Enterocystoplasty

1. Concept

  • Part of the urinary bladder (usually dome area) is divided and a detubularized bowel segment is anastomosed  to the bladder to achieve better bladder compliance and capacity thereby lower intravesical pressure 

2. History

  • In the late 1890s, the application of a segment of intestinal segment to the bladder was first used in humans to treat a small contracted bladder secondary to tuberculous cystitis.
  • In the early 1970s, introduction of CIC by Lapides allowed the widespread use of augmentation cystoplasty [Lapides 1972]. The acceptance of routine clean CIC eradicated concerns regarding satisfactory bladder drainage after a reconstructed urinary reservoir.

3. Terminology

  • Augmentation cystoplasty
  • Clam  cystoplasty operation
  • Ileocystoplasty, colocystoplasty, ileocecocystoplaty

4. Purpose of this procedure

  • Increase in bladder capacity
  • Reduce bladder pressures with preservation of kidney
  • Restore urinary continence
  • Alleviate VUR

5. Indication

6. Basic Principles of the Procedure

  • Detubularization and reconfiguration in a more spherical shape:
    • Increase capacity
    • Decrease luminal pressure due to the original peristaltic activities
  • The most commonly used bowel segments:
    • Ileum
    • Combination of terminal ileum and ascending colon

7. Characteristics of Bowel Segments

Stomach:

  • Advantages
    • Vascular supply is very dependable
    • Easy to create a flap valve for both the ureters and a continent catheterizable channel
    • Almost always available
  • Disadvantages
    • Production of acid that may result in the hematuria dysuria syndrome
    • Hypochloremic metabolic alkalosis

Ileum

  • Advantages:
  • Often readily available
  • Has a dependable blood supply
  • Is close to the pelvis
  • Provide a lower pressure reservoir than colon
  • Disadvantages
  • May have other underlying disease processes
  • Hyperchloremic metabolic acidosis, malabsorption of bile salts and vitamin B-12 (anemia)

Jejunum: not commloly used because

  • It results in hypochloremic, hyponatremic, and hyperkalemic metabolic acidosis
  • Electrolyte abnormalities are more difficult to correct
  • Hyperkalemic, hypochloremic, hyponatremic metabolic acidosis

Colon: many advantages such as

  • Colon has a  larger diameter
  • Proximity to the bladder
  • Tends to make more mucous than the ileum
  • Hyperchloremic metabolic acidosis

Ileocecal valve: not commonly employed because

  • Part of the continence mechanism in patients with neurogenic bowel
  • Diarrhea may result from its removal

8. Procedure: [Leng 1999] [VIDEO]

  • detubularizatin of the intestinal segment by incising along the antimesenteric border
  • reconfiguration of the segement
  • wide anastomosis between the reconfigured bowel and the bladder
  • A suprapubic tube, urethral catheter and pelvic drain are left in place at the close of the operation.
  • A cystogram is performed 2 weeks after surgery to ensure a water-tight anastomosis.

9. Clinical Outcomes

  • Positive results have been obtained in up to 90% of patients with neurogenic lower urinary tract dysfunction.

Authors

Material & Methods

Results

Comments

Khastgir J, Hamid R, Arya M, Shah N, Shah PJ.[Eur Urol. 2003]

32 SCI patients

Mean followup 6.0 years
 
'Clam' augmentation ileocystoplasty

Questionnaire/telephone interview

Assessment of patient satisfaction

 

Complete continence in all patients

Significant improvement in bladder capacity (from 143ml to 589 ml)

Maximum detrusor pressure decreased (from 108 cmH2O to 19 cmH2O)

VUR resolved in 4 out of 5 patients

High levels of satisfaction 96.2%

Successful surgical outcomes, in SCI patients following augmentation cystoplasty.

 

Chartier-Kastler EJ, Mongiat-Artus P, Bitker MO, Chancellor MB, Richard F, Denys P. [Spinal Cord. 2000]

Prospective Urodynamic Eevaluation and clinical assessment

17 SCI patients with history of refractory urge incontinence to pharmacotherapy

Partial cystectomy (subtrigonal for 15) was performed with Hautmann enterocystoplasty (15) or detubularized clam cystoplasty (two).

Mean follow-up 6.3 years

88.5% patients were Completely continent under self CIC

2 patients with pudendal nerve denervation had persistent stress urinary incontinence.

No operative complications

Long-term complications included recurrent pyelonephritis for one patient.

Maximal cystometric capacity increased from 174.1 to 508.1ml

Maximal end filling pressure decreased from 65.5to 18.3cm H2O

Long-term success without delayed complications in SCI patients.

Quek ML, Ginsberg DA. [J Urol. 2003 ]

26 patients with neurogenic voiding dysfunction (18 SCI; 6 myelomeningocele; 2 transverse myelitis)

Augmentation enterocystoplasty

Mean followup 8.0 years

Analysis of clinical outcomes

96% of patients complete resolution of urinary incontinence

Mean total bladder capacity increased (from 201 to 615ml

Mmean maximum detrusor pressure decreased (from 81 to 20cmH2O)

Mean interval between catheterizations: 5 hours, with volumes (314-743 ml)

8% of patients needed a low dose of oxybutynin postoperatively to maintain continence.

88% no significant change in bowel function

Nearly all patients extreme satisfaction

Subsequent urological procedure was required: 46% at a mean of 4.4 years after initial surgery

Bladder augmentation provides durable clinical and urodynamic improvement for patients with neurogenic bladder dysfunction refractory to conservative therapy.

There is a high level of patient satisfaction with bladder augmentation.

10. Complications

  • Surgical complications
    • 10% of patients undergoing ileocystoplasty [Krishna 1995]
    • Adhesion obstruction: in the early or late phase postoperatively
    • Dangers in re-operation: vulnerable vascular pedicle during re-operation
    • Urinary extravasation in the early postoperative period: clot or mucous obstruction of the catheters
  • UTI
    • Dramatically fewer episodes of symptomatic UTI postoperatively
    • Despite the fact that patients are as bacteriuric post operatively as they were prior to the operation.
  • Perforation
    • One of the most serious and life-threatening  problems
    • Equal frequency whatever piece of intestine used
    • Usually in the bowel segment or through the anastomosis to the native bladder
    • Causes:
      • Failure to catheterize, overdistention
      • Absence of sensation
      • High-pressure detrusor contractions [Anderson 1991]
      • Possible direct perforation from a bladder catheter
    • 5-10% [Krishna 1995; Rushton 1988]
  • Neoplasia
    • Difficult to determine whether this is caused partly by the underlying disease
    • Carcinogenesis mechanism:
      • Bacterial catalysis of nitrosamine formation from nitrate [Gough 2001]
      • Free oxygen-radical production by activated phagocytes during the inflammatory response occurring at the suture line between the urothelium and colonic mucosa [Dull 1988]
    • 28 cases of cancer associated with bladder augmentation till year 2004 on the literature [Soergel 2004]
      • adenocarcinoma (52%): common types of cancer
      • transitional cell (39%)
      • squamous cell (6%)
    • Occurred at or next to the suture line of the bowel and bladder
    • Prognosis: generally poor
  • Stone
    • Revervoir:
      • Particularly after continent diversion (Mitrofanoff stoma)
      • Possible cause: retention of mucus within the bladder
    • Upper urinary tract:
      • Common in patients with urinary diversion
      • 30% after colonic conduit diversion [Woodhouse 2001]
  • Mucus production
    • Fewer with ileocystoplasty and less likely to occur after sigmoid cystoplasty
    • Improves with time
    • Dietary manipulation helpful: cranberry juice [Gough 2001]
  • Metabolic complications
    • Bowel mucosa comes in contact with urine and reabsorb the chemicals
    • Details specific to the type of bowel segment

11. Advantages

  • Offers reliable improvement of bladder storage function
  • Provides a larger reservoir

12. Disadvantages serious potential short-term and long-term complications.

  • Ileus and bowel obstruction
  • Anastomotic urine leak
  • Intraperitoneal rupture of the augmented reservoir
  • Bladder stones
  • Metabolic derangements
  • Urosepsis
  • Potential malignant transformation of bowel segments [Filmer 1990]

13. Current significance

  • This procedure is an excellent treatment option for refractory detrusor overactivity and incontinence with a very high success rate in the great majority of patients. The procedure can ensure the integrity of the urinary tract and renal function by creating a low-pressure, large capacity reservoir with normal compliance.
  • Augmentation ileocystoplasty has been established as the procedure of choice when conservative management, such as anticholinergic medication and other conservative measures, fails.

Summary

Effectiveness

Very effective

Safety

Long term complications are serious and potentially fatal

Ease of application

Difficult surgery in this population

Patient Comfort

Prolonged hospital stay, bowel dysfunction, pulmonary problems

Cost

High initial cost related to surgery and  average LOS of 10  days

12. Questions & Answers

1. Is the necessity of a synchronous performance of an anti-reflux procedure at the time of cystoplasty necessary? If it is, what is the indication in the urodynamic criteria?

2. What is the followup plan after the augmentation cystoplasty? Long-term followup is mandatory for neurogenic bladder following bladder augmentation. Nearly 50% of our patients required a subsequent reintervention procedure (urinary stone, neglected stress incontinence, etc) at a mean of 4.4 years after the initial augmentation surgery [Quek 2003].

3. What kind of followup evaluation will be necessary? Routine annual evaluation with abdominal ultrasonography and plain radiographs to assess for the development of urinary stone should be standard. Basic blood chemistry studies to determine renal function and metabolic disturbances is also rational. Surveillance for the cancer in the augmented bladder could be done by periodic cystoscopic examination. Any patient who has hematuria on the followup period should be evaluated.

 

Key Points of This Section

  • Enterocystoplasty reduces bladder pressure very effectively
  • Complications both short and long term are quite numerous and serious.
  • Fully informed consent is required. .

References

  • Anderson PA, Rickwood AM. Detrusor hyper-reflexia as a factor in spontaneous perforation of augmentation cystoplasty for neuropathic bladder. Br J Urol. 1991 Feb;67(2):210-2. 
  • Chartier-Kastler EJ, Mongiat-Artus P, Bitker MO, Chancellor MB, Richard F, Denys P. Long-term results of augmentation cystoplasty in spinal cord injury patients. Spinal Cord. 2000 Aug;38(8):490-4.
  • Dull BJ, Gittes RF, Goldman P. Nitrate production and phagocyte activation: differences among Sprague-Dawley, Wistar-Furth and Lewis rats. Carcinogenesis. 1988 Apr;9(4):625-7. 
  • Filmer RB, Spencer JR. Malignancies in bladder augmentations and intestinal conduits. J Urol. 1990 Apr;143(4):671-8.
  • Gough DC. Enterocystoplasty. BJU Int. 2001 Nov;88(7):739-43.
  • Khastgir J, Hamid R, Arya M, Shah N, Shah PJ. Surgical and patient reported outcomes of 'clam' augmentation ileocystoplasty in spinal cord injured patients. Eur Urol. 2003 Mar;43(3):263-9.
  • Krishna A, Gough DC, Fishwick J, Bruce J. Ileocystoplasty in children: assessing safety and success. Eur Urol. 1995;27(1):62-6.
  • Lapides J, Diokno AC, Silber SJ, Lowe BS. Clean, intermittent self-catheterization in the treatment of urinary tract disease. J Urol. 1972 Mar;107(3):458-61. 
  • Leng WW, Blalock HJ, Fredriksson WH, English SF, McGuire EJ. Enterocystoplasty or detrusor myectomy? Comparison of indications and outcomes for bladder augmentation. J Urol. 1999 Mar;161(3):758-63.
  • Quek ML, Ginsberg DA. Long-term urodynamics followup of bladder augmentation for neurogenic bladder. J Urol. 2003 Jan;169(1):195-8.
  • Rushton HG, Woodard JR, Parrott TS, Jeffs RD, Gearhart JP. Delayed bladder rupture after augmentation enterocystoplasty. J Urol. 1988 Aug;140(2):344-6.
  • Soergel TM, Cain MP, Misseri R, Gardner TA, Koch MO, Rink RC. Transitional cell carcinoma of the bladder following augmentation cystoplasty for the neuropathic bladder. J Urol. 2004 Oct;172(4 Pt 2):1649-51.
  • Woodhouse CRJ. Urinary diversion and augmentation. In: Weiss RM, George MJR, O'Reilly PH eds, Comprehensive Urology. London: Mosby, 2001: 533 47.

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