Augmentation Cystoplasty

Histology of the neobladder mucosa after sigmoidocolocystoplasty

PURPOSE

The aim of this study was to examine the histopathology of neobladder mucosa biopsy specimens obtained routinely as part of postsigmoidocolocystoplasty (SCP) follow-up.

METHODS

One hundred cases of SCP (mean age at surgery, 10.6 years) performed by the authors were examined for the presence of dysplasia or malignant changes in the mucosa of the neobladder using H&E and proliferating cell nuclear antigen (PCNA) staining.

RESULTS

No dysplastic or malignant changes were identified in any case. Metaplasia was found in 5 cases and hyperplasia in 2. There were no major differences found on H&E and PCNA staining of specimens obtained after different periods of follow-up post-SCP; follow-up was short term (up to 5 years) in 44 cases, medium term (from 5 to 10 years) in 48 cases, and long term (over 10 years) in 8 cases. PCNA staining was significantly more intense in subjects who stopped regular bladder irrigations (BI) post-SCP and in subjects in whom bladder stones developed (P < .05; Welch's t test), compared with subjects who continued BI and subjects in whom bladder stones did not develop.

CONCLUSIONS

After SCP, patients are advised to continue BI. Regular biopsies should be part of routine follow-up, especially in subjects with bladder stones.

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.

Surgery for the treatment of overactive bladder

OBJECTIVES

To describe surgical options that may be indicated when conservative management of overactive bladder is unsuccessful.

METHODS

The literature on current endoscopic and open surgical procedures is reviewed.

RESULTS

The endoscopic approach of hydrodistention under anesthesia may be therapeutic, but normally offers only temporary relief of symptoms. Among open surgical procedures, cystolysis has not withstood the test of time and is no longer used. Partial rhizotomy can reduce reflex bladder contractility while preserving other important urogenital functions. Peripheral denervation via a vaginal approach appears effective in as many as 70% of patients with motor instability, but is not effective in interstitial cystitis or other sensory bladder disorders. Transvesical phenol injection is most effective for detrusor instability (DI) caused by multiple sclerosis. Enterocystoplasty is more helpful in intractable DI than in interstitial cystitis. Detrusor myomectomy has yielded excellent results in patients with neurogenic causes of DI. Urinary diversion is rarely required in DI, but may be preferable to enterocystoplasty when severe pelvic pain is present.

CONCLUSIONS

When appropriately chosen, surgical procedures can substantially improve the quality of life of some individuals with overactive bladder.

Functional urinary bladder wall substitute using a free innervated latissimus dorsi muscle flap

This study was designed to investigate the ability of the latissimus dorsi muscle in situ to evacuate a bladder reservoir and to study the functional, anatomic, and histopathologic results of partial or subtotal bladder reconstruction with an innervated free latissimus dorsi muscle in mongrel dogs. In group I (four dogs), the latissimus dorsi muscle was dissected and tailored in situ. Then the so-formed pedicled latissimus dorsi muscle flap was wrapped around tissue expanders of varying sizes (volumes of 50, 100, and 150 cc, respectively) to form a bladder-like reservoir. Electromyography and intraluminal pressure measurements were done at the time of surgery and 6 months thereafter using a standard electromyograph and a Dantec urodynamic unit. In group II (four dogs), the dome of the bladder wall was removed, with up to 50 percent of the mucosal layer being left intact. The resulting muscular defect was repaired with a free innervated latissimus dorsi muscle flap. The transferred latissimus dorsi muscle was shaped and wrapped around the bladder in a spiral form, with particular attention to the resting tension. The thoracodorsal vessels were anastomosed to the pelvic branches of the hypogastric vessels, and the thoracodorsal nerve was coapted to a pelvic motor nerve that was selected by use of a nerve stimulator. Cystography and urodynamic studies were performed after 3, 6, and 9 months. Electromyography was done after 9 months, before sacrifice of the animals, which was followed by regular histologic and electron microscopic examinations. Stimulation of the thoracodorsal nerve of the reconfigured latissimus dorsi muscle reservoirs in situ after 6 months yielded average intraluminal pressures of 190 cmH2O at maximum capacity and 35 cmH2O at a minimum capacity of 10 to 15 cc. Stimulation of the latissimus dorsi muscle transferred to the bladder resulted in a visible and measurable contraction of the transplanted muscle after 9 months. Urodynamic values preoperatively and postoperatively were basically unchanged. During cystography, the bladder outline was smooth during both filling and voiding. Light and electron microscopic examinations confirmed viable, reinnervated muscle. The reconfigured pedicled latissimus dorsi muscle has the ability to evacuate a bladder-like reservoir after nerve stimulation. A detrusor function of the bladder can be induced through the contractility of a reinnervated free latissimus dorsi muscle that was wrapped around the bladder. An innervated free latissimus dorsi muscle flap does not undergo severe muscle fibrosis, contracture, and atrophy such as occur after transfer of completely or partially denervated, pedicled muscle. This means that a functional bladder reconstruction/augmentation can be achieved by microneurovascular transfer of a latissimus dorsi muscle flap.

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.

Long-term results and complications using augmentation cystoplasty in reconstructive urology

One hundred and twenty-two augmentation cystoplasties performed over an 8-year period were reviewed. Mean age at surgery was 37 years (range 2-82 years). There were 82 female patients. The primary urodynamic diagnosis was reduced compliance in 92 (77%) patients and detrusor hyperreflexia/instability in the remainder. The clinical diagnostic groups were: spinal cord injury/disease in 32 (27%), myelodysplasia in 27 (22%), interstitial cystitis in 21 (17%), idiopathic detrusor instability in 13 (11%), radiation cystitis in 8 (7%), Hinman-Allen syndrome in 5 (4%), and miscellaneous in 11 (9%). A detubularized ileal augmentation was used in 82 (67%) patients. In 36 (30%) a detubularized ileocecocystoplasty was fashioned and in the remainder detubularized sigmoid was used. In 19 patients augmentation accompanied undiversion. Sixteen patients had a simultaneous fascial sling for urethral incompetence. Mean follow-up was 37 months (range 6-96 months). There was no postoperative mortality. During follow-up 4 patients died from unrelated causes, 11 have been lost to follow-up, and 5 patients await planned transplantation. Bladder capacity was increased from a preoperative mean of 108 ml (range 15-500 ml) to 438 ml (200-1,200 ml) postoperatively. Of the 106 assessable patients, 80 (75%) had an excellent result, 21 (20%) were improved, and 5 (5%) had major ongoing problems. During the period of follow-up, 17 (16%) patients underwent revision of their augmentation. Twenty-four (21%) patients developed bladder stones and 30% of these did so more than once. Urinary incontinence became manifest in 15 (13%) patients but required surgical treatment in only half of these. Pyelonephritis occurred in 13 (11%) patients. Five patients developed small bowel obstruction following discharge from hospital. There were 7 instances of reservoir rupture in 5 (4%) patients. Augmentation cystoplasty has a pivotal role in the treatment of a broad range of lower and upper urinary tract problems. Careful patient selection and close follow-up are essential.

Partial bladder reconstruction with pedicled rectus and gracilis muscle flaps: an experimental study in dogs

OBJECTIVE

To investigate the functional, anatomical and histopathological results of partial bladder reconstruction with skeletal muscle flaps.

MATERIALS AND METHODS

Partial bladder reconstruction with gracilis or rectus muscle flaps was performed in 10 mongrel dogs. Bladder compliance and uninhibited contractions were investigated in five female dogs. Pre-operative and post-operative cystograms were performed in four female dogs. The dogs were killed 8-12 weeks after the operation. Bladders and muscle flaps were grossly examined and removed for histopathological examination.

RESULTS

There was no extravasation on post-operative cystography. Bladder compliance was normal and uninhibited contractions were not present. Severe contracture and atrophy of the muscle flaps were observed in all dogs at necropsy. Bladder volumes were not changed significantly (P > 0.05). Histopathological examination revealed severe mesenchymal metaplasia in all of the flaps.

CONCLUSION

Partial reconstruction of the bladder with skeletal muscle flaps did not result in extravasation and bladder function was not altered. However, bladder volume could not be increased because of contracture and atrophy of the flaps.

Early clinical experience with adult bladder auto-augmentation

Five patients 18 to 73 years old underwent auto-augmentation for a small capacity, poorly compliant bladder. The mean operative time and hospital stay were 106 minutes and 6 days, respectively. No postoperative complications occurred. Followup ranged from 12 to 82 weeks. Bladder capacity increased from 75 to 310 cc or 40 to 310%. Compliance also improved in all patients. Three patients had reflux preoperatively, which resolved in 1 and improved in 2. Of 4 patients who were incontinent preoperatively 3 became continent postoperatively and extended the interval between catheterizations. Upper tract function has remained stable. No patient required enterocystoplasty to control bladder pressures.

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.

Lithogenic properties of enterocystoplasty

Calculi formed in 26 of 87 patients (30%) following augmentation enterocystoplasty, of which 23 formed within the reservoir, at a mean interval of 25 months postoperatively. The calculi were composed principally of triple phosphates suggesting an important etiological role of bacteriuria and the urease reaction. Open cystolithotomy was the most successful means of removing the calculi.

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.

Bladder neoplasms associated with augmentation cystoplasty: report of 2 cases and literature review

Bladder neoplasms associated with augmentation cystoplasty have been reported to date in 12 patients. We add 2 cases: 1 with invasive transitional cell carcinoma involving the native bladder and bowel segment, and 1 with a poorly differentiated invasive oat cell (small cell) carcinoma confined to the bladder. The predisposing factors and pertinent literature are reviewed.