AUTHOR AND EDITOR INFORMATION

Section 1 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

INTRODUCTION

Section 2 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Bladder augmentation, also called augmentation cystoplasty (AC), is a surgical procedure used in adults and children who lack adequate bladder capacity or detrusor compliance. Decreased bladder capacity or abnormal compliance may manifest as debilitating urgency, frequency, incontinence, recurrent urinary tract infections (UTIs), pyelonephritis, or progressive renal insufficiency. For many patients, augmentation cystoplasty can provide a safe functional reservoir that allows for urinary continence and prevention of upper tract deterioration.

History of the Procedure

Augmentation cystoplasty with a segment of native tissue (usually an intestinal segment), was first performed in the late 1880s in animals and in the 1890s in humans. The original indication for the procedure was a small contracted bladder caused by tuberculous cystitis. Since that time, advances in surgical technique, perioperative care, and antibiotics have greatly improved outcomes.

Because the augmented bladder typically empties poorly, the introduction of clean intermittent catheterization by Lapides et al in the early 1970s was pivotal in allowing the widespread use of augmentation cystoplasty.¹ This allowed convenient, controlled bladder emptying of a safe, functional reservoir.

Etiology

Both neuropathic and non-neuropathic causes for severe bladder dysfunction exist in pediatric and adult populations.

Neuropathic causes include the following:

• Spinal cord injury
• Multiple sclerosis
• Myelodysplasia
• Tethered spinal cord

Non-neuropathic causes include the following:

• Detrusor instability
• Chronic cystitis, including tuberculosis and schistosomiasis
• Interstitial cystitis
• Radiation cystitis
• Classic or cloacal exstrophy
• Defunctionalized bladder in a patient who is on dialysis

Clinical

Decreased bladder capacity or abnormal compliance may manifest as debilitating urgency, frequency, incontinence, recurrent UTIs, pyelonephritis, or progressive renal insufficiency.

• Urodynamics demonstrate a low-volume, poorly compliant reservoir, placing the kidneys at risk from high-pressure urinary storage.
• Simultaneous fluoroscopic videourodynamics may reveal vesicoureteral reflux.
• Renal ultrasonography or other imaging modalities may show renal scarring or impaired renal growth due to high-pressure urinary storage.

INDICATIONS

Section 3 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Any patient with marked reduction in bladder capacity or compliance may be a candidate for augmentation cystoplasty. Conservative management for these patients usually consists of intermittent self-catheterization and anticholinergic medications. Augmentation cystoplasty is considered when bothersome symptoms impair a patient’s lifestyle despite medical treatment or when high-pressure urinary storage places the upper urinary tracts at risk.

Neurogenic bladder in the pediatric population is often associated with congenital anomalies, including the following:

• Spina bifida/myelomeningocele
• Posterior urethral valves
• Prune belly syndrome (Eagle-Barrett syndrome)
• Bladder exstrophy
• Cloacal exstrophy

Patients with these conditions most commonly undergo augmentation cystoplasty when, despite behavioral and medical management, they experience continued incontinence, debilitating urgency, enuresis, complicated UTIs, vesicoureteral reflux, or impaired renal growth.

Some adult patients who underwent urinary diversion for an embryologic urinary defect as a child seek a healthier cosmetic and functional state. In other cases, adults have an acquired cause for bladder dysfunction, including some of those discussed in Etiology. Adults may present with symptoms very similar to those of children with congenital abnormalities. Again, surgery is indicated for adults with refractory symptoms and those with risk or progression of upper tract deterioration.

RELEVANT ANATOMY

Section 4 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

See Intraoperative details for a discussion of relevant anatomy.

CONTRAINDICATIONS

Section 5 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Patients who are unable or unwilling to perform life-long intermittent catheterization should not undergo augmentation cystoplasty because of the high likelihood of ultimately requiring catheterization.

Poor surgical candidates and patients with a short life expectancy should consider alternatives such as continued medical management or creation of a less complex, temporizing form of urinary drainage.

WORKUP

Section 6 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Lab Studies

• Urine analysis, urine culture, and cytology (in adults) allow proper preoperative treatment of infection and investigation of potential occult malignancy. Sterile urine at the time of surgery is crucial in all patients, especially those with ventriculoperitoneal shunts.
• Obtain a serum chemistry panel to rule out metabolic acidosis and to allow for assessment of renal failure with and without surgical therapy.
• Conduct a complete blood cell count to identify anemia or infection.

Imaging Studies

• Imaging studies of the kidneys and upper urinary tract with renal ultrasonography are used to assess any upper tract anomalies and renal parenchyma.
• In the presence of hydronephrosis, upper tract obstruction (eg, ureteropelvic junction obstruction) should be ruled out in addition to lower tract pathology.
• Voiding cystourethrography should be performed to evaluate the bladder size and contour, the presence of any diverticula, the anatomy of the bladder neck, and the presence of vesicoureteral reflux. This can also be performed as part of videourodynamic evaluation.

Other Tests

• Assess urinary continence with a voiding diary and Valsalva leak point pressure.
• Urodynamics should be performed if the patient has a history of dysfunctional voiding, although some surgeons perform this test in all patients in whom augmentation cystoplasty is being considered. Consider fluoroscopic video monitoring to assess for vesicoureteral reflux and to determine the bladder pressures at which reflux occurs.
• Twenty-four–hour urine-volume assessment helps to plan final reservoir size.

Diagnostic Procedures

• Cystoscopy, which can be performed under the same anesthesia immediately prior to augmentation cystoplasty, is useful to identify occult urethral valves, strictures, or unsuspected bladder pathology.
• Colonoscopy or barium enema may be considered in the older patient who has a potential for diverticular disease or colon cancer. This is even more important if the large intestine is the planned segment for augmentation cystoplasty.

TREATMENT

Section 7 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Medical therapy

Prior to consideration for augmentation cystoplasty, patients should have timed voids as often as necessary to maintain low bladder volume and pressure.

Anticholinergic medications (eg, oxybutynin, hyoscyamine, tolterodine): These medications decrease detrusor instability and symptoms of urgency. Medical management also allows increased bladder volume to protect renal function and to decrease the chance of pyelonephritis. The increase in bladder capacity with medical treatment has been modest (generally <50 mL), but some groups have found that higher doses may increase the effect, as Ellsworth et al (2005) demonstrated in young children with neurogenic bladders.²

Intermittent catheterization: Lack of coordinated detrusor contraction or increased bladder outlet obstruction (eg, external sphincter dyssynergia) can be overcome with intermittent self-catheterization at 4- to 6-hour intervals. This usually reduces bladder pressure and improves continence.

Intermittent catheterization and anticholinergic management are usually used in combination to accomplish symptom-management goals, to create continence, to eliminate vesicoureteral reflux, to prevent UTIs, and to ensure low bladder storage pressure. If these measure fail, augmentation cystoplasty should be considered.

Surgical therapy

Bladder-augmentation candidates may have 2 less-invasive surgical options prior to augmentation cystoplasty. These include cystoscopic injection of botulinum toxin A and sacral neuromodulation.

Botulinum toxin A injections are used in some patients with overactive bladder and may benefit bladder-augmentation candidates. Some small studies have demonstrated significant increases in bladder volumes, often superior to those seen with oral medications.^{3, 4, 5} However, in patients with extremely reduced bladder compliance or volume, this treatment may not be adequate or durable. Furthermore, Schurch et al (2007) demonstrated that botulinum toxin injections improved quality-of-life scores in many patients with neurogenic incontinence despite oral anticholinergic therapy.⁶

Sacral neuromodulation (also known as sacral nerve stimulation [SNS]), is a minimally invasive technique that has markedly improvemed bladder volume, urge symptoms, and incontinence rates in patients with detrusor overactivity and urge urinary incontinence. The procedure can also help patients with urinary retention with high residual volumes after voiding. In the first stage of this procedure, tunneled leads are placed, usually in the S3 foramen. After a trial of efficacy with an external device, the implantable neuromodulator is implanted in the second stage. Initial experience has shown promise as a way to avert major surgery in adult and pediatric patients who would otherwise be candidates for augmentation cystoplasty. Long-term follow-up is limited, but this appears to be a durable option.⁷

When medical treatment, behavioral modifications, and other less-invasive options fail, formal surgical therapy with augmentation cystoplasty is warranted. Failure is defined as debilitating urinary symptoms (eg, frequency, urgency, incontinence) or bladder-storage pressures (ie, >40 cm H₂0) that risk damage to the renal parenchyma. Appropriately counsel patients regarding the risks, benefits, requirements, and lifestyle impact of the operation.

When deciding among urinary conduit diversion, orthotopic bladder substitution, and augmentation cystoplasty, also consider patient renal function, serum acid or base status, and the potential need for dialysis.

Preoperative details

Adult patients should have good manual dexterity, proven by performing self-catheterization in front of the physician. In pediatric patients, the parents must be committed to catheterizing the child at least every 4-6 hours. Parents must be taught catheterization before surgery. Other preoperative considerations include planning for concomitant procedures, selection of enteric segments to be used, and bowel preparation.

Planning for concomitant procedures

• Some patients who are candidates for augmentation cystoplasty also have ureteral reflux.
• • Patients who have bladder exstrophy and who require augmentation cystoplasty should undergo simultaneous ureteral reimplantation. These patients have abnormal ureteral insertions to the bladder, and, with bladder neck repair for continence, they often have elevated bladder pressures. Thus, tunneled reimplantation is almost universally performed, usually in a cephalad manner toward the bladder dome to follow the course of the ureter.
  • The role of ureteroneocystostomy in other patients is less clear.
  • In patients with reflux at high bladder pressures, the augmentation procedure will hopefully resolve this issue.
  • However, if low pressure causes reflux, the problem may persist after augmentation. If a patient has grade 4 or 5 ureteral reflux at bladder-filling pressures of less than 40 cm H₂O, tunneled ureteral reimplantation into the native bladder tissue should be more strongly considered. Patients with low-grade reflux (ie, grade 1 or 2) at higher bladder pressures may undergo augmentation with the hope that the reflux will resolve with decreased bladder storage pressures.
  • A history of renal scarring, history of pyelonephritis, renal function, and the patient’s willingness to undergo future surgery should all be considered in counseling the patients and parents and deciding whether to perform concomitant ureteral reimplantation at the time of augmentation cystoplasty. In adult patients in whom continent catheterizable stoma is planned, some surgeons routinely perform bladder-neck closure; however, if the outlet is intact and continent, it should be maintained to provide an alternative route for catheterization. Importantly, many feel that surveillance endoscopy is much easier in patients with an open bladder neck.
• Associated urologic or gastrointestinal issues due to congenital anomalies or acquired neurologic impairment may necessitate concomitant procedures.
• • Urinary continence can be achieved with an artificial urinary sphincter (in males) or a urethral sling placement (in females).
  • Construction of a continent catheterizable stoma assists with urinary emptying.
  • A Malone antegrade catheterizable enema (MACE) procedure is used for neurogenic constipation.
  • In 2005 and 2007, De et al discussed augmentation cystoplasty as an ancillary procedure to salvage prostatectomy after failed radiation therapy for localized prostate cancer.^{8, 9} Because of the high risk of high-bother urinary incontinence in such patients, these authors studied salvage prostatectomy with concomitant ileal augmentation, bladder neck closure, and creation of a catheterizable appendicovesicostomy or Monti procedure. In this small uncontrolled study, improved continence was reported, and 7 of 9 patients who responded to a quality-of-life questionnaire reported that they would undergo the operation again.
  • In patients undergoing retropubic prostatectomy as primary treatment for prostate cancer who are at high risk of bladder dysfunction due to longstanding outlet obstruction, concomitant bladder augmentation is also an option.

Selection of tissue for augmentation cystoplasty

Proper selection of tissue segment begins with analyzing the patient’s anatomy and comorbidities but also requires consideration of intraoperative anatomic findings. Important preoperative considerations for the selection of tissue for augmentation cystoplasty include the following:

• Gastrocystoplasty can be considered in patients with renal insufficiency (creatinine level >2 mg/dL) or significant metabolic acidosis. Using a gastric segment does not appear to worsen the acidosis and may preserve renal function. However, this procedure can be difficult to perform, it does not eliminate the risk of severe electrolyte abnormalities, and a significant number of these patients develop dysuria.
• Patients who have a reduced amount of intestine (eg, anomalous short-gut, prior intestinal removal, cloacal exstrophy) may also be considered for augmentation cystoplasty with stomach rather than intestine. However, with short gut and cloacal exstrophy, with gastrointestinal consultation, ileum is also commonly used for Mitrofanoff channel and augmentation.
• Ureterocystoplasty is a favorable option in patients with a massively dilated ureter, as the use of ureteral tissue curbs the electrolyte imbalance and mucus production experienced with intestinal segments. If the ipsilateral kidney is minimally functional, nephrectomy can be performed at the time of surgery
• With removal of the ileocecal valve, patients with neuropathic causes for bladder dysfunction (eg, spina bifida) may experience severe diarrhea that can cause fecal incontinence; thus, the combined use of distal ileum and cecum is discouraged in these patients.
• In general, ileum and large intestine both handle well surgically and make excellent intestinal segments for augmentation. However, they both produce mucus and can have problematic peristalsis if not properly detubularized. Both segments are historically well-tested, and the use of one versus the other is largely surgeon's preference.
• Some patients with neurogenic bowel dysfunction have a redundant sigmoid colon, making this a good segment of choice. In addition, this is the preferred segment in patients who do not require continent catheterizable stoma.
• Jejunal segments are rarely used because of their importance in nutritional absorption and the severity of electrolyte abnormalities associated with its use.
• If a patient or their caretaker is poorly compliant, consider an incontinent ileovesicostomy (ileal chimney with stoma) to reduce the risk of perforation. This can be reversed when the patient can responsibly and independently manage the catheterization schedule.

Table 1. Comparison of Tissues for Augmentation Cystoplasty

Bowel preparation

• All patients undergoing augmentation cystoplasty require preoperative mechanical and antibiotic bowel preparation.
• Patients stay on a clear liquid diet for 2 days prior to the operation and take magnesium citrate the night before surgery.
• Preoperative inpatient hospital admission should be planned for patients with renal insufficiency, chronic constipation, or a high risk of dehydration so that intestinal evacuation can be performed with concomitant monitoring and treatment of serum electrolytes and fluid status.
• Scheduled oral erythromycin base and neomycin are often administered the night before surgery, and intravenous antibiotics are given one hour prior to the incision.

Intraoperative details

Two different methods can be used to prepare the bladder: (1) A U-shaped flap can be lifted with its base anterior upon the bladder or (2) the bladder can be opened via a sagittal incision extending from an anterior position posteriorly to the trigone.

If part of the bladder is being removed (eg, in patients with interstitial cystitis) to prevent symptom recurrence, note that the bulk of the bladder can be excised around the trigone. In this case, an orthotopic bladder substitution or continent urinary diversion may be a better option. The anastomosis should be widely patent as not to create a poorly draining diverticulum.

General principles of using enteric segments

• A standard midline laparotomy incision is used most often, although a lower abdominal transverse incision can be used for some nongastric enteric segments.
• Before dividing the intestine, test the mobility of the segment to ensure that it will reach the bladder without tension.
• Always create a vascular arcade within the mesentery to the isolated bowel segment.
• After re-establishing continuity of bowel segments, mesenteric defects should be closed to prevent internal hernia formation.
• Small bowel should not be divided more than 8 cm from an arcade artery to prevent ischemic necrosis.
• The abdomen should be packed and draped carefully to prevent contamination of the surgical field with enteric contents.
• Enteric segments should be irrigated thoroughly to remove gastrointestinal contents.
• Intestinal segments should be detubularized by incision with cautery on their antimesenteric side (see Image 1) to create a rectangular surface and to minimize forceful contractions in the augmented bladder.
• Intestinal segments should be sutured full-thickness with running absorbable suture, inverting the mucosal layer.
• A semispherical shape of the intestinal segment gives the augmented bladder maximal capacity and compliance.
• A wide anastomosis between the segment and the native bladder is important for optimal volume and drainage.
• A suprapubic tube should be placed through the opened bladder and brought out through a separate skin incision.
• A drain is placed near the bladder as an indicator for urine leak.

Ileocystoplasty

• The segment should be based 15-20 cm away from the ileocecal valve to preserve absorptive function of the terminal ileum.
• The segment of ileum should be approximately 15-40 cm long (most commonly 25 cm), depending on patient age and desired augment volume. A slightly longer segment is favored over one that is too short.
• Once the rectangular patch is formed, it can be folded and sutured into a U-shaped cup; longer segments can be folded into S- or W-shaped cups (see Image 2).
• Perform a vesicointestinal anastomosis in 1-2 layers using a 2-0 absorbable suture (see Image 3).

Sigmoid cystoplasty

• The sigmoid colon is the most commonly used segment of large intestine.
• Because of the strength of sigmoid contractions, proper detubularization of this segment is of particular importance.
• The surgical incision and exposure are similar to those used in ileocystoplasty.
• Inspect the sigmoid segment and palpate it to ensure that no pathology is present.
• A 15-20 cm segment should be used.
• The flap can be folded and sutured into an S- or U-shaped segment and anastomosed to the bladder in 2 layers with an absorbable suture.

Ileocecocystoplasty

• This segment is often used for patients who require a catheterizable stoma.
• The terminal ileum is narrowed over a catheter, and the continence mechanism of the ileocecal valve is supported by imbricating and intussuscepting the ileocecal junction.

Gastrocystoplasty

• A midline incision is made from the xiphoid process to the pubic symphysis.
• A 10-20 cm wedge of anterior and posterior stomach is isolated with the base along the greater curvature of the stomach. The apex should not extend to the lesser curvature, where branches of the vagus nerve can be damaged.
• The vascular segment used for the flap can be the right or left gastroepiploic artery; however, the right is often favored, as it is more frequently the dominant blood supply to the stomach.
• Reapproximate the stomach with 2 layers of absorbable sutures.
• Create windows in the transverse mesocolon and mesentery of the small intestine and bring the gastric wedge to the prepared bladder.
• Care should be taken to avoid twisting or angulating the vascular pedicle.
• The augmenting segment is anastomosed with 2 layers of absorbable sutures.

Ureterocystoplasty

• This procedure is possible only when the patient has massive ureteral dilation.
• The dilated ureter can be mobilized into the pelvis.
• Open the bladder in the sagittal plane and direct the posterior portion of the incision to the corresponding ureteral orifice.
• Do not separate the ureter from the bladder but fold it upon itself as a patching segment.
• Anastomose the ureter with an absorbable suture and patch it to the prepared bladder.
• If ipsilateral nephrectomy is not performed, be sure to preserve proximal ureteral blood supply.

Other options

Autoaugmentation (also called detrusor myectomy): In this procedure, the serosa and muscular components of the bladder dome are incised or excised, allowing the mucosa of the bladder to protrude out. The mucosa may then be left alone or supported by a cover of omentum or demucosalized bowel. An autoaugment can increase bladder volume and improve detrusor compliance without using enteric segments, significantly decreasing surgical morbidity.

Postoperative details

Intravenous fluids and nasogastric drainage are initially maintained for several days until the patient’s bowel function returns. Fluid and electrolyte status are monitored clinically with serum chemistry evaluation.

• Nasogastric tube decompression is typically maintained until bowel function is recovered, although some studies have found that this does not decrease early postoperative complications.
• Typically, a urethral Foley catheter and a suprapubic tube are used to drain the bladder, the latter exiting the abdomen directly or through the catheterizable stoma.
• The bladder should be manually irrigated 3 times per day and as needed to clear the suprapubic tube and urethral Foley of mucus.
• The pelvic drain can be removed when concern for urine leak is eliminated, either by low output or by fluid chemistries that indicate peritoneal fluid.
• The patient is discharged with the capped suprapubic tube in place and a urethral catheter draining the bladder. Taping the suprapubic tube to the abdomen can prevent unintentional manipulation.
• Low-dose antibiotic prophylaxis is continued for about 3 weeks postoperatively, until all catheters and drains are removed.
• During the first few postoperative weeks, the urethral catheter is removed, and the patient should begin catheterization at 2- to 3-hour intervals.
• The suprapubic tube should be irrigated 3 times per day to clear mucus.
• Cystography performed 2-3 weeks after surgery should confirm the augmented bladder's integrity prior to removal of the tube. To avoid false-negative urine-leak findings, the cystography should be performed with at least 300 mL of contrast.
• After removing the suprapubic tube, the patient may gradually increase the interval between intermittent catheterization to 4 hours. Patients should wake up at least once per night to catheterize.
• Patients without neurologic deficits may try to void, but postvoid residual volumes must be checked to ensure adequate emptying.

Follow-up

The patient should be seen for follow-up visits at 6 weeks, 3 months, 6 months, and yearly intervals. The focus is on preventing complications by monitoring with appropriate laboratory and radiologic studies.

• Serum electrolytes and renal panel should be monitored to assess the level of acidosis and the potential need for correction with alkali therapy.
• Renal and bladder ultrasonography is used to monitor for occult obstruction or calculi formation and to ensure appropriate renal growth in pediatric patients.
• Screening urine culture tests are used to check for bladder colonization with urease-producing bacteria; these species should be treated because they may cause bladder stones and have been associated with upper tract damage.
• Begin bladder malignancy screening 10 years after surgery with an annual cystoscopy, cytology, and biopsy if appropriate.
• Educate the patient about the symptoms of bladder perforation and the need for urgent treatment.

COMPLICATIONS

Section 8 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Perforation

Approximately 6% of patients who undergo augmentation cystoplasty experience perforation.¹⁰ These patients may present with various signs and symptoms, including acute abdomen or a vague illness with nausea, vomiting, fever, or abdominal distention. Patients are generally quite ill, and sepsis and death are possible.

Neurologically impaired patients with decreased abdominal sensation may present with different symptoms or may present later in the course than patients without neurological impairments.

Traditional or CT cystography (imaging after retrograde administration of intravesical contrast) is the best method of evaluation if the patient is clinically stable. Patients diagnosed with perforation of the augmented bladder and those who are hemodynamically unstable with suspected perforation require urgent operative exploration and repair.

Early perforation usually occurs along the anastomosis and is usually due to poor healing or technical issues. The etiology of late perforation is unclear; however, ischemia, infection, inflammation, and/or overdistention may be involved. Injury with self-catheterization may be responsible for some cases of perforation. Rivas et al (1996) showed in an animal model that augmented bladders stressed with infused volume tend to rupture within the dome (7 of 11 cases) and at a suture line (4 of 11 cases).¹¹

Consultation with a neurosurgeon should be considered in patients with a ventriculoperitoneal shunt who experience bladder perforation.

Urolithiasis and mucus

Stone formation, both of the kidney and of the bladder, occurs in 18-50% of patients after augmentation. Struvite is the most common stone compositing; thus, treatment should be initiated immediately for bacteruria with urea-splitting organisms. Other risk factors for stone formation include incomplete emptying (by poor voiding or by catheterization through a stoma) and increased mucus (which can serve as a nidus for stone formation). Large intestine creates more mucus than small intestine, and gastric patches produce little mucus. Gastrocystoplasty is also slightly protective against stones because of the increased acidity, which minimizes bacteria.

No uniform recommendations currently exist to guide the metabolic workup in patients with augmented bladders who form stones. A 24-hour urine profile for pH, volume, citrate, calcium, phosphorous, oxalate, and sodium, along with serum electrolytes and urine culture, is appropriate. A surveillance abdominal plain film obtained annually may be used to identify a few small stones before they grow into multiple large stones that require more involved treatment.

Treatment options for stones in the augmented bladder include (1) extracorporeal shockwave lithotripsy, (2) endoscopic fragmentation or removal through urethra or catheterizable stoma, (3) percutaneous fragmentation or removal, and (4) open surgery.

In addition to serving as a nidus for urolithiasis, mucus can obstruct the outlet and increase the possibility of infection or perforation. Daily irrigation may decrease the risk of these complications. Irrigants can include tap water, saline, urea, N-acetylcysteine, or 3% sodium chloride.

Metabolic derangements

Except for gastrocystoplasty, which causes hypokalemic hypochloremic metabolic alkalosis, most intestinal segments can cause metabolic acidosis. The jejunum, which is rarely used, can cause volume contraction and hyperkalemia, whereas ileal and colon segments can cause hyperchloremia. The acidosis caused by these segments is of concern in younger patients who are susceptible to growth retardation and bone density loss due to occult or recognized acidosis. The exact mechanism for this has yet to be elucidated, but oral bicarbonate replacement may obviate some of these effects.

In addition, patients with baseline renal insufficiency are at a significantly increased risk of developing marked serum acidosis. This can manifest as weakness, fatigue, thirst, and failure to thrive. Screening for patients who need bicarbonate replacement is also helpful in this setting.

Because of the effects on volume and electrolytes, the use of jejunum is typically avoided in bladder augmentation, urinary reservoirs, and urinary conduits. The use of gastric segments may decrease the potential need for bicarbonate replacement in the patients with renal insufficiency who have acidosis; however, severe metabolic derangements may still develop. Rink et al (1995) reported on episodes of severe hypokalemic hypochloremic metabolic alkalosis developing after gastrointestinal illness.¹²

Table 2. Metabolic Changes Caused By the Use of Various Tissues in Augmentation Cystoplasty

Hypercontractility and Hypocontractility

Hypercontractility and poor compliance are more common with the use of sigmoid bowel segments but can occur with any segment despite adequate detubularization of the segment. In some cases, this can lead to the need for reaugmentation.

Hypocontractility of the augmented bladder with incomplete voiding is also a possibility that patients should understand before surgery. They must be physically and emotionally prepared to perform intermittent catheterization for life.

Incontinence

This can occur from using an enteric segment for augmentation that provides insufficient volume or has forceful contractions. Preoperative assessment of urine output is helpful in determining the desired volume for the augmented bladder. In addition, proper detubularization is crucial to prevent forceful contractions of the enteric segment, especially when sigmoid colon is used. Retained mucus or stones may reduce the effective volume of the augment, and urine may leak through a poorly constructed catheterizable stoma. UTI may also lead to detrusor instability and incontinence. Poor outlet resistance at the bladder neck and/or external sphincter will cause urine leakage if undiagnosed before surgery and addressed at the time of augmentation cystoplasty.

Hematuria/dysuria syndrome

The symptom complex of hematuria and/or dysuria occurs with voiding or catheterization in up to 33% of patients after augmentation gastrocystoplasty. Continence is particularly important in patients with gastrocystoplasty because of perineal and peristomal skin irritation that can occur owing to low urine pH. Patients with renal insufficiency, low urine volume (acting as acid buffer), incontinence, and a sensate abdomen and pelvis may be at an increased risk for this syndrome. Treatment options include type II histamine blockers or proton pump blockers, and failed medical treatment may necessitate takedown and re-augmentation using ileum.

Malignancy

Augmented bladders appear to be at an increased risk for malignancy. Adenocarcinoma is the most commonly observed tumor, and all segments seem to be equally at risk. The average time to malignancy after augmentation is around 2 decades, but cancer has been found as early as 4 years after surgery. For this reason, some begin surveillance cystoscopy as soon as 2 years after surgery. Filmer and Spencer (1990) recommend that patients with augmentation cystoplasty undergo yearly cytology and endoscopy and that patients undergo biopsy beginning 10 years after surgery.¹³ Some advocate general anesthesia during surveillance cystoscopy, as thorough examination is crucial and should not be limited by patient discomfort.

Small bowel obstruction

Approximately 3% of patients may develop a small bowel obstruction at any time after augmentation cystoplasty. Parastomal hernia, internal hernia, and volvulus can also occur.

Diarrhea

Diarrhea can result from removing the ileocecal valve from the intestinal tract in the augment construction. This is more likely in the pediatric patient with neurogenic bladder and intestinal dysfunction. Removal of the ileocecal valve may allow decreased transit time of stool or may allow retrograde colonization of the distal small intestine, with fat malabsorption in this segment. Increased bile salt delivery to the colon may cause secretory diarrhea.

Other complications

With removal of the terminal ileum from the alimentary tract, vitamin B-12 and bile salt reabsorption is compromised. In addition, retrograde colonization of colonic bacteria into the small bowel can interfere with absorption. These can lead to megaloblastic anemia and diarrhea.

Early satiety after gastrocystoplasty is uncommon and is usually self-resolving.

OUTCOME AND PROGNOSIS

Section 9 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

In properly selected patients, augmentation cystoplasty is an excellent procedure that provides a safe and effective way to improve urinary storage. Bladder emptying is almost universally impaired, and the patient must be prepared to perform lifelong intermittent catheterization. The patient and physician must recognize the need for surveillance to identify potential problems. Stones, metabolic and nutritional abnormalities, renal insufficiency, and malignancy are best treated by early recognition and prompt therapy.

Patient satisfaction

Herschorn et al (1998) reported on an augmentation cystoplasty population using a survey to address patient complications and satisfaction.¹⁴ At a mean of 6 years after surgery, 41% of the patients had 1 or more complications, with 36% of all patients requiring intervention. Most took medications (ie, anticholinergics, antidiarrheals, antibiotics). Of 59 patients, 56 required clean intermittent catheterization at a mean interval of 4.6 hours, and 18% percent had postoperative bowel dysfunction versus 7% with preoperative dysfunction.

FUTURE AND CONTROVERSIES

Section 10 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Role of autoaugmentation

McGuire's group compared patients treated with augmentation cystoplasty to patients treated with autoaugmentation.¹⁵ They stratified patients by etiology of bladder dysfunction and compared urodynamic and symptomatic improvement. They determined that autoaugmentation causes less morbidity, commonly reduces symptoms, and routinely improves bladder compliance; however, the gains in bladder capacity were much less than those seen with augmentation cystoplasty. Patients with myelomeningocele did not fare as well with autoaugmentation because of the smaller increases in bladder capacity, and augmentation cystoplasty was more beneficial in these patients. Reportedly, autoaugmentation was unsuccessful in 27% of the patients who required augmentation cystoplasty.

Laparoscopy and robotics

Hedican et al (1999) used laparoscopy to mobilize the intestine in complex pediatric procedures, including augmentation cystoplasty.¹⁶ They found laparoscopy useful in mobilizing the right colon and in isolating the appendix for a continent catheterizable stoma. A smaller lower-midline or Pfannenstiel incision can be used for surgery on the bladder and/or for re-establishment of bowel continuity.

Laparoscopic autoaugmentation has also been shown to be technically feasible. Braren and Bishop (1998) performed laparoscopic autoaugmentation in 7 pediatric female patients aged 3 months to 15 years.¹⁷ The operative times ranged from 55-93 minutes. Bladder capacity increased 55-95%, all had symptom improvement, and 6 of 7 were completely dry.

With the advent of robotic instruments with increased range of motion and the facilitation of intracorporeal suturing, many reconstructive procedures including bladder augmentation have become more amenable to fully laparoscopic procedures. These procedures may reduce morbidity, reduce intra-abdominal adhesions, and improve body self-image.

Alternative tissue sources

Desai et al (2003) used ureteral tissue balloon expanders prior to laparoscopic bladder augmentation in a porcine model. In addition, basic science researchers continue to investigate the possibility of using alternatives to autologous tissues for augmentation cystoplasty. Small-intestine submucosa and synthetic polymeric substances continue to be investigated. Tissue-engineering efforts continue, although many challenges exist in reproducing the elastic and contractile properties of the bladder. A newer type of tissue engineering with nano-structured polymeric scaffolds appears to offer promising direction.

The use of any such surfaces could expand bladder volume and decrease bladder compliance without the morbidity and potential complications of intestinal harvest. Potential benefits would include decreases in complications, operative time, metabolic derangements, and deleterious effects on bowel function.

FURTHER READING

Section 11 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

For additional information, see Medscape’s Urinary Incontinence & OAB Resource Center.

MULTIMEDIA

Section 12 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Media file 1:  Augmentation cystoplasty. Isolate the segment of ileum chosen for augmentation on an adequate mesentery and re-establish intestinal continuity. Close the ends of the segment with suture and open the antimesenteric surface.
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Media type:  Image

Media file 2:  Fold the segment of ileum for augmentation cystoplasty and sew it upon itself. This detubularizes the segment, reduces enteric contractions, and maximizes the volume that the segment contributes to urinary storage.
	View Full Size Image
Media type:  Image

Media file 3:  Augmentation cystoplasty. Anastomose the augmenting segment to the prepared bladder. Perform a wide-mouthed anastomosis to ensure that the augmentation is spherical. If this is not carried out properly, the augmenting segment can exist only as a poorly draining diverticulum that is prone to complications.
	View Full Size Image
Media type:  Image

REFERENCES

Section 13 of 13

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

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