Augmentation cystoplasty in neurogenic bladder

Treatment of neurogenic detrusor overactivity and overactive bladder with Botox (onabotulinumtoxinA): Development, insights, and impact

Neurogenic detrusor overactivity (NDO) is a complication of multiple sclerosis, spinal cord injury (SCI), stroke, head injury, and other conditions characterized by damage to the upper motor neuronal system. NDO often leads to high bladder pressure that may cause upper urinary tract damage and urinary incontinence (UI). Prior to the use of onabotulinumtoxinA, oral anticholinergics and surgical augmentation cystoplasty were the treatment options. Overactive bladder (OAB) is non-neurogenic and affects a much larger population than NDO. Both NDO and OAB negatively impact patients' quality of life (QOL) and confer high health care utilization burdens. Early positive results from pioneering investigators who injected onabotulinumtoxinA into the detrusor of patients with SCI caught the interest of Allergan, which then initiated collaborative clinical trials that resulted in FDA approval of onabotulinumtoxinA 200U in 2011 for NDO and 100U in 2013 for patients with OAB who inadequately respond to or are intolerant of an anticholinergic. These randomized, double-blind, placebo-controlled trials for NDO showed significant improvements in UI episodes, urodynamic parameters, and QOL; the most frequent adverse events were urinary tract infection (UTI) and urinary retention. Similarly, randomized, double-blind, placebo-controlled trials of onabotulinumtoxinA 100U for OAB found significant improvements in UI episodes, treatment benefit, and QOL; UTI and dysuria were the most common adverse events. Long-term studies in NDO and OAB showed sustained effectiveness and safety with repeat injections of onabotulinumtoxinA, the use of which has profoundly improved the QOL of patients failing anticholinergic therapy and has expanded the utilization of onabotulinumtoxinA into smooth muscle.

Treating Neurogenic Lower Urinary Tract Dysfunction in Chronic Spinal Cord Injury Patients-When Intravesical Botox Injection or Urethral Botox Injection Are Indicated

Lower urinary tract symptoms (LUTS), such as urgency, urinary incontinence, and/or difficulty voiding, hamper the quality of life (QoL) of patients with spinal cord injury (SCI). If not managed adequately, urological complications, such as urinary tract infection or renal function deterioration, may further deteriorate the patient's QoL. Botulinum toxin A (BoNT-A) injection within the detrusor muscle or urethral sphincter yields satisfactory therapeutic effects for treating urinary incontinence or facilitating efficient voiding; however, adverse effects inevitably follow its therapeutic efficacy. It is important to weigh the merits and demerits of BoNT-A injection for LUTS and provide an optimal management strategy for SCI patients. This paper summarizes different aspects of the application of BoNT-A injection for lower urinary tract dysfunctions in SCI patients and provides an overview of the benefits and drawbacks of this treatment.

The concerns of mechanical upper urinary tract obstruction in neurogenic lower urinary tract dysfunction: Beyond augmentation cystoplasty

Purpose

To evaluate the efficacy of augmentation uretero-enterocystoplasty (AUEC), a modified surgical procedure that focuses the mobilization of the ureter and the necessity of ureteroplasty in a series of neurogenic lower urinary tract dysfunction (NLUTD) patients with mechanical upper urinary tract obstruction (mUUTO).

Methods

We retrospectively reviewed the medical records of NLUTD patients who underwent an AUEC from 2005 to 2022. mUUTO was diagnosed by preoperative bladder drainage, magnetic resonance urography (MRU), and isotope renography. Upper urinary tract dilatation (UUTD) was evaluated using MRU with the Liao MRU-UUTD system.

Results

A total of 58 patients and 103 ureters were analyzed. Improvement in maximum bladder capacity (from 79.0 [41.3-163.8] to 500.0 [450.0-597.5] ml, P < 0.001), maximum detrusor pressure (from 32.0 [13.0-50.8] to 5.5 [4.0-10.0] cmH₂O, P < 0.001) and bladder compliance (from 6.5 [3.0-11.9] to 50.1 [37.5-65.0] ml/cmH₂O, P < 0.001), and stabilization of serum creatine (93.4 [73.0-142.7] to 94.9 [72.2-148.7] μmol/L, P = 0.886) were observed. The proportion of high-grade UUTD was significantly reduced after the surgery (92.3% vs. 13.5%, 92.1% to 9.8%, P < 0.001), and the typical imaging signs of preoperative obstruction disappeared.

Conclusion

Beyond traditional augmentation cystoplasty, more attention should be paid to the relief of mUUTO and mobilization of the ureter in NLUTD patients.

Retrospective analysis of bladder perforation risk in patients after augmentation cystoplasty using an extraperitoneal approach

BACKGROUND

Initial management of pediatric patients with neurogenic bladder is focused on clean intermittent catheterization and medical therapies. Those with more hostile or small capacity bladders require surgical intervention including bladder augmentation that can result in significant clinical sequelae. This study examines a rarely described approach wherein the bladder reconstruction is extraperitonealized by bringing bowel segments through a peritoneal window and then closed.

OBJECTIVE

The aim of this study was to determine if the rate of bladder rupture and subsequent morbidity differed between patients who have undergone an intraperitoneal versus extraperitoneal bladder augmentation. We hypothesized that an extraperitoneal approach reduced the risk of intraperitoneal bladder perforation, downstream Intensive Care Unit (ICU) admission, small bowel obstruction (SBO) requiring exploratory laparotomy, and ventriculoperitoneal (VP) shunt-related difficulties as compared to the standard intraperitoneal technique.

METHODS

A retrospective chart review was conducted to assess surgical approach and outcomes in patients who underwent bladder augmentation performed between January 2009 and June 2021. Patients were identified through an existing database and manual chart review was conducted to extract data through imaging studies, operative notes, and clinical documentation. The primary outcome was bladder perforation. Secondary outcomes were ICU admission, exploratory laparotomy, and VP shunt externalization, infection, or revision for any cause. Nonparametric statistical analyses were performed.

RESULTS

A total of 111 patients underwent bladder augmentation with 37 intraperitoneal and 74 extraperitoneal procedures. Median follow up was 5.8 years [IQR 3.0-8.6 years] and did not vary between groups (P = 0.67). Only one patient was found to have a bladder perforation in the intraperitoneal group (log-rank P = 0.154). There were no significant differences in time to post-augmentation ICU admission, exploratory laparotomy, or VP shunt events between the two groups (log-rank P = 0.294, log-rank P = 0.832, and log-rank P = 0.237, respectively). Furthermore, a Kaplan-Meier analysis assessing time to composite complication demonstrated no significant difference between the two techniques (log-rank P = 0.236).

DISCUSSION

This study provides important data comparing the rate of bladder perforation and subsequent morbidity between intraperitoneal and extraperitoneal bladder augmentation. As expected, with a complex procedure, both groups suffered complications, but these data showed no difference between the two procedures. Rates of prior (abdominal) surgery may influence the decision to perform this procedure extraperitoneal.

CONCLUSIONS

Outcomes related to bladder perforation and secondary consequences do not differ significantly between patients who had bladder augmentation performed with an intraperitoneal versus extraperitoneal approach. Given the low number of adverse events in this study, larger studies are warranted.

Successful engraftment of bladder organoids in de-epithelialized mouse colon

PURPOSE

To engraft bladder organoids (BO) on de-epithelialized mouse colon using an epithelial replacement technique.

METHODS

BO cultured using bladder specimens from enhanced green fluorescent protein (EGFP) transgenic mice were engrafted to replace proximal colon epithelium stripped from an approximately 1 cm long target site in syngeneic wild-type recipient mice (n = 9) by exposure to ethylenediaminetetraacetic acid by infusion and flushing with phosphate buffered saline. Target sites were harvested on postoperative days 2, 7, and 28 for hematoxylin-eosin staining and immunofluorescence.

RESULTS

Histology on postoperative days 7 and 28 showed BO derived EGFP + cells forming multiple layers on the luminal surface of the colon. Immunohistochemistry showed that EGFP + areas were positive for CK5 and CK14, markers for basal and immature subtype urothelium, respectively, but negative for CA2, a marker for colonic epithelium. Ki67 was detected predominantly in the basal parts of EGFP + areas on postoperative day 7 and day 28.

CONCLUSIONS

This is the first report of successful engraftment of BO in de-epithelialized colon with urothelial tissue reconstituted by actively proliferating cells. This technique could be developed for augmentation cystoplasty to prevent bladder calculi formation and malignant transformation.

The Significance of Biomechanics and Scaffold Structure for Bladder Tissue Engineering

Current approaches for bladder reconstruction surgery are associated with many morbidities. Tissue engineering is considered an ideal approach to create constructs capable of restoring the function of the bladder wall. However, many constructs to date have failed to create a sufficient improvement in bladder capacity due to insufficient neobladder compliance. This review evaluates the biomechanical properties of the bladder wall and how the current reconstructive materials aim to meet this need. To date, limited data from mechanical testing and tissue anisotropy make it challenging to reach a consensus on the native properties of the bladder wall. Many of the materials whose mechanical properties have been quantified do not fall within the range of mechanical properties measured for native bladder wall tissue. Many promising new materials have yet to be mechanically quantified, which makes it difficult to ascertain their likely effectiveness. The impact of scaffold structures and the long-term effect of implanting these materials on their inherent mechanical properties are areas yet to be widely investigated that could provide important insight into the likely longevity of the neobladder construct. In conclusion, there are many opportunities for further investigation into novel materials for bladder reconstruction. Currently, the field would benefit from a consensus on the target values of key mechanical parameters for bladder wall scaffolds.

Introducing a novel experimental model of bladder transplantation in mice

Bladder dysfunction is a common clinical problem attributed to various conditions such as posterior urethral valves, neurogenic bladder, ureteral ectopy, or bladder exstrophy. Currently, the main therapeutic option for these dysfunctions is neobladder reconstruction with gastrointestinal tract segments. However, the latter was associated with significant long-term complications. To provide a new candidate of possible surgical solution for bladder dysfunction, we propose a novel orthotropic mouse bladder transplantation model. The donor bladder with abdominal aorta and inferior vena cava was isolated and orthotopically sutured to the recipient, whose bladder above the ureteral opening level was removed. The recipient mice showed more than 80% 6-month survival rate and comparable body weight to control mice. At both 1 month and 6 months posttransplant, the urine voiding behavior of recipient mice and control mice was monitored by cystometry. We found that the recipient mice displayed similar bladder pressure and urine secretion ability compared to control mice especially at 6 months posttransplant. Similarity of bladder structure between recipient and control mice was confirmed by histology. As a proof of principle, we tested our model in an allogeneic setting. Early acute rejection was noted after day 5 that was histologically more profound by day 10 posttransplant. These results indicate that the mouse bladder transplant is able to provide normal bladder function.

Robot-assisted Supratrigonal Cystectomy and Augmentation Cystoplasty with Totally Intracorporeal Reconstruction in Neurourological Patients: Technique Description and Preliminary Results

BACKGROUND

Augmentation cystoplasty as a third-line therapy for neurogenic detrusor overactivity performed by an open approach has long been studied. Few laparoscopic and robot-assisted series have been reported.

OBJECTIVE

To evaluate the feasibility, safety, and functional outcomes of completely intracorporeal robot-assisted supratrigonal cystectomy and augmentation cystoplasty (RASCAC) in patients with refractory neurogenic detrusor overactivity.

DESIGN, SETTING, AND PARTICIPANTS

We identified all patients undergoing RASCAC, as treatment for refractory neurogenic detrusor overactivity, from August 2016 to April 2018.

SURGICAL PROCEDURE

RASCAC was performed in all cases using a standardized technique with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in a four-arm configuration.

MEASUREMENTS

Perioperative data, and functional and urodynamic results at 1-yr follow-up were assessed. Statistical analysis was performed using Stata version 15.1.

RESULTS AND LIMITATIONS

Ten patients were identified. No conversion to open surgery was needed. The median operative time was 250 (interquartile range 210-268) min, the median estimated blood loss was 75 (50-255) ml, and the median hospitalization time was 12 (10.5-13) d. The 30-d major complication rate was 10%. Two patients presented a late urinary fistula; in one of the cases, surgical revision was needed. In both cases, low compliance to intermittent self-catheterization was identified. At 1-yr follow-up, functional and urodynamic outcomes were excellent.

CONCLUSIONS

Robot-assisted augmentation cystoplasty has been shown to be safe and feasible, with a reasonable operative time and low complication rate in experienced hands. A higher number of patients and longer follow-up are, however, warranted to draw definitive conclusions.

PATIENT SUMMARY

In this report, we look at the outcomes of robot-assisted supratrigonal cystectomy and augmentation cystoplasty in neurourological patients. Perioperative, functional, and urodynamic results are promising. Further studies with a longer follow-up are needed to confirm these findings.

Pediatric bladder augmentation - Panacea or Pandora's box?

INTRODUCTION

Bladder augmentation is a surgery that can increase bladder capacity and compliance. The objective of this study was to provide a longitudinal review of pediatric bladder augmentation at a tertiary Canadian center.

METHODS

A retrospective review was performed on patients who underwent bladder augmentation at a tertiary pediatric hospital between 1986 and 2014. The primary objective was short- and long-term complications of augmentation. Secondary objectives were to review number of augmentation procedures performed over time and the utility of routine postoperative cystograms.

RESULTS

A total of 56 procedures were performed on 54 patients (28 males, 26 females) of mean age 10 years (standard deviation [SD] 5) and mean followup eight years (SD 5). The most common bowel segment used was ileum (87.5%). Twenty-eight patients (50%) received catheterizable channels. Overall complication rate was 15% and the most common complications were urinary tract infections (68.5%), worsening hydronephrosis (14.8%), bladder stone formation (14%), and hematuria (13%). In total, 19 of 54 (35.2%) patients returned to the operating room. The incidence of bladder perforation was 3.6%. Complications with the catheterizable channel occurred in 13 of 28 (46.4%), of which 10 were related to stomal stenosis. Forty patients had postoperative cystograms and extravasation was seen in three (7.5%). There was no malignancy during the followup. Only four augmentations were performed from 2008-2014.

CONCLUSIONS

Bladder augmentation likely represents a safe surgical treatment option. Extravasation on postoperative cystogram was uncommon and, thus, it may not be indicated routinely. The number of augmentation procedures performed has declined in recent years.

Use of the extracellular matrix from the porcine esophagus as a graft for bladder enlargement

INTRODUCTION

Some patients with diseases that involve increased bladder pressure or low-capacity bladders may need bladder enlargement surgery. In current techniques for bladder enlargement, autologous tissue such as small intestine or colon tissue is used to perform cystoplasties, which is far from ideal for these patients. In search of biomaterials with appropriate regeneration and safety profiles, tissue engineering has resulted in preclinical studies with acellular matrices in animal models that have yielded positive preliminary results with respect to the urothelial cell and smooth muscle repopulation; these studies have primarily been performed with matrices originating from the bladder or intestinal submucosa.

OBJECTIVE

The aim of the study was to assess an extracellular matrix device derived from the porcine esophagus for augmentation cystoplasty in an animal model.

STUDY DESIGN

Seven male Wistar rats weighing 357-390 g were subjected to augmentation cystoplasty with a circular segment of the acellular matrix from the porcine esophagus. Daily postoperative follow-up was performed with evaluation of changes in body weight, behavior, and wound status.

RESULTS

During follow-up, there were no complications associated with the process. Three specimens were sacrificed at day 30, and three, at day 60. Necropsy was performed, with a description of the macroscopic findings and a morphological study. Epithelialization was observed, with different stages of mucosal development in all specimens analyzed. Repopulation of smooth muscle cells, mixed inflammatory infiltrate, and vascular neoformation were identified in the matrices.

DISCUSSION

The urothelium and fibers of the smooth muscle were observed inside the implanted matrix. Additional investigations in larger animal models that allow urodynamic evaluation of the bladder with the matrix implanted are needed. However, to compare the results of this study model with those reported in the literature, a matrix derived from an organ different from the bladder was used because it could prevent the use of an intestinal segment in augmentation cystoplasty.

CONCLUSION

The acellular porcine esophagus matrix offers positive results regarding the repopulation of the urothelium and smooth muscle when used in augmentation cystoplasty in a murine model.

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.

Perioperative care of a patient with clam cystoileoplasty undergoing caesarean section: A case review

This case report describes the care provided to a 35-year-old primagravida having an elective section who had undergone clam cystoileoplasty eight years prior. It examines the literature relating to this surgical technique and its implications for obstetric practice. It also examines anaesthetic considerations related to the surgery. Close involvement with urology surgeons is essential and the patient must be supported in their choices relating to ongoing management of continence.