Reconstruction of the urinary tract by cecal and ileocecal cystoplasty: review of a 15-year experience

Augmentation cystoplasty in the patient with neurogenic bladder

PURPOSE

To review the indications and techniques of augmentation cystoplasty (AC) in patients with neurogenic bladder (NGB) while also examining the long-term outcomes, complications, and follow-up surgeries.

METHODS

PubMed/MEDLINE, Cochrane Library, and Embase databases were searched for articles related to AC and NGB.

RESULTS

AC is indicated for an overactive or poorly compliant bladder refractory to conservative therapies, such as anticholinergic medications and bladder botulinum toxin injections. A variety of surgical techniques using gastrointestinal segments, alternative tissues, and synthetic materials have been described, though bowel remains the most durable. Ileocystoplasty is the most common type of AC, which uses a detubularized patch of ileum that is anastomosed to a bivalved bladder. Some patients undergo concomitant surgeries at the time of AC, such as catheterizable channel creation to aid with clean intermittent catheterization, ureteral reimplantation to treat vesicoureteral reflux, and bladder outlet procedure to treat incontinence. Following AC, the majority of patients experience an improvement in bladder capacity, compliance, and continence. Most patients also experience an improvement in quality of life. AC has significant complications, such as chronic UTIs, bladder and renal calculi, metabolic disturbances, bowel problems, perforation, and malignancy. AC also has a high rate of follow-up surgeries, especially if the patient undergoes concomitant creation of a catheterizable channel.

CONCLUSIONS

Enterocystoplasty remains the gold standard for AC, though more research is needed to better evaluate the morbidity of different surgical techniques and the indications for concomitant surgeries. Experimental methods of AC with tissue engineering are a promising area for further investigation.

Bladder Augmentation (Enterocystoplasty): the Current State of a Historic Operation

PURPOSE OF REVIEW

The goal of this paper was to evaluate the current use of enterocystoplasty, a historical operation for bladder dysfunction but with continued and increasing modern relevance.

RECENT FINDINGS

Since the advent of third line neuromodulation techniques for neurogenic and idiopathic overactive bladder (OAB), the usage of enterocystoplasty has decreased. However, this procedure continues to be utilized in pediatric urology patients and the most refractory OAB patients. Adult urologist should be familiar with this operative technique in an effort to manage pediatric patients transitioning to adulthood. Minimally invasive techniques for this surgical procedure have been described with very limited outcome data. It is important for all urologists to be familiar with enterocystoplasty, both technically and with the unique needs of these patients postoperatively. Further studies evaluating the outcomes of this procedure in idiopathic overactive bladder patients and efforts to standardize recommendations for neurogenic bladder patients will help guide care in the future.

Ureteric implantation into the bowel portion of augmented bladders during kidney transplantation: a review of urological complications and outcomes

BACKGROUND

In patients with bladder augmentation undergoing kidney transplantation, conventional technique recommends anastomosing the transplanted ureter to the bladder. We report our technique of ureteric implantation into the bowel portion of the enterocystoplasty, and review the urological outcomes of transplantation in these patients.

METHODS

Seven patients (mean age: 26 years (range 24-54 years), two females, five deceased donors) with augmented cystoplasty and subsequent kidney transplantation by a single surgeon from 2011 to 2015 were reviewed. Following standard vascular anastomosis and reperfusion of the transplanted kidney, ureteric implantation involved continuous 5/0 polydiaoxanone anastomosis between the spatulated ureter and full thickness bowel portion of the cystoplasty over a 6-Fr double J stent. A second peri-anastomosis layer of bowel plication was performed to prevent reflux using interrupted 3/0 vicryl sutures. Short-term urological and kidney function outcomes were evaluated.

RESULTS

Causes of renal failure included: posterior urethral valve with reflux nephropathy (two patients), bilateral vesicoureteric reflux (two patients), lumbosacral agenesis with neurogenic bladder (one patient), tuberculosis of the urinary tract with post-infective ureteric stricture (one patient), and lupus nephritis (one patient). Bladder reconstruction was performed at median duration of 103 months (35-171 months) before transplantation. Gastrocystoplasty was performed in two patients while colon and/or ileum were used in the remaining six. After transplantation, all reconstructed bladders except one had a Mitrofanoff for clean intermittent self-catheterization, 5-8 times per day. There were no post-operative ureteric/surgical complications. Delayed graft function occurred in three of seven patients. 30-day asymptomatic bacteriuria rate was three out of seven after stent removal. 1-year post-transplantation, patient and graft survival were 100%. Mean serum creatinine was 142.7 (standard deviation: 51.48). Median number of hospital admissions for urinary tract infections was 0.225 (range 0-0.40). Over a median follow-up period of 4 years (2-7 years), one graft failed from acute T-cell-mediated rejection. This patient passed away from cardio-respiratory collapse after a seizure, 35 months post-transplantation. As of June 2018, the other six kidney grafts were functioning. No complications including calculi formation and/or malignancy were reported.

CONCLUSION

In patients with previously augmented bladders now undergoing kidney transplantation, ureteric implantation into the bowel portion of the cystoplasty appears to be safe.

Augmentation cystoplasty: Contemporary indications, techniques and complications

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.

The past, present and future of augmentation cystoplasty

What's known on the subject? And what does the study add? There is a wealth of evidence on the development, indications, outcomes and complications of augmentation cystoplasty (AC). Over the last decade, new evidence has been emerging to influence our clinical practice and application of this technique. AC is indicated as part of the treatment pathway for both neurogenic and idiopathic detrusor overactivity, usually where other interventions have failed or are inappropriate. The most commonly used technique remains augmentation with a detubularised patch of ileum (ileocystoplasty). Controversy persists over the role of routine surveillance following ileocystoplasty for the detection of subsequent bladder carcinoma; however the indication for surveillance after gastrocystoplasty is clearer due to a rising incidence of malignancy in this group. Despite a reduction in the overall numbers of AC operations being performed, it clearly still has a role to play, which we re-examine with contemporary studies from the last decade.

A review of metabolic consequences and long-term complications of enterocystoplasty in children

This review summarizes the important metabolic consequences and long-term complications associated with enterocystoplasty, with a particular emphasis on the pediatric patient with genitourinary abnormalities. A directed Medline literature review for metabolic and long-term complications following enterocystoplasty was performed. Information gained through published literature and from our database was reviewed and summarized to provide the reader with a thorough review of the subject. Bowel is not a perfect tissue for substitution or augmentation, and its use to treat functionally and structurally compromised bladders is associated with several metabolic consequences and long-term complications. Metabolic acidosis is the most common metabolic abnormality seen. The rates and severity of these complications vary, though they may have a profound impact on a patient's quality of life after enterocystoplasty. The metabolic consequences and long-term complications associated with enterocystoplasty are important clinical features of this intervention, and careful consideration should be given to them before pursuing enterocystoplasty.

[Metabolic aspects of bowel use in urologic surgery]

Urinary diversion, pouches and orthotopic bladder replacement have been made possible by the use of bowel segments in urologic surgery. The most important complications at short and long-term are metabolic disorders due to the permanent contact of urine with the bowel segment or the exclusion of this segment from bowel continuity. Metabolic acid-base problems occur immediately after the derivation beginning and depend on the renal capacity to compensating. The metabolic disorder due to the exclusion of a bowel segment appears generally years later, after complete depletion of physiologic reserves (vitamin B12). Perfect knowledge of early and late metabolic complications of urinary diversion allows a more accurate indication, a more adequate selection of the derivation type, an improved patient followup, and better long-term results. Metabolic complications constitute the best selection criteria for urinary diversion; subsequently, only a few techniques are likely to persist in the future.

Chapitre C-2 C - Traitement de l’hyperactivité détrusorienne neurologique : entérocystoplasties

The importance of a good capacity bladder reservoir able to fill at low pressure has now been clearly established. These properties have a double advantage: they ensure urinary continence and prevent damage to the upper urinary tract. In the case of failure of the various medical treatments, including botulinum toxin injections, surgical bladder augmentation can be considered, especially in the presence of poor bladder compliance. The authors present the technical details of bladder augmentation by enterocystoplasty or by alternative techniques and their medium- and long-term results, and define the postoperative surveillance of this type of surgery.

Bladder augmentation for the treatment of chronic tuberculous cystitis. Clinical and urodynamic evaluation of 25 patients after long term follow-up

AIMS

Clinical and urodynamic evaluation of the late outcome of 25 patients with chronic tuberculous cystitis who underwent bladder augmentation.

PATIENTS AND METHODS

Twenty men and five women with median age of 40 years were evaluated. The tubularized ileocecal segment was used in 8 cases, the detubularized sigmoid in 13, and the tubularized sigmoid in 4. Patients underwent a postoperative clinical and urodynamic evaluation. Miccional diurnal frequency of more than 2 hr together with patient satisfaction as assessed by the quality of life question of the ICSmaleSF questionnaire was considered a good result.

RESULTS

The average postoperative follow-up was of 11.1 +/- 9.1 (1 to 36) years. A good result was seen in 80% of the patients. Bad results occurred statistically in the cases using tubularized sigmoid and in patients with prostatitis. Patients with good results showed augmented bladders with normal sensation (P = 0.03) and greater capacity (P < 0.01) and compliance (P < 0.01) than did those with bad results. There was no statistically significant difference in the frequency of involuntary contractions (P = 0.27) but in the good result patients, the contractions started with greater bladder filling volume (P = 0.02).

CONCLUSIONS

The sigmoid should be detubularized but the ileocecal segment may be used in its original tubularized form to augment the bladder with chronic tuberculous cystitis. Augmented bladder with capacity of more than 250 ml, good compliance, and normal sensation are necessary for diurnal frequency of more than 2 hr. The presence of involuntary contractions does not lead to a decrease in the diurnal frequency.

METABOLIC CONSEQUENCES AND LONG-TERM COMPLICATIONS OF ENTEROCYSTOPLASTY IN CHILDREN: A REVIEW

PURPOSE

We summarize important metabolic consequences and long-term complications associated with enterocystoplasty with particular emphasis on the pediatric patient with genitourinary abnormalities.

MATERIALS AND METHODS

A directed MEDLINE literature review for metabolic and long-term complications following enterocystoplasty was performed. Information gained through the published literature and from our database was reviewed and summarized to provide the reader with a thorough review of the subject.

RESULTS

Bowel is not a perfect tissue for substitution or augmentation and its use to treat functionally and structurally compromised bladders is associated with several metabolic consequences and long-term complications. Metabolic acidosis is the most common metabolic abnormality seen. The rates and severity of these complications vary, although they may have a profound impact on patient quality of life after enterocystoplasty.

CONCLUSIONS

The metabolic consequences and long-term complications associated with enterocystoplasty are important clinical features of this intervention. Careful consideration should be given to them prior to pursuing enterocystoplasty.

Bladder stone formation after sigmoidocolocystoplasty: statistical analysis of risk factors

PURPOSE

Bladder stone formation (BSF) after sigmoidocolocystoplasty (SCP) is a major source of morbidity. The authors identify risk factors and analyze them statistically.

METHODS

Medical records of 106 patients who had SCP at our institute were reviewed to examine the incidence of post-SCP BSF, the stone removal method and length of follow-up. The primary underlying pathological conditions were myelomeningocele in 103 patients and other conditions in 3. Risk factors for BSF were statistically assessed by comparing cases with and without BSF.

RESULTS

Bladder stone formation occurred in 20 (18.9%) of 106 patients (BSF group). The remaining 86 did not have stones (NBSF group). Mean age at SCP was 11.7 years in the BSF group and 10.2 years in the NBSF group. Mean follow-up was 12.0 years in the BSF group and 11.0 years in the NBSF group. BSF developed after a mean of 30.3 +/- 25.6 months after SCP. Twenty-two stone removal procedures were performed in the BSF group and spontaneous evacuation occurred in 4 instances. Once stone free, BSF recurred in 4 patients. Although differences between the 2 groups with respect to sex, age at SCP, follow-up period, bladder capacity, bladder compliance, incidence of gram-negative bacteriuria, incidence of gram-positive coccus bacteriuria, electrolytes, frequency of urinary catheterization, post-SCP incidence of vesicoureteric reflux, and incidence of ureteric reimplantation were not statistically significant, differences in the incidence of spontaneous micturition, bladder neck tightening procedures, or gram-positive bacillus bacteriuria, or frequency of bladder irrigation were all statistically significant (P < .05 in all, Fisher's Exact test).

CONCLUSIONS

The authors are the first to statistically analyze a wide range of varying risk factors for BSF. BSF would appear to be common after SCP.

Entérocystoplastie d'agrandissement

Augmentation enterocystoplasty refers to a technique that consists in removing a bowel segment in order to suture it onto the bladder. This technique is indicated in case of reduced bladder capacity and/or compliance, in case of failure of conservative treatments. The goal is to improve the patient's urination comfort, but above all to ensure long-term protection of the upper urinary tract. All bowel segments may be utilized but the ileum is the segment of choice. The selected digestive segment must be detubulized in order to better decrease its peristaltic contractions and obtain low-pressure urine storage. Bi-valving the bladder while preserving the detrusor usually performs augmentation enterocystoplasty. However, in case of very fibrous and thickened detrusor, a supra-trigonal cystectomy should be considered. The digestive segment is removed and detubulized, then it is sutured on to the bladder as a patch at the incision level. Following such surgery, over 90% of the patients report significantly improved quality of life. Nocturnal bladder competence is obtained in more than 90% of the patients, while 91 to 100% report diurnal bladder competence. Long-term complications may be observed, such as chronic infections with asymptomatic bacteruria (70% of the cases) not necessitating any treatment. Within the two first years, there is a 10% to 15% risk for stone formation following intestinal mucus development. Enterocystoplasty perforation may occur at a frequency estimated to range from 5 to 13%, which is a very serious and life-threatening complication. Similarly, a risk of enterocystoplasty cancer may be observed after five to ten years, in 1% of the cases.

Long-term results of trigone-preserving orthotopic substitution enterocystoplasty for interstitial cystitis

PURPOSE

Interstitial cystitis is a chronic debilitating condition mainly affecting women. Conservative treatment often produces unsatisfactory results and the identification of the best surgical treatment modality is difficult. We evaluate retrospectively the long-term results of trigone-preserving cystectomy followed by orthotopic substitution enteroplasty for women suffering from interstitial cystitis.

MATERIALS AND METHODS

The study comprised 18 women with a mean age of 55.9 years. All surgical interventions were performed by 1 surgeon. All patients completed a voiding log and were interviewed about symptoms. Renal ultrasonography was done to evaluate the upper urinary tract. Followup data also comprised blood chemistry studies, including vitamin B12 blood levels and blood gas analysis. Pain and lower urinary tract problems were measured using a validated self-assessment symptom index.

RESULTS

Ileocoecal augmentation was performed in 10 women and ileal substitute was done in 8. After a mean followup of 57 months 14 patients are completely pain-free, 12 void spontaneously and 15 report complete resolution of dysuria. Three patients perform intermittent self-catheterization and 1 woman prefers a suprapubic catheter for control of urinary hypercontinence. These 4 patients underwent ileoplasty. Surgery failed to relieve symptoms in 2 of the 18 patients. Surgery achieved a statistically highly significant improvement of diurnal and nocturnal voiding frequencies, functional bladder capacity and symptom index score.

CONCLUSIONS

Substitution enterocystoplasty is a valuable and safe therapeutic option for patients with intractable interstitial cystitis resistant to conservative therapy. In our series use of the ileocecal bowel segment showed better functional results.

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.

Seromuscular colocystoplasty lined with urothelium protects dogs from acidosis during ammonium chloride loading

PURPOSE

We compared the metabolism of intravesical ammonium chloride in dogs in which the bladder had been enlarged by seromuscular colocystoplasty lined with urothelium, dogs that had undergone conventional colocystoplasty and control dogs.

MATERIALS AND METHODS

Eight adult female mongrel dogs were divided into control (2), colocystoplasty (3) and seromuscular colocystoplasty (3) groups. Serum creatinine, bicarbonate, sodium, chloride, and potassium levels were measured every 2 weeks during the 6-week recovery period. Six weeks after augmentation the dogs were placed under general anesthesia, the bladder was instilled with a hyperosmolar solution of 400 mmol/l. ammonium chloride, the femoral artery and portal vein were cannulated to obtain blood samples and the ureters were divided with the proximal ends diverted to allow serial urine measurements. Blood and urine electrolyte analysis was performed at 0, 60, 120, 180 and 240 minutes after the intravesical instillation of ammonium chloride.

RESULTS

During acid loading dogs that had undergone conventional colocystoplasty had a progressive decrease in serum carbon dioxide and arterial pH as well as increased levels of serum chloride and a significant increase in plasma ammonia concentration in the portal vein compared to controls and dogs that had undergone seromuscular colocystoplasty. In contrast, there were no differences in seromuscular colocystoplasty compared to control animals.

CONCLUSIONS

Increased ammonia in the portal vein and hyperchloremic acidosis in dogs that underwent conventional colocystoplasty suggest intravesical absorption of ammonium chloride. Dogs that underwent augmentation with seromuscular colocystoplasty lined with urothelium seemed to respond to acute intravesical ammonium in a way similar to that of control dogs and they are protected from these metabolic anomalies.

Bladder replacement in women: a new experience

Bladder replacement in women in a new experience. In this article the authors reviewed in a critical way the patho-physiological principles involved in the previous male bladder replacement techniques and the results achieved both leading to the recent experience of bladder replacement in women. The authors present the recent acquirements about pelvic surgical anatomy and postcystectomy oncological radicality in female, and the more common surgical techniques for building a neobladder in women with the results achieved up to now. They also examined the problems arising from this exciting but precocious experience which will surely involve the urological community in the future.

Intermittent catheterization following enterocystoplasty

OBJECTIVE

To assess the segment of bowel used in enterocystoplasty and the need to perform intermittent self-catheterization (ISC) after enterocystoplasty for the treatment of incontinence.

PATIENTS AND METHODS

Of 123 patients undergoing enterocystoplasty, 77 (mean age 29.5 years, range 13-61) had neurogenic disease (NB group) and 46 (mean age 45.7 years, range 16-74) had non-neuropathic bladders (NNB group). The success of enterocystoplasty, with respect to the segment of bowel used and the need for ISC, was assessed during a follow-up of 6-125 months.

RESULTS

Ileum was used in 84 (63.8%), ileum and caecum in 19 (15.4%) and sigmoid in 20 (16.3%) patients. In the NB group, more patients had a sigmoid cystoplasty (24.7 vs 2.2%) and less (67 vs 80%) had an ileo-cystoplasty than in the NNB group. A total of 87 (71%) patients required ISC; 63 (82%) of the NB group and 24 (52%) of the NNB group. The influence of the intestinal segment was conspicuous in the NB group, with 82% and 95% of patients with ileocaecal and sigmoid cystoplasty needing ISC against 77% of those patients with ileal cystoplasty. The difference was not so evident in the NNB group.

CONCLUSIONS

A social continence rate of 93.6% in the NB and 84.8% in the NNB patients was achieved, partly due to the patients' success with ISC, a necessary skill to be mastered by all patients before undergoing enterocystoplasty.

Intestinal de-epithelialization and augmentation cystoplasty: an animal model

OBJECTIVES

An animal model of augmentation cystoplasty was developed in New Zealand rabbits to study the effects of intestinal de-epithelialization on subsequent re-epithelialization by bladder urothelium.

METHODS

Twenty-four rabbits underwent augmentation cystoplasty using intestinal segments that were either treated with protamine sulfate and urea solution or else anastomosed with an intact epithelium. Half of the rabbits receiving the de-epithelialized intestinal segments were subjected to glycosaminoglycan replacement therapy by administration of intravesical heparin. Experimental and control rabbits were sacrificed at 1-, 2-, and 3-month intervals.

RESULTS

Histologic examination of the augmented sections showed small areas of urothelium growing over the intestinal epithelium (approximately 15%). The heparin-treated group demonstrated the greatest amount of re-epithelialization. There was no obvious histologic difference in the amount of collagen present in the augmented tissues in any of the experimental groups.

CONCLUSIONS

In a preliminary study, New Zealand rabbits appear to be satisfactory as an experimental animal for studying the augmentation cystoplasty procedure and for the development of therapeutic interventions for enhancing epithelial growth. Protamine and urea will de-epithelialize the bowel and heparin may promote epithelialization of augmented intestinal segment by transitional epithelium.

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.

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.

Refluxes in orthotopic neobladders: can the ileocecal sphincter be considered an adequate antireflux mechanism?

OBJECTIVES

To evaluate the usefulness of the ileocecal sphincter in preventing ureteral refluxes in ileocecal orthotopic neobladder, thus avoiding the use of antireflux technique for ureteroileal anastomosis.

METHODS

From 1980 to 1992, 95 patients underwent orthotopic bladder substitution. In 30 our detubularized ileal reservoir was used and in 65 first only an integral ileocecal segment was used and subsequently multiple transverse teniamyotomies on the cecal portion to increase the capacity and reduce the pressure. The upper urinary tract was indirectly protected in the ileal reservoir technique by leaving an integral 8 to 10 cm long afferent segment folded behind the reservoir and in the ileocecal technique by the ileocecal sphincter, thus keeping the anastomosis between ureters and ileum simple and direct.

RESULTS

The mean follow-up of the 65 patients with ileocecourethrostomy is 37 +/- 33 months (range, 2 to 141 months); in 13.8% of the patients (9/65) monolateral refluxes appeared, but without any evident clinical consequences. The appearance of monolateral stenosis on the ureterointestinal anastomosis requiring treatment occurred in 4 patients (6%): 3 underwent an endoscopic treatment and 1 a surgical one. Modifications of renal function with respect to the preoperative status were not verified in any of the patients.

CONCLUSIONS

The ileocecal sphincter is an effective antireflux mechanism for an orthotopic neobladder in which multiple transverse teniamyotomies (5 to 7) increase the capacity of the neobladder itself, reduce its internal pressure, and confer a nearly spherical configuration. Moreover, a correct anastomosis between the cecum and membranous urethra decisively reduces the resistance to emptying of the neobladder, thus avoiding too strong pressures against the ileocecal sphincter. The integrity of the circular muscular layer maintains a healthy tonic wall: this fact, combined with the low peripheral resistances, ensures good emptying and a stable capacity. The procedure is easy to perform and not time-consuming; these considerations lead us to consider the ileocecal unit an excellent structure for bladder substitution.

Management of colovesical fistulae associated with pelvic malignancy

Thirteen patients with malignant colovesical fistulae are presented. The underlying pathology was cancer of the colon (seven cases), bladder (four cases) and cervix (two cases). The series demonstrates that wide surgical excision may be needed to achieve tumour clearance and that this may necessitate pelvic exenteration. Three patients who underwent inadequate tumour excision developed recurrence in the bladder, two with a fatal outcome. Wide excision of the bladder may be performed without urinary diversion by subtotal cystectomy and a reconstructive procedure. Substitution cystoplasty was performed on two patients at the time of tumour excision. Urinary tract involvement by such tumours is often extensive and optimal results may be achieved with a multidisciplinary approach.

Perforation and intravesical erosion of a ventriculoperitoneal shunt in a child with an augmentation cystoplasty

Bladder augmentation has evolved into a common method of management in children with a low capacity and/or poorly compliant bladder secondary to a neuropathic condition. We report on a 4-year-old girl with myelodysplasia who presented with sepsis and who had a perforation of the augmented bladder, which was surgically repaired. She returned for evaluation 1 month after she was discharged from the hospital when the distal component of the ventriculoperitoneal shunt was noted to protrude per urethram after clean catheterization. Distal shunt replacement with prolonged bladder drainage successfully resolved this perforation of the augmented bladder. The patient has had no further difficulties. We discuss the diagnosis and management of this case with reference to the current literature regarding complications of augmentation cystoplasty.

Bladder augmentation and replacement. Urodynamic and clinical review of 25 patients

Bladder augmentation has a role in the management of patients with neuropathic bladder dysfunction and in urinary undiversion. Several reports attest to its clinical value, but there have been few detailed urodynamic studies of its effects. We have carried out a prospective review over a 4-year period of 25 patients undergoing bladder augmentation or substitution assessed by conventional and ambulatory urodynamic studies. All patients had a detubularised reservoir made of ileum in 6, and of the ileocaecal segment in the remainder. Six patients also had an artificial sphincter fitted and 2 underwent colposuspension. There was no mortality. After operation, bladder capacity increased from 122 +/- 91 ml to 659 +/- 431 ml and there were significant decreases in the pressure rise during filling and increases in bladder compliance. Hyper-reflexia was present in 74% before operation and 23% after operation. Regular phasic activity was observed in 77% of patients at the end of filling after operation, probably due to bowel activity despite detubularisation. Four patients described urge incontinence associated with this activity. After operation, one man had persistent major stress incontinence. He has since undergone insertion of an artificial urinary sphincter (AUS) and is now completely dry. Of the remainder, 10 patients had minor, infrequent defects in continence, 9 patients with leakage when the bladder was full and 4 with occasional leakage at night. With the exception of the patient with major stress incontinence, all but one felt the operation had been worthwhile--40% reporting complete success and 52% excellent improvement. Reconstruction of the neuropathic lower urinary tract is a major surgical procedure, but the final clinical outcome is very satisfactory.

Ileocecocystoplasty for the management of refractory neurogenic bladder: surgical technique and urodynamic findings

A total of 21 incontinent adults with a neurogenic bladder who were refractory to conservative management underwent a modified technique of ileocecocystoplasty. Followup ranged from 1 to 6 years (mean 3.1 years). To ensure a wide anastomosis the augmentation was accomplished by suturing a detubularized ileocecal patch to a large posterior based bladder flap anchored to the psoas muscles. Postoperatively 20 of 21 patients were continent. The remaining woman was cured after surgical correction of sphincteric incontinence. Mean bladder capacity increased from 185 +/- 17 to 595 +/- 43 ml. (standard error). Mean maximum detrusor pressure decreased from 53 +/- 6.3 to 16 +/- 2.3 cm. water (p less than 0.0001). Followup revealed a persistently large capacity, low pressure reservoir in all patients. No patient required anticholinergic medication. None experienced acid-base imbalance, tumors in the augmented bladder or upper tract deterioration. We conclude that this technique of ileocecocystoplasty is suitable for the management of patients with a refractory neurogenic bladder.

Detubularisation in cystoplasty: clinical review

Cystoplasty using a detubularised bowel segment is preferable to using a tubularised length of intestine. This has been shown experimentally to result in a reduction in the contractility of the neobladder, although contractions are not completely abolished. Incontinence, especially nocturnal, may still be a problem. Assessment of renal function has shown a marked incidence of upper tract dysfunction despite detubularisation. All patients remain at risk of upper tract obstruction following cystoplasty. Because bowel contraction waves are brought on by distension, it may be possible either to postpone or to prevent the onset of contractions by avoiding an excessive build-up of bladder volume. Clean intermittent self-catheterisation is an efficient means of emptying the bladder, although sphincter rebalancing may also be required.

Urinary tract re-functionalization after long-term diversion. A 20-year experience with 177 patients

From 1969 to 1990, previously diverted urinary tracts were 'undiverted' in 177 patients whose ages ranged from 1 to 31 years. Fifty-six of the patients (32%) had been diverted for 10 years or longer. There were 67 female and 110 male patients. Forty-four patients had only one kidney and in two of those patients it was a previous renal transplant. One patient was anephric at the time of reconstruction, having had two unsuccessful transplants. Most of the diversions had been considered permanent. Types of diversions that were reversed include ileal loop, colon conduit, loop ureterostomy or pyelostomy, end ureterostomy, cystostomy or vesicostomy, long-term nephrostomy, and ureterosigmoidostomy.

Failure of combined supratrigonal cystectomy and Mainz ileocecocystoplasty in intractable interstitial cystitis: is histology and mast cell count a reliable predictor for the outcome of surgery?

Eight women with severe intractable interstitial cystitis were treated with supratrigonal cystectomy and Mainz ileocecocystoplasty. The preoperative evaluation consisted of symptom analysis, cystometry, cystoscopy and bladder pathological findings. Seven patients had increased mast cell density. Median followup was 10 months. The symptoms resolved in 2 patients but recurred in 6 shortly after the operation. Voiding could not be established in 4 patients. Self-catheterization was difficult and painful. Ultimately, cystectomy and urinary diversion were performed in 5 patients and is scheduled in 1. The 2 cured patients had a small contracted bladder preoperatively while they were under anesthesia, while all 6 failed cases had a large bladder capacity. Postoperative biopsies from the trigone showed no difference in the amount of fibrosis, the degree of degenerative changes in the muscle and mast cell density between the 2 cured patients and the 6 who failed to improve. The mast cell density and the histological status of the trigone cannot be used as predictors of the outcome of supratrigonal cystectomy. The role of the mast cells in interstitial cystitis is reviewed. Combination of supratrigonal cystectomy and a Mainz augmentation cystoplasty cannot be recommended in patients with intractable interstitial cystitis and a large bladder capacity.

Bladder augmentation: experience with 129 children and young adults

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

Augmentation cystoplasty and closure of the urethra for the destroyed lower urinary tract

Five paraplegic patients with pressure ulceration complicated by incontinence related to fistula formation were treated by deliberate closure of the urethra and augmentation cystoplasty with a continent stoma. This procedure is similar in scope to urinary diversion but preserves a low-pressure reservoir and obviates the use of tubes for drainage of urine. Overall outcome was excellent. Valvular failure occurred in one patient and required revision. The follow-ups range from 1 to 5 years, with a mean of 24 months. One patient developed reservoir calculi as a late complication, necessitating removal with flexible endoscopy via the continent conduit. All patients have preserved normal upper tracts. Augmentation cystoplasty with closure of the urethra is a reasonable procedure in such patients providing for low-pressure urinary storage and permitting secondary or simultaneous plastic surgical procedures on perineal pressure ulceration and osteomyelitis.

[Review of a 14-year experience of augmentation enterocystoplasty. Observations on bowel dynamics]

Fifteen patients with low compliance bladder of varying etiologies (neurogenic bladder, radiation induced contracted bladder after radical hysterectomy, bladder tuberculosis and interstitial cystitis) underwent augmentation enterocystoplasty. The ileocecal tubular segment was used in 12 patients, ileal-patch in 2 and ileal-cup patch in 1. In all patients in whom partial reconstruction was done, the functional bladder capacity satisfactorily increased and the maximum detrusor pressure was low. The upper urinary tract did not deteriorate in 12 patients. Three died from recurrence of uterine or bladder cancer. Five neurogenic patients were managed by intermittent self-catheterization postoperatively. Another 10 patients was dry without voiding difficulty. Of 18 ureteral reimplantations in ileocecal cystoplasty, 13 had reflux without resultant progressive hydronephrosis. In 3 patients ureteral reimplantation was not required without reflux after ileal-patch and ileal-cup patch cystoplasty.

A juvenile animal model to study the growth potential of bowel segments in the urinary tract

A juvenile animal model has been developed to study the growth potential of ileum in the urinary tract. Patch ileocystoplasties of known surface area were constructed in dogs of Group 1. Nonrefluxing ileal nipple valves of known length were created to replace one ureter in dogs of Group 2. After the juvenile animals grew and at minimum doubled their weight, they were reoperated and augmentation surface areas were remeasured at various physiologic intravesical pressures. Nipple valve lengths were remeasured after cystograms ruled out reflux. Results show that the bowel augmentation and an identical control segment increased in surface area proportionate to animal growth and that hydrostatic dilation caused further surface area increase. Nipple valves did not grow and in fact shortened, but remained nonrefluxing. The conclusion is that in the pediatric population, consideration should be given to downscaling the size of bladder augmentations or diversions in anticipation of future bowel growth, but that one should not shorten the ileal nipple valves.

Functional and biochemical alterations in the rabbit urinary bladder following ileocystoplasty

Although the use of ileocystoplasty has increased significantly in recent years, very little is known concerning the smooth muscle properties of the implanted bowel segment. In a previous study, preliminary evidence was presented which indicated that the pharmacological response of the cytoplastic ileal segment to autonomic agonists changed toward that of the bladder. The present study extends and expands these preliminary observations on the physiology and pharmacology of augmentation cystoplasty. Augmentation cystoplasty with detubularized ileum was carried out in 16 rabbits. In vivo and in vitro physiological and pharmacological studies were carried out one and three months after surgery. The results can be summarized as follows: 1) in-vivo CMG at one month was similar to that of the preoperative bladder, but at three months there was a 24% increase in capacity, with the presence of multiple phasic contractions beginning at a volume of approximately 65% of capacity. 2) The frequency and magnitude of spontaneous activity in the cystoplastic ileum did not significantly alter from that of the normal ileum. 3) Cystoplastic ileum responded to muscarinic stimulation differently from the normal ileum. The bladder responded with an increase in the tension whereas the ileum responded with an increase in the frequency and amplitude of phasic contractions. The cystoplastic ileum responded with a pronounced sustained contraction with phasic contractions superimposed. The tonic contraction at three months was of a significantly greater magnitude than that at one month. 4) The qualitative and quantitative response to field stimulation of the cystoplastic ileum was altered from that of the ileum towards that of the bladder. 5) The normal bladder contains greater amount of creatine phosphate and lesser amounts of creatine than the normal ileum. Cystoplasty, after three months induced a change in the ileal segment towards the bladder (increased creatine phosphate and decreased creatine). 6) The normal ileum was found to have greater number of muscarinic receptors than the normal bladder whereas the cystoplastic ileum at three months was intermediate.

Metabolic complications of cystoplasty

A series of 48 patients with intestinal segments incorporated into the urinary tract underwent assessment of acid-base and electrolyte balance. All patients had abnormal blood gas analyses, usually a metabolic acidosis with respiratory compensation; 33% had hyperchloraemia. Radioisotope studies using sodium, potassium and bromine showed that all were absorbed and that absorption was unaffected by renal function. The results suggest that all such patients, but particularly women and children, may be at risk of the secondary effects of chronic acidosis, especially skeletal demineralisation, unless some compensatory mechanism is working to offset the effects of the acidosis.

The hemi-Kock augmentation ileocystoplasty: a low pressure anti-refluxing system

Experiences with various methods of using intestinal segments for bladder augmentation and urinary undiversion, as well as with clinical applications of the Kock continent ileostomy for urinary diversion have led us to develop the hemi-Kock augmentation ileocystoplasty for selected patients requiring a nonrefluxing bladder augmentation. In 6 of 7 patients this bladder augmentation technique fulfilled the requirement for a low pressure nonrefluxing reservoir. Renal function has been preserved and electrolyte problems have not occurred. Nocturnal incontinence has been eliminated. Although 2 of 7 patients required surgical revision patient acceptance has been excellent. Prerequisites to implementing this approach are appropriate patient selection and familiarity with the surgical principles of the continent ileal reservoir.