Gastrointestinal complications of gastrocystoplasty

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.

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.

Preliminary report of electrogastrography in pediatric gastroresection: can it be predictive of alteration of gastric motility?

BACKGROUND/PURPOSE

Gastric resection is an infrequent surgical procedure in childhood. However, the use of the stomach for bladder augmentation and substitution is well documented. Partial gastrectomy performed in gastrocystoplasty (GCP) involves the greater curvature of the stomach, the same area in which gastric pace-maker cells are known to be placed. The aim of this study was to assess, by electrogastrography (EGG), if subtotal gastric resection can alter gastric motility in children submitted to partial gastrectomy for GCP.

METHODS

Gastric electrical activity (GEA) was evaluated in 25 children using EGG: 10 patients (4 boys, 6 girls; mean age, 11.6 years) previously submitted to GCP, and 15 normal subjects (12 boys, 3 girls; mean age, 8.62 +/- 2.77 years) as controls. All patients were submitted to cutaneous EGG; recording GEA for 30 minutes before and after a standard test meal. The percentage of 3 cycles per minute (3CPM), bradygastria, tachygastria, DFIC (dominant frequency instability coefficient), DPIC (dominant power instability coefficient), PDP (period dominant power), PDF (period dominant frequency) were recorded and analyzed using Wilcoxon matched-pair test. Data were considered statistically significant if P <.05.

RESULTS

Normal subjects as well as operated patients showed a statistically significant difference in bradygastria (P =.05), PDP and PDF (P =.05) percentage, comparing pre versus postprandial period. In the normal group, 3CPM (P =.0012) and DFIC (P =.0008) were statistically different between the pre- and postprandial period. Patients who underwent GCP did not show any statistically significant difference in 3CPM and DFIC pre- and postprandial.

CONCLUSIONS

In normal subjects, GEA showed a complete variation after the meal, whereas in operated patients GEA was impaired and only partially modified after the meal. This observation suggests that in patients with gastric resection, adaptation of the stomach to food ingestion is present but incomplete with respect to normal subjects; it can be caused by surgical removal of the pace-maker cells of the greater curvature. For this reason a follow-up analysis of gastric function is recommended for all patients undergoing GCP.

Gastrocystoplasty and chronic renal failure: an acid-base metabolism study

PURPOSE

To verify in an experimental model whether gastrocystoplasty may protect patients with chronic renal failure from acid loading associated acidosis a wedge-shaped portion of the middle stomach was used to improve bladder capacity in animals with chronic renal failure.

MATERIALS AND METHODS

An experimental model was used to study 112 adult female Wistar rats (EPM-1) weighing between 156 and 259 gm. The animals were randomly assigned to groups, including 41 controls, 24 undergoing five-sixths nephrectomy to create chronic renal failure, 26 undergoing gastrocystoplasty and 21 undergoing gastrocystoplasty and five-sixths nephrectomy to create renal failure. To provide an acid overload a 5% NH(4)Cl diet was administered to a subgroup of each group. Two months after surgery 24-hour urine was collected, and volume and pH were measured as well as the amount of bicarbonate, ammonium, titratable acidity and chloride. The animals were then exsanguinated through an abdominal aorta puncture. The blood was used for blood gas analysis and to measure sodium, potassium, chloride, ionized calcium and creatinine.

RESULTS

When undergoing an acid overload, the animals with gastrocystoplasty had no acidosis since acid radicals were eliminating in the urine as NH(4)Cl. When given the same acid overload, metabolic acidosis developed in the animals with gastrocystoplasty and chronic renal failure.

CONCLUSIONS

Gastrocystoplasty protected healthy rats from acidosis when they were given an acid overload but failed to protect the rats with chronic renal failure under the same conditions.

Bladder calculi in augmentation cystoplasty in children

OBJECTIVES

To determine the best preventive strategies for bladder calculi in children with an augmented bladder, the risk factors and prevention strategies for urolithiasis were evaluated.

METHODS

The records of 89 patients following augmentation cystoplasty were reviewed to assess the results of augmentation cystoplasties and in particular the formation and prevention of calculi.

RESULTS

The median follow-up was 4.9 years after augmentation. Most patients (71) had an ileocystoplasty. Bladder calculi occurred in 14 of the 89 patients (16%) and recurred in 4 patients. Girls had a higher incidence of urolithiasis. Other risk factors were cloacal malformations, vaginal reconstructions, anal atresia, clean intermittent catheterization problems and retention, bladder neck surgery, and symptomatic urinary tract infections.

CONCLUSIONS

Subgroups with cloacal malformations, vaginal reconstructions, ureter reimplantation, and bladder neck surgery were identified that have an increased risk for stone formation and therefore warrant special care in the follow-up after augmentation. This care should include clear emphasis on the role of treating symptomatic urinary tract infections, especially in patients with cloacal malformations and vaginal reconstructions. Girls have a higher incidence of bladder calculi than boys.

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.

Female bladder exstrophy

Bladder exstrophy is one of the most challenging congenital urinary tract abnormalities. Apart from the open bladder the patient also has various other abnormalities, including urogenital, musculoskeletal and anorectal defects. The size of the exstrophic bladder varies from patient to patient. In the female the clitoris to bifid and the vagina is anteriorly placed. In this paper various aspects of female bladder exstrophy are reviewed in detail, including incidence, etiology, anatomy and clinical features, together with early, medium-term and long-term surgical management. The aim is to achieve a functional bladder closure, although some patients are better off with a urinary diversion. Considering the complexity of the urogenital problems and the surgical management thereof, all patients require lifelong follow-up.

Gastrocystoplasty: technical and metabolic characteristics of the most versatile childhood bladder augmentation modality

The authors report on 23 patients who underwent complex continent urinary reconstructions, made successful by the selection of gastrocystoplasty as the chosen augmentation modality. The mean patient age was 6.1 years, and the mean weight was 17.9 kg. The minimum follow-up period was 1.5 years. The bladder capacity increased from a preoperative mean of 77.8 +/- 52.2 (SD) mL to a postoperative mean of 303.5 +/- 117.4 mL (P < .000001). No adverse effects on renal function or serum electrolyte composition were encountered, and there were no instances of acidosis or alkalosis. Continence was achieved in 91% of patients. In two patients (0.9%), hematuria-dysuria developed; one case was extremely mild. The other occurred only during a period of severe oliguria and resolved after transplantation. Gastrointestinal complications were minimal. Five patients had end-stage renal disease at the time of reconstruction and have since had successful transplantation. Gastrocystoplasty is particularly applicable to the pediatric population because of its unique anatomic and metabolic characteristics, which bestow tremendous versatility.

Urodynamic and clinical follow-up of 28 children after gastrocystoplasty

OBJECTIVES

To determine the efficacy of gastrocystoplasty in creating a large and compliant urinary reservoir.

PATIENTS AND METHODS

Twenty-eight children (14 boys, 14 girls), with a median age of 9 years (range 4-17), were evaluated before and for a median of 2 years and 5 months after gastrocystoplasty. Evaluation included urodynamic and renal function studies and a survey of their post-operative complications and their sense of well-being. Renal function was assessed by ultrasound and serum creatinine, and electrolytes were measured.

RESULTS

After gastrocystoplasty bladder size increased, compliance improved, hydronephrosis decreased or was stable, and renal function remained stable. There were minimal complications and the children's subjective impression of their well-being was markedly improved.

CONCLUSION

Gastrocystoplasty, using our surgical technique, is a reliable method of creating a large and compliant urinary reservoir. Advantages include the absence of clinical urinary tract infections, the absence of mucus and the preservation of renal function. Complications, such as haematuria, dysuria and hypochloraemic alkalosis, might be avoided by excluding the antrum from the gastrocystoplasty, maintaining the child on a normal salt-containing diet, employing catheterization or buffering the urine in children with normal urethral sensation.

Autoaugmentation gastrocystoplasty: early clinical results

OBJECTIVE

To assess the urodynamic and clinical outcome of five patients following an autoaugmentation gastrocystoplasty.

PATIENTS AND METHODS

Four patients, two boys and two girls aged between 8 and 16 years, with a neuropathic bladder and incontinence, and one boy, aged 16 years, with an ileal conduit were included in the study. The bladder augmentation technique combined autoaugmentation and the addition of a demucosalized patch of gastric muscle to the created bladder diverticulum.

RESULTS

All patients have improved bladder function, although one may require further surgery. Three had temporary difficulty tolerating full meals.

CONCLUSIONS

This new technique seems to have a place in the management of the neuropathic bladder, but further laboratory study and cautious clinical application is required to ascertain its role in bladder augmentation.