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Surgical Augmentation of the Bladder to Enhance Volume

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Bladder augmentation or augmentation cystoplasty is a surgical repair to the bladder typically suggested when conservative approaches such as anticholinergics with IC have failed to create an adequate bladder volume under low pressure for storage (Chartier-Kastler et al. 2000b; Quek & Ginsberg 2003). Intolerable incontinence, renal deterioration, and local erosions or infections related to the use of catheters are common final pathways that may lead the clinician to consider definitive urological surgery. There are several approaches that have been described in the SCI literature with a common method being variations of the “clam-shell” ileocystoplasty in which the bladder is opened up like a clam and isolated intestine (ileum) are patched in to create a larger bladder (Chartier-Kastler et al. 2000a; Nomura et al. 2002; Quek & Ginsberg 2003; Chen & Kuo, 2009). Surgical techniques that are focused on urinary diversion away from the bladder and subsequent drainage (e.g., cutaneous ileal conduit diversion) are discussed in the section on incontinent urinary diversion in the section that is focused on drainage (see section 3.4.6 Continent Catheterizable Stoma and Incontinent Urinary Diversion).

Table: Surgical Augmentation of the Bladder to Enhance Volume

Discussion

Like most surgical approaches, the evidence for surgical augmentation of the bladder exists in the form of clinical experience from individual centres as is described in retrospective chart reviews (Nomura et al. 2002; Quek & Ginsberg 2003; Chen & Kuo 2009; Reyblat et al. 2009) or more rarely may be found in prospective studies that are limited to pre-post (cohort) study designs (Chartier-Kastler et al. 2000b). Long-term retrospective results associated with ileocystoplasty in persons with traumatic and non-traumatic SCI (or spina bifida) were reported over a mean period of 5.5, 8 and 14.7 years by Nomura et al. (2002; n=21), Quek and Ginsberg (2003; n=26), and Gurung et al. (2012; n=19), respectively. Chartier-Kastler et al. (2000b) conducted a prospective evaluation of 17 persons with longstanding traumatic SCI who underwent enterocystoplasty (i.e., ileocystoplasty) with systematic follow-up at 1, 3, 6, 12 months and then yearly for a mean follow-up of 6.3 years. Chen and Kuo (2009) reported on 40 adults with SCI. Gobeaux et al. (2012) presented data on 61 SCI patients who underwent supratrigonal cystectomy with Hautmann pouch.

Augmentation ileocystoplasty, Mitrofanoff appendicovesticostomy, Kock ilial reservoir, and Indiana pouch are described by Zommick et al. (2003) as efficacious lower urinary tract reconstruction options for select tetraplegic patients. In all cases, this was conducted in individuals with overactive bladder and/or detrusor-sphincter dyssynergia with reflex incontinence which failed to respond to conservative treatment. Across all these studies, significant resolution of incontinence occurred in the majority of patients. Chartier-Kastler et al. (2000b) conducted systematic urodynamic investigations and showed a significant increase in maximal cystometric capacity by 191% (174.1 to 508.1 ml, p<0.05) with a concomitant decrease in maximal filling pressure of 72% (65.5 60 18.3 cm H2O, p<0.05). These results are similar to those reported by Nomura et al. (2002) and Quek and Ginsberg (2003). Reyblat et al. (2009) compared an “extraperitoneal” approach (small peritoneotomy and standard ‘clam’ enteroplasty) vs. the standard intraperitoneal approach in which the extraperitoneal approach was found to result in shorter operative time, shorter hospital stay, and eventual return of bowel function. No serious complications were noted across most studies, and other complications were noted in only a few individuals (e.g., transient paralytic ileus, vesicoureteral reflux, wound infection, urethral stricture of unknown cause, recurrent pyelonephritis possibly due to non-compliance with IC and use of Crede maneuver) with the vast majority of these responding well to conservative treatment (Chartier-Kastler et al. 2000b; Nomura et al. 2002; Quek & Ginsberg 2003). Subsequent subjective assessment of patient satisfaction with the procedure was reported to be extremely high (Quek & Ginsberg 2003) which is consistent with other similar investigations in SCI patients (Khastgir et al. 2003; Zommick et al. 2003). Chen and Kuo (2009) noted, however, that issues with UTI, reservoir calculi and new onset upper-tract urolithiasis that commonly follow the ileoplasty still require resolution. In a retrospective chart review Reyblat et al. (2009) reported equivocal postoperative continence using an extraperitoneal (small peritoneotomy and standard ‘clam’ enteroplasty) versus the standard intraperitoneal augmentation. The extraperitoneal approach resulted in shorter operative time, shorter length of stay, and more rapid return of bowel function. There was a potential for selection bias in this study that was mitigated with a subgroup analysis in an effort to control for a significant confounding variable of higher rates of prior abdominal surgery in the intraperitoneal group (Reyblat et al. 2009). Although the Gobeaux et al. (2012) study reflected an impressive average 5.84 year follow-up result of 74% complete continence, decreased rates of infection and preserved upper tract function as measured through urodynamics, the presence of 27.5% of patients with subsequent bowel dysfunction (e.g., new onset diarrhea and/or fecal incontinence resulting from the ileal resection) requires that patients need to be counseled carefully before choosing this intervention as a treatment option. Gurung et al. (2012) did report that although bladder stones are a common complication following cystoplasty, the additional encouraging long-term patient-reported satisfaction would serve to counterbalance the increased risk of this treatable complication.

Conclusion

There is level 4 evidence (from three pre-post, three case series, and one case control; Gobeaux et al. 2012; Chen & Kuo 2009; Chartier-Kastler et al. 2000b; Gurung et al. 2012; Quek & Ginsberg 2003; Nomura et al. 2002; Reyblat et al. 2009) that surgical augmentation of the bladder (ileocystoplasty) may result in improved continence in persons with SCI who previously did not respond well to conservative approaches for overactive bladder.

There is level 3 evidence (from one case control; Reyblat et al. 2009) that extraperitoneal versus intraperitoneal augmentation enterocystoplasty produces equivocal postoperative continence with easier early postoperative recovery.

  • Surgical augmentation of bladder may result in enhanced bladder capacity under lower filling pressure and improved continence in persons with SCI.

    Extraperitoneal versus intraperitoneal augmentation enterocystoplasty may result in better postoperative recovery.