13 Bladder Augmentation

W. Stuart Reynolds, M.D.

Melissa R. Kaufman, M.D.

Roger Dmochowski, M.D.

 Video

13-1. Technique for Bladder Augmentation (Example 1)

13-2. Technique for Bladder Augmentation (Example 2)

Introduction

When less invasive measures have failed in the treatment of bladder storage (phasic contraction and compliance) abnormalities, the most aggressive management option is augmentation cystoplasty. The goal of bladder augmentation is to create a large-capacity, low-pressure (i.e., high compliance) reservoir for urine storage. Larger volumes of urine may be stored for longer periods, which is beneficial for continence, while the detrusor pressure remains low, protecting the upper urinary system and kidneys from dysfunction and ultimately renal failure. This goal is generally achieved at the cost of efficient bladder emptying, and at least one third of patients are dependent on intermittent catheterization for bladder drainage after augmentation.

Many different techniques have been developed for augmentation cystoplasty using various tissues for augmentation, including segments of detubularized large and small intestine (ileocystoplasty, cecocystoplasty, sigmoid cystoplasty, and gastrocystoplasty), dilated ureter (ureteroplasty), autoaugmentation (removal of the overlying detrusor muscle of the dome of the bladder), and, more recently, biologic substitutes employing bioengineered tissue. The most common procedure involves the use of small intestine, specifically the ileum.

If the native urethra is to be abandoned, a cutaneous catheterizable stoma can be created to allow for efficient intermittent catheterization and emptying. Direct obstructive closure of the bladder neck can be achieved surgically with ablation (via transection and oversewing of the bladder outlet) or functionally with a compressive suburethral sling.

Case Scenario

 (Video 13-1)

A 62-year-old woman who has had urge incontinence and bothersome urinary frequency (12 voids per 24 hours) for more than 3 years, without known neurologic disease or other significant morbidities, with a normal physical examination, and negative urinalysis and cytology requests therapy for her symptoms. She has received two different antimuscarinic agents, each for 1 month, with dose escalation being used and with no significant reduction in symptoms despite medication combination with optimized behavioral therapy. Percutaneous tibial stimulation was performed with some short-term success, after which botulinum toxin injections (100 units) were attempted without significant benefit. Urodynamics reveals a bladder capacity of 180 mL, with detrusor overactivity occurring at 30 mL, 60 mL, and 180 mL with incontinence and no evidence of obstructed voiding and minimal post-void residual. Diagnostic cystoscopy is unremarkable. Based on the severity of the situation and the fact that objective testing noted very low-capacity, high-pressure detrusor overactivity with very poor compliance, it is decided to proceed with an augmentation cystoplasty.

Surgical Technique

The general procedure for augmentation ileocystoplasty is illustrated in Figure 13-1.

1. The patient is typically positioned supine on the operating room table or in the low lithotomy position with legs in stirrups. Surgical skin preparation should include the abdomen, perineum, and genitalia (to provide access to the urethral catheter for bladder volume manipulation with saline and controlled drainage during detrusor resection and bowel-to-bladder anastomosis).

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