoaugmentation.

CONCLUSIONS

Autoaugmentation effectively reduces high intravesical pressure and provides a sufficient increase in bladder capacity with a concomitant improvement in urodynamic values. The present method allows the extent of the surgical procedure to be limited to the extraperitoneal space and thus maintains all of other options. Bladder autoaugmentation is a reasonable alternative to enterocystoplasty in selected patients.

Historical perspective of the use of bowel in urology

The use of bowel has been used in urinary tract reconstruction for more than a century. In the past 20 years, however, indications and methods for bowel utilization have multiplied enormously. This article outlines some of these exciting developments.

Early experience with the use of gastric segment in lower urinary tract reconstruction in adult patient population

OBJECTIVES

To review our experience with the potential use of stomach as a substitute to bowel in lower urinary tract reconstruction in adults.

METHODS

Twenty-two adult patients underwent lower urinary tract reconstruction using stomach. Fourteen patients had augmentation cystoplasty, and in 8 patients a continent reservoir was constructed; mean follow-up was 9.8 months. In 6 patients, gastric tube was constructed and used as catheterizable stoma.

RESULTS

Renal functions remained stable or improved in all patients. Two patients developed hypochloremic alkalosis. There was significant decrease in urinary pH. All patients were completely continent, with no problems in mucus production. There was no mortality or significant morbidity.

CONCLUSIONS

Stomach offers a good alternative to ileum or colon for bladder reconstruction. Stomach has various unique advantages, such as less mucus production, acidic milieu in the urine, and protection against hyperchloremic acidosis.

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.

Enzymatic treatment of ileal segments used for urinary tract reconstruction

Urinary tract reconstruction by using various gastrointestinal segments is not devoid of complications which may hamper to a great extent the beneficial effects of the procedure. Intestinal mucosa is the primary site responsible for these complications and any procedure aiming at the prevention of untoward effects of intestinal interposition should abolish the absorptive and secretory functions of the mucosa. Augmentation cystoplasties by ileal segments were performed on 24 male albino Wistar rats. In 12 animals de-epithelialization of the mucosa with an enzymatic cock-tail, consisting of type I and type V collagenases and trypsin, preceded the cystoplasty. The functional capacity of the epithelium was determined by a simplified glucose absorption test in the third postoperative week. Morphological examination before the absorption test did not reveal any fibrosis or shrinkage of the ileal segments. Complete elimination of the absorptive capability in enzyme treated mucosa was found during the glucose absorption test, while a rapid and highly effective absorption was observed in the control group (p < 0.05). As a result, it seems possible to obtain intestinal segments covered with a mucosa which acquired similar characteristics to uro-epithelium, therefore closely resembling the original urinary tissues.

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.

Laparoscopic laser-assisted bladder autoaugmentation

OBJECTIVES

The purpose of this study is to examine the feasibility of performing a laparoscopic bladder autoaugmentation and to assess the urodynamic characteristics of an autoaugmented bladder.

METHODS

Laparoscopic bladder autoaugmentation was performed in 9 female canines (20 to 30 kg). Following laparoscopic access to the peritoneal cavity, a midline bladder seromyotomy was performed using the potassium titanyl phosphate 532 nm laser. This produced a large bladder diverticulum. Changes in bladder volume and compliance were quantified over a 3-month period of follow-up.

RESULTS

Urodynamic evaluation demonstrated an increase in bladder capacity 6 weeks postoperatively in 8 of 9 dogs, with an average volume increase of 45%. Bladder compliance improved in 7 of 9 dogs with an average increase in compliance of 67%. Three months postoperatively, bladder capacity remained increased in 5 of 9 dogs, with an average increase in volume of only 5.3%. An improvement in compliance was sustained in 5 of 9 animals with an average increase of 13.9%. Laparoscopic exploration revealed grossly normal bladders with adhesions of omentum to the seromyotomy site in all canines and the anterior abdominal wall in 2 of 9 canines. Histologically, the seromyotomy site was devoid of muscle with an intact urothelium and a proliferation of loose connective tissue.

CONCLUSIONS

The technique of laparoscopic bladder autoaugmentation can be performed easily in the canine model. Although results at 6 weeks show significant improvement, the longer term, 3-month results were not statistically significant. This technique has the potential to offer a minimally invasive correction for patients with low-capacity, high-pressure bladders that have failed pharmacologic treatment.

Nonsecretory sigmoid cystoplasty: experimental and clinical results

We report the results of experimental and clinical studies in which a de-epithelialized segment of sigmoid colon was used to cover the bladder dome where the mucosa was exposed (auto-augmentation) to increase bladder capacity. Experimentally, the technique was performed in 10 healthy female mongrel dogs and the intestinal segments established continuity perfectly over the exposed bladder mucosa. Histology 30 and 60 days postoperatively showed transitional epithelium lining the intestinal segment at the site of implantation. One island of intestinal mucosa was found. The technique was performed in 10 patients, including 9 with neurogenic bladder secondary to myelomeningocele and 1 with posterior urethral valves. Bladder capacity improved in all cases and intravesical pressure was reduced. Followup ranged from 6 to 43 months. The technique is proposed as a valuable alternative to traditional full-thickness patches of the digestive tract and auto-augmentation.

Continent urinary diversion using the Mitrofanoff principle

OBJECTIVE

To review the clinical and symptomatic outcome of patients undergoing cystectomy and continent urinary diversion using the Mitrofanoff principle.

PATIENTS AND METHODS

There were seven men and five women (median age 62 +/- 21 years: range 21-79). The underlying diagnoses were: bladder carcinoma (8), neuropathic bladder disease (1), bladder exstrophy (1), tuberculosis (1) and interstitial cystitis (1). An ileo-caecal segment was used for construction of the reservoir. The appendix was used as a catheterizable conduit in 11 patients and a narrowed ileal tube in one patient. Symptomatic outcome was assessed by using a modified Visick grading. The median follow-up period was 15 +/- 10 months (range 6-39).

RESULTS

The median hospital stay was 22 days. There were no post-operative deaths, but major post-operative complications developed in three patients and included intra-abdominal lymphocele (1), intra-abdominal abscess formation (1) and prolonged ileus (1). In the late post-operative period (> 30 days), four patients developed stenosis of the mucocutaneous junction and required dilatation. The overall symptomatic outcome was satisfactory in 11 patients. There were no deaths in the peri-operative period and none of the patients has since required revision. Urinary continence was achieved in all 12 patients during the day. One patient reported minimal, occasional leakage at nights. The median catheterization interval was 4 +/- 1 hours during the day (range 3-5) and 7 +/- 1 hours at night (range 6-9).

CONCLUSION

Our experience with the Mitrofanoff procedure has been limited to a small number of patients. Despite this, the clinical outcome of the procedure was satisfactory. The procedure potentially offers an effective continence mechanism with acceptable post-operative morbidity.

Conservative management of suspected bladder rupture after augmentation enterocystoplasty

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.

Indications for bladder augmentation in the exstrophy-epispadias complex

OBJECTIVE

To determine whether bladder augmentation has a role in avoiding urinary diversion in patients with exstrophy-epispadias complex (EEC), whether it can improve the lifestyle in patients who have previously undergone diversion or improve the result of any single surgical step in the staged functional reconstruction of the bladder in these patients.

PATIENTS AND METHODS

From 1970 to 1991, 85 patients were treated for EEC. Between 1981 and 1991, 12 bladder augmentations were performed in 11 patients (seven girls and four boys) with bladder exstrophy, male epispadias (one case) and cloacal exstrophy (one case).

RESULTS

No significant early surgical complications were reported. Follow-up ranged from 18 months to 11 years. Late complications included bowel obstruction in one patient, a partial left ureteric stenosis at the level of the anastomosis with the gastric patch wall in one patient and bladder lithiasis in five patients (sigmoidocystoplasty in one and ileocystoplasties in four). No metabolic problems, no bladder perforations or malignancies were observed. The results on continence were good and, with the one exception reported, the condition of the upper urinary tract following surgery was satisfactory in all patients.

CONCLUSION

Augmentation cystoplasty is of use in the treatment of patients with bladder exstrophy when staged functional reconstruction is unsuccessful. This technique greatly reduces the indications for urinary diversion and can be used in the surgical treatment of EEC. The only disadvantage is that clean intermittent catheterization must be performed, sometimes only temporarily, but patient acceptance is usually high.

Fatal perforation of augmentation cystoplasty in an adult

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.

Delayed spontaneous rupture of an ileocolonic neobladder

A case of delayed spontaneous rupture of an ileocolonic neobladder and subsequent peritonitis 4 years after the initial operation is reported. Many of the features of this case are similar to those noted in recent reports of spontaneous rupture of an augmented bladder and it is postulated that the etiology is the same.

Continent cutaneous diversions in children: experience with the Mitrofanoff procedure

Continent cutaneous diversions with a urinary reservoir emptied by clean intermittent self-catheterisation (CISC) using a non-refluxing conduit--the Mitrofanoff principle--were carried out in 10 children. Their age range was 3.9 to 17.1 years (average 12.2). The underlying diagnoses were ectopia vesicae (7), myelodysplasia (2) and a cervical cord injury secondary to birth trauma (1). The indications were incontinence secondary to poor bladder neck resistance in 8 children and an inaccessible urethral orifice in 2. The catheterising conduits used were the appendix in 9 and a vascularised gastric tube in 1. Eight children are bone-dry with CISC. Another child needed a reoperation following dehiscence of her bladder neck closure. The other child has an intact bladder neck and urethra and occasionally leaks overnight. Mitrofanoff diversions are a reliable means of continence with CISC. This means of urinary diversion can be permanent or temporary in children who cannot or will not catheterise urethrally. Elective appendicectomy in children with potential urinary incontinence or complicated urogenital anomalies is not recommended.

Perforation of the augmented bladder

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.

Perforation of the gastric segment of an augmented bladder secondary to peptic ulcer disease

Gastrocystoplasty consists of bladder augmentation using part of the gastric body. We describe a child in whom peptic ulcer disease developed in the gastric portion of the bladder, with subsequent perforation of the ulcer. Chronic renal failure, hypercalcemia and oliguria are potential ulcerogenic conditions commonly present in patients with gastrocystoplasty. Perforation of the ulcer is a potentially fatal complication. Periodic cystoscopy and prophylactic treatment with hydrogen blockers and alkalization of the urine should be considered in patients with those risk factors.