Preoperative preparation must include a thorough review of the anticipated goals of the surgery with the parent and patient, when he or she is an older child or adolescent. During this meeting, the family’s ability to comply with the postoperative care of a bladder augmented with bowel must be assessed. When CIC has been performed preoperatively, the postoperative catheterization and irrigations are more readily adhered to. Urinary infection, bladder calculi, or perforation may result when routine emptying and augment cleansing is not performed regularly. Table 107.1 outlines the most common complications of augmentation cystoplasty in the early and late postoperative periods. Some complications are specific to the method of augmentation cystoplasty performed, but the most serious, perforation, occurs whenever CIC is not rigorously performed and is not restricted to any one type of enterocystoplasty.

The patient with neurogenic bladder dysfunction is likely to have coexistent constipation, thus necessitating that the bowel
preparation be started well in advance. The patient should be contacted with explicit instructions to begin clear liquids at home 2 days prior to surgery and to arrive early for a preoperative admission 1 day prior to surgery. Intravenous fluids should be started at the same time that the patient begins ingestion (orally or by nasogastric tube) of GoLYTELY solution (Table 107.2). Enemas and oral antibiotics are administered as well following completion of the GoLYTELY prep, depending on the severity of the patient’s fecal load and estimated efficacy of the oral bowel prep. For patients with marginal renal function, the use of phosphate containing laxatives is contraindicated. Instead, twice-daily oral administration of polyethylene glycol 3350 beginning 3 days preoperatively as an adjunct to a clear liquid diet is sufficient to clear most children.

There is no ideal segment of bowel for augmentation cystoplasty; each has a set of characteristics that are advantages or liabilities depending on the clinical scenario (Table 107.3). The following section will review the aspects of each intestinal segment that sets it apart from the remainder in the context of the results and complications following enterocystoplasty. It should be noted that none of these complications are seen following ureterocystoplasty, making it the ideal tissue for bladder augmentation (8,9). However, it is a procedure ideally performed in a patient with a severely dilated ureter that subtends a nonfunctioning kidney. Ironically, most patients with neuropathic bladder dysfunction rarely present with such anatomy as a result of close followup and the early institution of anticholinergic medications and CIC. Currently, boys with posterior urethral valves are most likely to present with severely hydronephrotic kidneys and massively dilated ureters that can be used to augment the bladder. In those circumstances, ureterocystoplasty has achieved comparable capacity and compliance as with enterocystoplasty (8).

The patient is positioned supine on the operating table. General anesthesia with endotracheal intubation is mandatory; however, if no spinal abnormality exists that contraindicates the use of an epidural catheter, consideration should be given to regional anesthesia as well. The surgical field is prepared and draped from the xiphoid process inferiorly, including the genitalia. A Foley catheter is inserted urethrally. A midline incision is created beginning at the symphysis pubis an extending superiorly toward the umbilicus. In order to avoid the insensible loss of heat and water from peritoneal surfaces, it is recommended that any concomitant procedures on the bladder or bladder neck be performed through a limited incision that does not enter the peritoneal space. Retraction can be provided by either a Denis Browne or Bookwalter retractor at this point.

When a continent diversion is not planned, a midline cystotomy suffices to prepare the bladder for augmentation (Fig. 107.1). Ureteral reimplants can be easily performed at this point. However, when a continent catheterizable stoma is planned, either a paramedian or transverse cystotomy should be considered since these incisions create bladder flaps that facilitate the creation of a long submucosal tunnel for the appendix or ileal tube. Regardless of the bladder incision created, it must be sufficiently long to open the bladder widely. If the cystotomy is too short, the augmented segment may behave as a diverticulum, thus facilitating urinary stasis and stone formation. Once the bladder has been prepared, the midline incision is carried above the umbilicus and the peritoneum is entered. Retraction at this point is provided by a Bookwalter retractor.

Should one encounter an augmented bladder in which the intestinal segment has formed a pseudodiverticulum the following technique has been helpful. Create a cystotomy incision that transects the anterior lip of the opening into the intestinal segment. Through this cystotomy, incise
the posterior lip of the opening with electrocautery until it is seen to spring open. This incision is not full-thickness. This defect should be closed transversely with continuous 3-0 polyglycolic acid (PGA), thus completing a Heineke-Mikulicz-like repair. The anterior cystotomy should then be closed transversely as well. (Author’s personal observation of W. H. Hendren)

Ileum is by far the most popular segment used for bladder augmentation. The segment, 20 to 25 cm long, is based on a pedicle that is supplied by branches of the superior mesenteric artery and that is sufficiently mobile to be brought into the pelvis (Fig. 107.2). On occasion, an abnormally thick, fatty, or short mesentery can limit mobility of the vascular pedicle, thus necessitating extensive division of the mesentery posteriorly. The terminal 15 to 20 cm of ileum, as measured from the ileocecal valve proximally, is spared in order to retain bile salt absorption, thus preventing steatorrhea and vitamin B₁₂ deficiency (Fig. 107.3). The portion of ileum to be used is measured, and 5-0 silk sutures used to mark the proximal and distal limits of resection. Prior to dividing the mesentery, the vascular supply to the isolated segment should be observed by transillumination and the proposed incisions in the mesentery marked. Beginning at the mesenteric border of the bowel, the mesentery is divided between pairs of fine hemostats, and the vascular arcades are ligated with 5-0 silk suture ties. The bowel is then divided between atraumatic bowel clamps that have been applied at the proximal and distal limits of resection. Once the ileal segment reaches into the pelvis without tension on the vascular pedicle, no further mesenteric division is needed. An ileoileal anastomosis is performed cephalad to the isolated ileal segment and the mesenteric trap is closed. The bowel clamps are removed and a thorough lavage of the ileal segment is performed with sterile saline. It is the preference of the authors to configure the ileal segment into a U configuration (Fig. 107.4). The antimesenteric border of the ileal segment can then be opened using scissors or the cutting current with little concern for bleeding that usually ceases spontaneously. The segment is folded 180-degrees and the adjoining edges are sutured as full-thickness using continuous locking 4-0 PGA. Once the ileal cap has been formed, it is anastomosed to the opened bladder beginning at the most posterior portion of the bladder incision (Fig. 107.5). Hemostatic clamps may be left on the short ends of the tied sutures in order to identify
the most posterior limit of the anastomotic line, thus facilitating placement of the second, reinforcing suture layer between the serosal surfaces of the bladder and ileum. A suprapubic catheter is placed through the bladder wall prior to completion of the first anastomotic closure (Fig. 107.6).