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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).

Table 7 Surgical Augmentation of the Bladder to Enhance Volume

Author Year

Country
Research Design
Score
Total Sample Size

MethodsOutcome
Anquetil et al. 2016

France

Cohort

N=30

 

Population: Detrusor overactivity; Mean age: 41.9 yr; Gender: males=16, females=14; Level of injury: paraplegia=12, tetraplegia=18; Severity of injury: complete=23, incomplete=7; Mean time post-injury: 16.57 yr.

Intervention: Study participants had received either at least two successive botulinum therapy injections (BT) or augmentation enterocystoplasty (AC).

Outcome Measures: Method of bladder drainage, urinary incontinence, complications, maximum detrusor pressure, low compliance, maximum cystometric bladder capacity, Qualiveen-30.

1.     In the BT group, 12 used clean intermittent self-catheterization, 2 used clean intermittent catheterization, and 0 used indwelling catheterization, while in the AC group, 14 used clean intermittent self-catheterization, 1 used clean intermittent catheterization, and 1 used indwelling catheterization.

2.     Urinary incontinence occurred more frequently in BT than AC (p=0.0187).

3.     Four AC participants had postoperative complications while there were no complications for BT participants. No significant differences between groups were observed in terms of urinary lower tract infections.

4.     Two participants had a high maximum detrusor pressure and one participant had low compliance in the BT group compared to none in the AC group.

5.     Maximum cystometric bladder capacity in BT group was 418 mL compared to 550 mL in AC group.

6.     The mean Qualiveen-30 score was significantly higher (worse) in BT group than in AC group (p=0.037).

Reyblat et al. 2009

USA

Case Control

N=73

Population: SCI=68; Mean age: 34 yr; Gender: males=55, females=18.

Intervention: Charts were reviewed for individuals who had previously undergone extraperitoneal augmentation (n=49) and intraperitoneal augmentation (n=24) to assess effectiveness.

Outcome Measures: Complication rate, operation time, bowel function, catheterization time.

1.     Overall complication rate was similar in both groups (extraperitoneal 37% versus intraperitoneal 42%).

2.     Intraperitoneal group had a significantly higher operation time than the extraperitoneal group (p<0.0001).

3.     Bowel function returned earlier in extraperitoneal group than the intraperitoneal group (p=0.0005).

4.     No significant difference was seen between the groups in mean time to catheter removal.

Krebs et al. 2016

Switzerland

Pre-Post

N=29

Population: Neurogenic lower urinary tract dysfunction; Mean age: 34 yr; Gender: males=17, females=12; Level of injury: paraplegia=26, tetraplegia=3; Severity of injury: incomplete=13, complete=16; Injury etiology: trauma=12, non-trauma=6, myelomeningocele=11.

Intervention: Partcipants had received supratrigonal cystectomy and augmentation ileocystoplasty.

Outcomes: Continence, detrusor relaxation therapy, maximum detrusor pressure, reflex volume, bladder capacity, detrusor compliance, maximum detrusor pressure >40 cm H2O, detrusor compliance <20 mL/cm H2O, risk of renal damage, complications.

1.     At a median follow-up of 2.4 yr post-operatively, compared to prior treatment, there was a significant increase in the number of continent participants (p=0.001) and a significant decrease in number of participants requiring detrusor relaxation therapy (p=0.02).

2.     Compared to prior treatment, participants receiving treatment had significant increases in reflex volume (p=0.006), bladder capacity (p=0.001), and detrusor compliance (p=0.001).

3.     Compared to prior treatment, there was a significantly lower number of participants with high detrusor pressure (p=0.001), low detrusor compliance (p=0.001), and risk of renal damage (p=0.001).

4.     Of the 29 participants, complications were observed in 11 participants, with 6 participants requiring surgical interventions to resolve the complications.

Perrouin-Verbe et al. 2016

France

Pre-Post

N=29

Population: Median age: 35 yr; Gender: males=7, females=22; Level of injury: cervical=17, thoracic=10, lumbar=2; Median time post-injury: 9 yr.

Intervention: Individuals unable to perform intermittent self-catheterization through the native urethra received continent cutaneous urinary diversion with a concomitant supratrigonal and augmentation enterocystoplasty.

Outcome Measures: Postoperative complications, duration of hospitalization, long-term complications, urethral continence, antimuscarinics, onabotulinum toxin A, detrusor overactivity, low bladder compliance, maximal cystometric capacity, maximal detrusor pressure, creatinine clearance, upper urinary tract dilation, quality of life.

1.     During the first month post-surgery, there were three minor complications, two major complications and no deaths.

2.     The overall complication rate was 44.8% and the total reoperation rate was 24.1%.

3.     Compared to before surgery, the number of participants with urethral incontinence (p=0.013), using antimuscarinics, using onabotulinum toxin A, with detrusor overactivity (p=0.0006), with low bladder compliance (p=0.05), and upper urinary tract dilation significantly decreased.

4.     There was a significant increase for the median maximal cystometric capacity (p=0.021), a significant decrease for maximal detrusor pressure (p=0.05), and no significant difference in creatinine clearance.

5.     Urethral continence was achieved in 96% of participants and quality of life was improved in 90%.

Gobeaux et al. 2012

France

Pre-Post

N=61

Population: Mean age: 34.7±11.2 yr (range=14-68); Gender: males=30, females=31; Level of injury: Above T6=18, T6-12=32, Below T12=11; Injury etiology: Traffic accident=41, Defenestration=7, Spinal cord surgery=6, Sport=3, Firearm=3, Other=1.Mean time post-injury: 9.7±1.6 yr.

Intervention: Participants underwent supratrigonal cystectomy with Hautmann pouch surgery.

Outcome Measures: Total continence rate, surgery success, maximum cystometric capacity (MCC), mean compliance (MC), mean detrusor pressure (MDP), neurogenic detrusor overactivity (NDO), complication rate, incidence of bowel dysfunction.

1.     Continence was significantly improved for 52 of the 58 participants (89.7% (p<0.05)) and total continence was achieved in 74.1% of cases (N=43).

2.     Mean MCC and MC after treatment significantly increased (p<0.05).

3.     MDP before versus after treatment significantly decreased from 54.1 to 19.1cmH2O resp. (p<0.05).

4.     Persistent NDO was evident in 36 participants (59%) pre-surgery versus 12 participants (20.7%) post-surgery (p<0.05).

5.     The overall surgery complication rate was 37.7% (N=23) of which 82.6% were ≤ grade 2 (N=19).

Chen & Kuo 2009

Taiwan

Pre-Post

N=40

 

Population: Mean age: 36.3 yr; Gender: males=36, females=4; mean follow up: 7.8 yr (range 1-14 yr); level of SCI – suprasacral: 33, sacral: 7; 95% of participants had incontinence

Intervention: Augmentation enterocystoplasty surgery

Outcome Measures: Urodynamic variables; adverse events

1.     The bladder capacity improved from 115 to 513mL postoperatively (p<0.0001).

2.     Bladder compliance also improved significantly (p<0.0001). Four participants could achieve continence while 29 required clean IC for bladder management.

Chartier-Kastler et al. 2000b

France

Pre-Post

N=17

Population: Mean age: 36.5 yr; Gender: males=11, females=6; Level of injury: above T6=4, T6-T12=9, below T12=4; Severity of injury: complete=14, incomplete=3; Mean duration of SCI=7.5 yr.

Intervention: Participants underwent partial cystectomy with enterocystoplasty or detubularized clam cystoplasty.

Outcome Measures: Continence, maximal cystometric capacity, filling pressure, complications.

1.     15 participants were completely continent postoperatively.

2.     A significant increase in maximal cystometric capacity by 191% was seen (p<0.05).

3.     Maximal filling pressure decreased by 72% (p<0.05).

4.     No complications were encountered.

Gurung et al. 2012

UK

Case Series

N=19

Population: Mean age: 28.9 yr (range=12-52); Gender: male=12, female=7; Level of injury: Cervical=1, Thoracic=16, Lumbar=2; injury etiology: RTA (road traffic accident) (N=11), Fall (N=6), Gunshot (N=2); Mean time from injury to operation: 4.5 yr (range=0.3-22).

Intervention: Participants underwent augmentation ileocystoplasty (AIC), with follow-up at 3 mo, 1 yr, 5 yr and <10 yr.

Outcome Measures:

Maximum cystometric capacity (MCC), Maximum detrusor pressure (MDP), Quality of life (QoL).

 

1.     Of the 26 participants who had undergone AIC before 1998, only 19 participants were available for long-term follow-up/analysis. Two participants died from unrelated causes.

2.     Of the 17 participants, continence was reported in 15/17 participants (vs 0 before surgery).

3.     MCC at the latest follow-up at>10 yr post-surgery increased significantly from an estimated preoperative mean of 229ml to a mean of 494ml (range=387-601 ml) (p<0.001).

4.     MDP at the latest follow-up at >10 yr post-surgery, decreased significantly from a preoperative value of 81cmH2O to a mean of 28cmH2O (range=15-40 cmH20) (p<0.001).

5.     Of the 14 participants who completed the questionnaire survey, 13/14 were satisfied with the outcome such that they would consider undergoing the procedure again and would recommend it to someone else.

Quek & Ginsberg 2003

USA

Case Series

N=26

Population: Individuals with SCI and bladder augmentation: Mean age: 29 yr; Gender: males=18, females=8.

Intervention: Bladder augmentation with a minimum of retrospective review of 4 yr. The majority of participants had this done in conjunction with various other continence or antireflux techniques.

Outcome Measures: Bladder capacity, maximum detrusor pressure, subsequent operations, bowel function, UTI, complications, satisfaction. Mean follow up=8 yr.

1.     There was a signficant increase in bladder capacity from preaugmentation to postaugmentation (p<0.001).

2.     Mean maximum detrusor pressure decreased significantly (p<0.01).

3.     No significant changes in bowel function were seen in 23 participants.

4.     88% of participants with previous symptomatic urinary infections had significant improvement in the frequency of infections.

5.     Participants were very satisfied with the bladder augmentation and would recommend it to a friend.

Nomura et al. 2002

Japan

Case Series

N=11

Population: SCI: Mean age: 29.0 yr; Gender: males=10, females=1; Level of injury: thoracic=11; Severity of injury: complete=10, incomplete=1; Injury etiology: trauma=10, transverse myelitis=1; Mean time post-injury=73.5 mo.

Intervention: Retrospective review of augmentation ileocystoplasty.

Outcome Measures: Bladder capacity, continence, complications.

1.     Bladder capacity increased significantly postoperatively (p<0.001).

2.     All participants showed improvement in urinary incontinence.

3.     Complications included:

·       Transient paralytic ileus occurred in 4 participants.

·       Wound infection occurred in 1 particpant.

 

 

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.

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

Extraperitoneal compared to intraperitoneal augmentation enterocystoplasty may result in a quicker postoperative recovery.