Surgical Augmentation of the Bladder to Enhance Volume
Bladder augmentation or augmentation cystoplasty is a surgical procedure that increases bladder capacity and prevents detrusor overactivity. It is typically considered when conservative approaches such as anticholinergics or intravesical botulinum toxin with IC have failed, or when there is a small capacity poorly compliant bladder (Chartier-Kastler et al. 2000b; Quek & Ginsberg 2003). Intolerable incontinence or renal deterioration are common reasons that may lead the clinician to consider definitive urological surgery. Several approaches 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 an isolated segment of intestine (ileum) is used to create a patch that is then sewn into the bladder to create a larger bladder (Chartier-Kastler et al. 2000a; Nomura et al. 2002; Quek & Ginsberg 2003; Chen & Kuo 2009). Surgical techniques focused on urinary diversion from the bladder and subsequent drainage (e.g., cutaneous ileal conduit diversion) are discussed in the section addressing incontinent urinary diversion and drainage (see section 3.4.6 Continent Catheterizable Stoma and Incontinent Urinary Diversion).
Discussion
Like most surgical approaches, the evidence for surgical augmentation of the bladder exists in the form of clinical experience from individual centres and is described in retrospective chart reviews (Nomura et al. 2002; Quek & Ginsberg 2003; Chen & Kuo 2009; Reyblat et al. 2009) or less often in prospective studies limited to pre-post (cohort) study designs (Chartier-Kastler et al. 2000b; Anquetil et al. 2016; Krebs et al. 2016; Perrouin-Verbe et al. 2016). 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. Krebs et al. (2016) monitored 29 individuals, pre- and post-supratrigonal cystectomy and augementation ileocystoplasty for a median follow-up of 2.4 years. Similarly, Perrouin-Verbe et al. (2016) followed individuals who were unable to perform intermittent self-catheterization and subsequently underwent supratrigonal and augmentation enterocystoplasty. Anquetil et al. (2016) compared results after augmentation enterocystoplasty to repeated (at least 2 successive) botulinum therapy injections. Chen and Kuo (2009) reported on 40 adults with SCI. Gobeaux et al. (2012) presented data on 61 persons with SCI individuals who underwent supratrigonal cystectomy with Hautmann pouch.
Augmentation ileocystoplasty with Mitrofanoff appendicovesticostomy or continent urinary diversions (such as Kock ilial reservoir, or Indiana pouch) are described by Zommick et al. (2003) as efficacious lower urinary tract reconstruction options for select tetraplegic individuals. 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 individuals. 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, and found that the extraperitoneal approach resulted in shorter operative time, shorter hospital stay, and eventual return of bowel function. Serious complications were absent across most studies, and other complications were noted in relatively 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 responding well to conservative treatment (Chartier-Kastler et al. 2000b; Nomura et al. 2002; Quek & Ginsberg 2003). Subsequent subjective assessment of satisfaction with the procedure was reported to be extremely high (Quek & Ginsberg 2003); consistent with other similar investigations of individuals with SCI (Khastgir et al. 2003; Zommick et al. 2003). Chen and Kuo (2009) noted, however, that issues which commonly follow ileoplasty (e.g., UTI, reservoir calculi, new onset upper-tract urolithiasis) still require treatment. In a retrospective chart review Reyblat et al. (2009) reported equivocal postoperative continence using an extraperitoneal (small peritoneotomy and standard ‘clam’ enteroplasty) versus 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 to control for a significant confounding variable of higher rates of prior abdominal surgery in the intraperitoneal group (Reyblat et al. 2009). The Gobeaux et al. (2012) study reported 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 subsequent bowel dysfunction (e.g., new onset diarrhea and/or fecal incontinence resulting from the ileal resection) in 27.5% of individuals, however, indicates that candidates need to be counseled carefully before choosing this intervention as a treatment option. Gurung et al. (2012) reported that although bladder stones are a common complication following cystoplasty, the encouraging long-term individual-reported satisfaction counterbalances the increased risk of this treatable complication.
Conclusion
There is level 4 evidence (from six pre-post, one post-test, one cohort, three case series, and one case control: Gobeaux et al. 2012; Chen & Kuo 2009; Chartier-Kastler et al. 2000b; Anquetil et al. 2016; Krebs et al. 2016; Perrouin-Verbe et al. 2016; 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 failed to respond adequately to alternative approaches and interventions for neurogenic bladder dysfunction.
There is level 3 evidence (from one case control: Reyblat et al. 2009) that extraperitoneal compared to intraperitoneal augmentation enterocystoplasty produces equivocal postoperative continence with better early postoperative recovery.
