Cecocystoplasty in the surgical management of the small contracted bladder

Reconstructive bladder surgery in genitourinary tuberculosis

Genitourinary tuberculosis (GUTB) occurs in 15-20% cases of pulmonary tuberculosis with a prevalence of 400 per 100,000 population. Reconstructive surgery for GUTB is required for cases with grossly distorted and dysfunctional anatomy that are unlikely to regress with chemotherapy alone. In the recent past, there has been a tremendous increase in the variety of reconstructive procedures for the urinary bladder, used in the management of GUTB. Augmentation cystoplasty includes the goals of increasing bladder capacity, while retaining as much of bladder as possible. Various bowel segments (from the stomach to the sigmoid colon) have been used for bladder reconstruction. The choice of material for reconstruction is purely the surgeon's prerogative--his skill, the ease, the mobility and length of mesentery (allowing bowel to reach the bladder neck without tension and maintaining an adequate blood supply). The presence or absence of concomitant reflux is of considerable importance. In the former, an ileocystoplasty with implantation of ureter to the proximal end of the isolated ileal loop and anastomosis of the distal end of the ileal loop to the bladder neck and trigone is advocated. In the latter case, the ureterovesical valve is preserved and colocystoplasty is preferred, wherein the sigmoid colon on being opened along its antimesentric border is joined to the trigone and bladder neck and then to itself to form a capacious pouch. Gastrocystoplasty reduces the risk of acidosis but is associated with complications like hypochloremic alkalosis and ‘hematuria-dysuria’ syndrome. Orthotopic neobladder reconstruction is a feasible option, suitable in cases of tubercular thimble bladder with a markedly reduced capacity (as little as 15 ml), where an augmentation alone may be associated with anastomatic narrowing or poor relief of symptoms. In this article, we review the various bladder reconstruction options used for the surgical management of GUTB, along with their indications and complications.

Bladder autoaugmentation

Autoaugmentation has proved effective in many patients in lowering bladder pressures, increasing bladder capacity, and improving their related symptoms. Patients with sever bladder hyperreflexia, uncontrolled with medications, have also benefited greatly from autoaugmentation procedures. Only patients who failed conventional medical management have undergone autoaugmentation at the authors' institution.

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.

Ileocecocystoplasty bladder augmentation and renal transplantation

In 4 patients with a small contracted bladder and end stage renal failure ileocecocystoplasty bladder augmentation was done in conjunction with renal transplantation. All 4 patients have stable renal and bladder function 13 to 46 months after transplantation. In carefully selected patients bladder augmentation may be an alternative to urinary diversion.

The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion

The surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis. Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the remainder void spontaneously without significant residual urine. Of 12 patients with Mainz pouch urinary diversion 6 have an ileoileal intussusception valve and are completely continent, as are 3 of 4 with an alloplastic stomal prosthesis. Two patients still are awaiting implantation of a sphinteric prosthesis.

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

Intestinocystoplasty in combination with clean intermittent catheterization has been used in the management of 60 young patients with bladder dysfunction. Of the patients 39 (65 per cent) had the primary diagnosis of myelomeningocele, 8 had sacral agenesis, 3 had spinal cord tumors and 1 had spinal cord trauma. The remaining 9 patients had either congenital, surgical or traumatic loss of all or a large portion of the bladder. Of the 60 patients 30 had undergone prior urinary diversion, while the remaining 30 were considered failures with management by clean intermittent catheterization and medication. A total of 16 patients underwent ileocecocystoplasty, while 44 had augmentation with either cecum (8), sigmoid (18) or ileum (18). Mean followup was 4 years (range 16 months to 7 years). Fifty-nine patients have stable or improved renal function and the excretory urogram is stable or improved in all 60. Of the patients 38 (63 per cent) were considered dry after the initial bladder augmentation, while an additional 14 were rendered dry by a second procedure consisting of bladder neck reconstruction or placement of the artificial urinary sphincter, for a total of 52 (87 per cent) currently considered to be dry. Eleven patients have had at least 1 symptomatic urinary tract infection (18 per cent) and 21 had a positive urine culture but remained asymptomatic. In contrast to earlier beliefs, intestinocystoplasty can be applied effectively and appropriately to patients with bladder and urethral dysfunction. Intestinocystoplasty combined with clean intermittent catheterization offers a significant alternative to diversion in such patients.

The role of bladder augmentation in undiversion

Twenty-nine pediatric patients underwent bladder augmentation as part of their urinary undiversion. Indications included spina bifida deformity, contracted small bladder, and extrophy. Cecal and sigmoid segments were used. Prior diversion included ureterointestinal conduits, vesicostomies, ureterostomies, and suprapubic catheter drainage. In most cases the renal function was normal. Intermittent catheterization is used in almost every cases. Several illustrative cases are shown.