Ileo-caecal doughnut bladder augmentation in children with exstrophy– epispadias complex- a study of 100 cases

Abstract

The small bladder in failed exstrophy needs to be augmented and also accommodate bladder neck surgery, ureteric re-implantations and a catheterizable channel. We present a novel method of ileocecal bladder augmentation providing a non-implanted, un-detached appendicular channel, rendered non refluxing by an ileal "fundoplication". The colonic segment could receive ureteric reimplantation when bladder plate is unsuitable. Operative technique: Bilateral cephalo-trigonal reimplantation and bladder neck surgery is done. The ileocecal segment is isolated and arranged as a ring (doughnut) around the un-detached appendix which is made to pass behind the terminal ileum, through the ileal mesentery and then in front of the ileum as it exits as a catheterizable channel. The bowel segment is opened on the antimesenteric aspect except for the retro appendiceal ileal segment. The opened ileo-caecum is reconfigured as a de-tubularised augmentation pouch while the retro appendiceal ileal segment is wrapped around the appendix like a fundoplication. The colon segment may receive the ureteric reimplantation if required. 100 children (mean age 6.3 years) with failed exstrophy underwent doughnut augmentation (3 neobladders) in 2006-2021. Ninety eight were incontinent, with 30 open/dehisced bladder plate, 48 units were hydronephrotic (HUN), 105 ureters were refluxing (VUR) and eGFR was subnormal in 20 children. 79 children underwent YDL bladder neck plasty and 23 underwent bladder neck closure (primarily in 18). Three infants with HUN did not undergo bladder neck surgery. 126 ureters were reimplanted into the bladder, 44 into the colon segment while 30 were not reimplanted. 95 children are continent on CIC, which was gradually introduced starting with once or twice daily change of indwelling Mitrofanoff catheter leading to regular 3-4 hourly CIC as the child became confident. The appendicular channel was easily catheterizable without any leak in 95, had minor issues in 4 while one necrosed and replaced by a gastric tube. HUN recovered (25/48) or stabilized with a significant reduction in the grade of hydronephrosis (p=0.001). VUR resolved in 90% of bladder reimplants, 85% of colonic reimplants and 70% of non-reimplanted ureters. In the 20 children with compromised renal function eGFR improved (71-106 ml/m2/min) significantly (p=0.036) at follow up (mean 5 years). Urodynamics study (N=33) showed a mean capacity of 95% of expected bladder capacity (EBC) with end filling pressure less than 25cm of water (Mean end filling cystometric pressure=15cm of water). Complications included adhesive intestinal obstruction (N=16) and bladder calculi (N=12). The doughnut ileocecal augmentation provides a easily catheterizable, non-refluxing, appendicular channel, not requiring isolation of the appendix nor its reimplantation into the bladder. The colonic segment can provide a bed for ureteric reimplantation. Dryness with a good capacity bladder and preserved upper tract is achieved.