Patients Underwent Augmentation Cystoplasty Research Articles

Long-term Outcomes of Augmentation Cystoplasty in Genitourinary Tuberculosis in Adults: A 12-year Follow-up Experience at a Tertiary Care Center

ObjectivesTo evaluate the long-term effectiveness and consequences of augmentation cystoplasty in adult patients with small capacity bladder due to genitourinary tuberculosis (GUTB). MethodsAfter approval of the institutional ethical committee, we retrospectively analyzed the database of adult patients with small capacity bladder due to GUTB treated by augmentation cystoplasty from January 2010 to December 2022 at our center. The patients were followed up at six weeks postoperatively, then every three monthly for 1st year and six monthly in second year, and then annually. Patients were assessed for symptoms, renal function, blood biochemistry levels, and ultrasound KUB at each follow-up visit. ResultsA total of 40 patients underwent augmentation cystoplasty were included. All patients underwent augmentation cystoplasty either with ileum (n=35) or sigmoid colon (n=5). On long term follow up, there were statistically significant improvement in bladder capacity, decrease in voiding frequency (p=0.00), decrease in eGFR (p=0.02) and increase in serum creatinine (p=0.02). Significant complications were wound infection 4 (10%), intestinal obstruction 1(2.5%), urinary tract infection 6 (15%), bladder stone 2 (5%), mucus retention 3 (7.5%), hypocalcemia with metabolic acidosis 2 (5%) and need of intermittent catheterisation in 11 (27.5%) patients. ConclusionsMultidrug therapy with judicious reconstructive surgery is the optimal treatment modality for GUTB with cicatrization sequelae. In GUTB, augmentation cystoplasty is a safe procedure and strict long term follow up is needed to prevent complications.

Augmentation Cystoplasty: Experience in the Developing World

ObjectiveTo assess functional outcomes and classify postoperative complications of augmentation cystoplasty by the Clavien-Dindo classification system.MethodsA total of 197 adult patients undergoing augmentation cystoplasty between January 2016 and December 2020 at the Department of Urology, Sindh Institute of Urology and Transplantation (SIUT), were included in the study after obtaining approval from the ethics review committee. Patients’ records were reviewed for assessment of complications up to 3 months of follow-up. Functional outcomes were assessed by comparing preoperative video urodynamics study (VUDS) findings with follow-up VUDS findings at 1 year. IBM SPSS v23 was used to record and analyze all the complications, treatments, and pre- and postoperative VUDS data.ResultsOf the 197 patients included in this study, 127 (64.5%) were male and 70 (35.5%) were female. The mean age of the patients was 38.4 ± 9.92 years. Eighty-seven patients (44.2%) remained complication-free, 64 patients (32.5%) had grade I-II complications, 44 patients (22.3%) had grade III and IV complications, and only 2 patients (1%) had grade V complications. Stomal stenosis was the most frequent complication, occurring in 14.7% of patients, followed by renal function deterioration and high-grade fever, each noted in 13.7% of patients. Mean preoperative bladder capacity was 144.3 ± 63.09 mL, mean preoperative filling pressure was 43.34 ± 26.92 cm3 H2O, while mean postoperative bladder capacity was 460.83 ± 70.69 mL and mean postoperative filling pressure was 7.47 ± 5.79 cm3 H2O.ConclusionAugmentation cystoplasty can increase bladder capacity and improve bladder function. Because of the potential for complications, it is essential to carefully choose patients for surgery and provide proper preoperative counseling. Additionally, it is crucial to give proactive postoperative care.

Augmentation Cystoplasty in Adult Patients with Renal Impairment.

Bladder augmentation is beneficial in patients with neurogenic bladder due to spinal cord injury, multiple sclerosis, and tuberculous bladder. This retrospective study was done to determine the outcome of augmentation cystoplasty in adult patients with renal dysfunction. The study was done at the Sindh Institute of Urology and Transplantation (SIUT), Karachi from January 2010 till December 2019. A total of 153 patients underwent augmentation cystoplasty. Among these, 28 patients met the inclusion criteria of adult patients with age >18 years, and renal impairment at the time of the procedure. Exclusion criteria were patients with normal renal functions. Out of 28 patients, 17 (60%) showed improvement in renal functions post-augmentation cystoplasty, while 2 (7.14%) deteriorated and 9 (32.13%) patients showed static function in the same chronic kidney disease stages. Results from this study showed that augmentation cystoplasty is a safe operative procedure even in renal failure patients. It leads to improvement in renal functions in a significant number of patients. Key Words: Adults, Augmentation cystoplasty, Renal failure, Bladder compliance.

P0027 - Long term continence rates in patients undergoing augmentation cystoplasty with 30 year follow up

P0027 - Long term continence rates in patients undergoing augmentation cystoplasty with 30 year follow up

Course of Urological Problems in Children with Spinal Dysraphism: Long-Term Follow-Up Results

Background/Aims: We aimed to evaluate the course of urinary problems in children with spinal dysraphism. Methods: This multicenter study evaluated data on pediatric patients diagnosed with spinal dysraphism between 2010 and 2019. The neurological and urological conditions of the patients were examined retrospectively. This study focused on the course of urological problems. Urodynamic examinations including urodynamic bladder capacity, bladder pressure in maximal capacity, compliance, detrusor hyperactivity, uroflowmetry, and residual urine amount were evaluated. All patients underwent urinary system ultrasonography, urinalysis, hemogram and biochemical tests, and urodynamics at admission and follow-ups. Results: A total 62 patients (35 males, 27 females) with a mean age of 7.50 ± 4.01 years and age range of 1–16 years were included in the study. Ultrasonographic evaluation revealed normal results in 32 patients and abnormal findings, including moderate-to-severe calyceal dilatation, parenchymal thinning, and residual urine, in 30 patients. At the time of diagnosis, culture-positive urinary tract infection was detected in 22 patients, and leukocyte and/or bacterial positivity was detected in 18 patients. The differences between bladder capacity, bladder pressure at maximal capacity, compliance, and detrusor hyperactivity at first admission and post-treatment were statistically significant (p < 0.05). Vesicoureteral reflux was also detected in 25 patients. Thirty patients underwent oral anticholinergic and antibiotic prophylaxis, while 17 additionally underwent clean intermittent catheterization. Five patients underwent intravesical Botox injection, clean intermittent catheterization, and medical treatment, and 10 patients underwent augmentation cystoplasty. Conclusion: The prevalence of urinary tract problems is high in patients with spinal dysraphism for whom early diagnosis is very important for both urologic and neurosurgical considerations. Early follow-up of urodynamics should be performed, and treatment should be carried out if necessary. Regular follow-up and appropriate treatment have positive effects on the quality of life of these patients and may also prevent the occurrence of severe renal dysfunction.

Paediatric cystolitholapaxy through the Mitrofanoff/Monti channel

Bladder calculi are a known complication of bladder augmentation. Open cystolithotomy remains the preferred option for treating large or multiple stones. Increasingly, however, minimal access techniques have been used. Reports of Mitrofanoff cystolitholapaxy are rare and have been limited to adults. This study presented a two centre series of children treated by cystolitholapaxy via the Mitrofanoff/Monti channel. With institutional approval the current study retrospectively reviewed and identified 14 patients, on a prospective database, who underwent Mitrofanoff cystolitholapaxy to treat bladder calculi at two independent institutions in the UK and Chile between 2004 and 2016. It looked at patient demographics, surgical technique, stone clearance and recurrence, as well as leak or catheterisation difficulties of the Mitrofanoff/Monti channel post-procedure. Fourteen patients underwent Mitrofanoff cystolitholapaxy during the period 2004-2016. One patient was excluded due to lack of follow-up. The remaining 13 patients were aged 5-22 (median 14) years at the time of the procedure. Their underlying diagnoses were four neuropathic bladders, four bladder exstrophy, four cloacal exstrophy and one posterior urethral valve. Patients underwent augmentation cystoplasty at a median age of 5 (range 1-15) years, using ileum in 10 and sigmoid colon in three. The channel for clean intermittent catheterisation was an appendix Mitrofanoff in nine and a Monti channel in four. An Amplatz sheath was placed through the Mitrofanoff to allow safe access to the bladder for treating the stones (see Summary Table). Recurrent stones were treated using the same technique. Stone and channel outcomes were analysed for each procedure. There were 22 procedures in 13 patients; five (38%) patients had recurrent stones. Median time to recurrence was 6 months. There were no immediate complications. Stone clearance was confirmed by ultrasound and abdominal x-ray at 3-6 months after the procedure. Median follow-up was 15 (range 3-53) months. There were no leaks or difficulties catheterising the channel on follow-up. This was the first series of Mitrofanoff/Monti cystolitholapaxy for the treatment of calculi in augmented bladders of paediatric patients. Previous concerns about damaging the continence mechanism of the conduit appeared to be unwarranted. The use of an Amplatz sheath protected the continence system from repeated instrumentation, and permitted free backflow of irrigation and rapid clearance of stone fragments. Recurrence of stones occurred in 38%, which was in keeping with rates reported in the wider literature. Mitrofanoff cystolitholapaxy was safe, and with appropriate care did not result in leakage or difficulty catheterising.

Follow-up urodynamics in patients with neurogenic bladder.

Introduction:Neurogenic bladder patients are at long-term risk of secondary upper urinary tract damage. Symptoms are unreliable and follow-up urodynamics is the only method of ascertaining safety of bladder pressures. This review examines the recommendations, shortcomings and utilization of existing guidelines. The evidence with regard to follow-up urodynamics in different settings relevant to neurogenic bladder is evaluated and an algorithm is proposed.Methods:A pubmed search was conducted for studies on follow-up urodynamics in patients with neurogenic bladder. Additional search was made of secondary sources including reviews and guidelines.Results:The need for follow-up urodynamics should be considered in all patients undergoing an initial assessment and weighed against the risks. Existing guidelines, while unanimous in their recommendation of its utilization, give scant details regarding its incorporation in clinical management. Follow-up urodynamics can document efficacy and identify the need for escalation of therapy in patients on intermittent catheterization and antimuscarinics. Patients with spinal injury, spinal dysraphism and anorectal malformations are at higher risk for upper tract damage. Follow-up urodynamics can help identify patients suitable for intravesical botulinum and mark those destined for failure. Patients undergoing augmentation cystoplasty may be candidates for less aggressive urodynamic follow-up.Conclusions:Neurogenic bladder is managed by a broad cross-section of physicians. Clear recommendations and a management algorithm are important for improving patient care. Follow-up urodynamics can identify patients at risk, prevent renal dysfunction and improve the quality of life. There is an urgent need for more evidence on this important subject.

Urinary Tuberculosis with Renal Failure: Challenges in Management.

India is the country with the highest burden of TB, an estimated incidence figure of 2.1 million cases of TB for India out of a global incidence of 9 million according to World Health Organization (WHO) statistics for 2013. Renal impairment in these patients is slow and due to continuous infection causing destruction of renal mass. Reconstruction of urinary tract which is frequently required for patients with Urinary TB poses significant challenges. This paper analyses these challenges. To analyse challenges in reconstruction of urinary tract in patients with urinary tuberculosis and renal failure. Thirty-one patients with renal tuber-culosis were seen from August 2011 to August 2013. We faced major problem in outcomes of surgery in patients with multifocal disease. Out of 31 patients 18 patients were males and 13 were females. Total 11 patients had serum creatinine more than 2mg/dl (1.5 mg/dl being upper normal range of our laboratory) at the time of presentation. These patients had simultaneous kidney, ureter and bladder involvement or with bilateral disease. Four of these patients underwent uretero-calicostomy, five patients underwent augmentation cystoplasty with bilateral ureteric reimplantation and two patients underwent ileal conduit as they were having serum creatinine of more than 2.5 mg/dl. All patients who underwent ureterocalicostomy had re stricture and failure of surgery and augmentation cystoplasty had raised creatinine requiring second procedure in the form of percutaneous nephrostomy. Patients with ileal conduit remained stable with overnight bladder drainage at bed time. Though renal failure is not considered contrain-dication for augmentation cystoplasty, reconstruction using large segment of bowel predisposes them to metabolic complications and sepsis. Use of short segment of ileal conduit with continued drainage at night in creatinine above 2.5 mg% is reasonable option for augmentation to avoid further metabolic complications.

Does Lower Urinary Tract Status Affect Renal Transplantation Outcomes in Children?

BackgroundLower urinary tract dysfunction (LUTD), an important cause of end stage renal disease (ESRD) in children, can adversely affect renal graft survival. We compared renal transplant patients with LUTD as primary renal disease to those without LUTD. MethodsThe data of 60 children who underwent renal transplantation (RTx) between 2000 and 2012 were retrospectively reviewed. All patients with LUTD were evaluated with urodynamic tests preoperatively; 15 patients required clean intermittent catheterization and 9 patients underwent augmentation cystoplasty before RTx. ResultsThere were 25 children with LUTD. The mean follow-up for LUTD (+) and LUTD (−) groups were 63 (22–155) and 101 months (14–124), and graft survival were 76% for LUTD (+) and 80% for LUTD (−), respectively (P = .711). On the other hand, creatinine levels at last follow-up were significantly higher in the LUTD (+) group (1.3 ± 0.3 mg/dL vs 0.96 ± 0.57 mg/dL, P < .001). Infectious complications and postoperative urinary tract infection incidences were also higher in the LUTD (+) group (68% vs 25.7%, P = .002 and 60% vs 11.4%, P < .01). ConclusionUTI is significantly higher after kidney transplantation in patients with LUTD. Despite the higher risk of UTI, renal transplantation can be performed safely in those patients with careful patient selection, preoperative management, and close postoperative follow-up. Restoration of good bladder function is the key factor in the success of kidney transplantation in those patients.

Simultaneous Augmentation Cystoplasty and Cuff Only Artificial Urinary Sphincter in Children and Young Adults with Neurogenic Urinary Incontinence

We review our experience with artificial urinary sphincter and augmentation cystoplasty in patients with neurogenic bladder. This is the largest known series to specifically evaluate cuff only artificial urinary sphincter at augmentation cystoplasty. A total of 18 males underwent simultaneous artificial urinary sphincter and augmentation cystoplasty at our institution between 1982 and 2012, of whom 13 (72%) underwent cuff only artificial urinary sphincter. Outcomes included urinary continence, emptying modality, artificial urinary sphincter status, complications and additional procedures. Of the patients undergoing augmentation cystoplasty and cuff only artificial urinary sphincter 10 (77%) were initially continent. Average time of continence was 52.9 months. Four patients (31%) required no additional procedures and remained continent. Urinary incontinence developed in 3 patients (23%) immediately postoperatively and in 6 (46%) subsequently. Ultimately 9 patients (69%) required conversion to complete artificial urinary sphincter at a mean of 36.9 months postoperatively. Overall 12 patients (92%) were continent at followup. There were no artificial sphincter specific complications in patients undergoing the cuff only procedure with conversion to complete artificial urinary sphincter. After conversion to complete artificial urinary sphincter 3 patients (23%) experienced artificial sphincter specific complications. Reoperation was performed in 10 patients (77%), for 13 total procedures (1.3 per patient). There were no complications with cuff only artificial urinary sphincter and 6 complications with complete artificial urinary sphincter (p = 0.025). Finally, patients undergoing cuff only artificial urinary sphincter requiring revision were younger than those not requiring revision (15.6 vs 30.8 years, p = 0.026). Simultaneous cuff only artificial urinary sphincter and augmentation cystoplasty appears safe and efficacious in patients with neurogenic bladder, with fewer complications than complete artificial urinary sphincter, and may provide definitive urinary continence in up to a third of patients. This procedure is technically easy, allows for outpatient revision, provides time for the child to mature and may be cost effective in avoiding placement of additional components in this select patient population.

2265 URODYNAMIC PREDICTORS OF DE NOVO CLEAN INTERMITTENT CATHETERIZATION AFTER AUGMENTATION CYSTOPLASTY FOR REFRACTORY OVERACTIVE BLADDER

INTRODUCTION AND OBJECTIVES: In developed countries, numerous minimally invasive procedures are available for refractory Overactive bladder (OAB). Augmentation ileocystoplat (AC) remains an option for cultural and economic reasons in other countries. This study aimed to evaluate preoperative urodynamic variables that may predict subjects with refractory idiopathic OAB who may need CIC after AC. METHODS: Patients with refractory idiopathic urodynamically proven OAB completed UDI-6 and IIQ-7 questionnaires, urodynamics and post-void residual urine assessment before and 6 months after AC. Excluded from our study are subjects with suspected neurological deficit. RESULTS: 13 patients underwent augmentation cystoplasty for refractory OAB. Rate of De novo CIC after augmentation is 30% (n 4). Peak flow rate (Qmax) and detrusor pressure at Qmax were significantly higher among subjects who did not need CIC compared to those who needed CIC after augmentation (see table). In addition, the Qmax occurs during the down limb of the Pdet curve during voiding (see Figure). CONCLUSIONS: Qmax, Pdet at the Qmax and flow rate at the maximum detrusor pressure may ai to predict subjects who might require De novo CIC after AC for refractory idiopathic OAB.

Low Incidence of Urinary Tract Infections Following Renal Transplantation in Children With Bladder Augmentation

Children with end-stage renal disease and bladder dysfunction may require augmentation cystoplasty before kidney transplantation. Previous reports have suggested unacceptable urinary tract infection rates in these immunosuppressed patients. We reviewed our experience in this population. We retrospectively studied patients undergoing augmentation cystoplasty and subsequent renal transplantation by a single surgeon between 1989 and 2007. This cohort was compared with a control group on clean intermittent catheterization who had undergone transplantation without augmentation. Patient demographics, etiology of renal failure, surgical details, surgical/allograft outcomes and occurrence of urinary tract infection were analyzed. The augmented group included 17 patients with a median age at reconstruction of 6.4 years. Stomach was used in 15 patients and colon in 2. Median time between reconstruction and transplantation was 1.2 years. Median followup after transplantation was 7.7 years. The control group included 17 patients with a median age at transplantation of 10.9 years. Median followup in the controls was 6.1 years. All ureteral reimplantations were antirefluxing. Patients on clean intermittent catheterization were maintained on oral antibiotic suppression and/or gentamicin bladder irrigations. In the augmented group 35 episodes of urinary tract infection were noted, and the number of documented infections per patient-year of followup was 0.22, compared to 32 episodes of urinary tract infection and 0.28 infections per patient-year of followup in the controls. No allograft was lost to infectious complications. In our series there was no increase in urinary tract infection rate following renal transplantation in patients with augmented bladders compared to controls. This finding may be due to the use of gastric augmentation, antirefluxing reimplantation and gentamicin irrigations.

Botulinum toxin A in the treatment of spinal cord injury patients with refractory neurogenic detrusor overactivity

To evaluate the efficacy of botulinum toxin type A injections in the detrusor muscle in patients with spinal cord injury and urinary incontinence due to detrusor overactivity and refractory to anticholinergic agents. We prospectively evaluated 22 patients with spinal cord injuries, whose bladders were emptied by intermittent catheterization. All patients had detrusor overactivity and urinary incontinence that proved difficult to treat, despite using high doses of two different anticholinergics. The pre-treatment assessment included a complete urodynamic study and ultrasonography of the kidneys and urinary tract. A one-month follow-up was completed with urodynamic evaluation and the clinical response was evaluated through outpatient consultations and telephone contact. After the procedure, the maximum cystometric capacity and the bladder reflex volume increased, whereas the maximum detrusor pressure and compliance decreased. The mean duration of continence was 7±7 months. In 18 patients (81.8%), it was necessary to administer anticholinergics to achieve continence. Five patients (22.7%) had indication of reinjection, and augmentation cystoplasty was indicated in 9 patients (40.9%). The use of botulinum toxin in the treatment of neurogenic detrusor overactivity refractory to anticholinergics is an option before more invasive treatments, such as augmentation cystoplasty, are attempted. In our study as well as in the literature, there was improvement in most urodynamic parameters. Overall, 40.9% of patients underwent augmentation cystoplasty and 81.8% of patients needed anticholinergic agents to reach urinary continence. Further studies are necessary to improve the procedure and to achieve better clinical results.

Early Cellular and Stromal Responses in Regeneration Versus Repair of a Mammalian Bladder Using Autologous Cell and Biodegradable Scaffold Technologies

Internal organ regeneration holds promise for changing medical technology and decreasing organ shortages. Current medical treatment for internal organ failure is largely limited to organ transplantation. A construct composed of synthetic biopolymer with autologous cells has shown long-term clinical benefit in patients undergoing augmentation cystoplasty. However, to our knowledge early cellular and stromal events during bladder regeneration have not been elucidated. In situ cellular responses to 2 biopolymer implants, including a poly(lactic-co-glycolic acid) (Sigma-Aldrich) based biodegradable mesh scaffold with autologous urothelial and smooth muscle cells (construct) and a poly(lactic-co-glycolic acid) based biodegradable mesh scaffold alone without cells (scaffold), were compared in a canine model of augmentation cystoplasty. Healing events were correlated with urodynamic assessments. Construct implants regenerated baseline urodynamics as early as 4 months after implantation. Urodynamics following scaffold implantation failed to return to baseline by study termination at 9 months. Functional differences elicited by construct and scaffold implants correlated with structural differences in the neotissues. Construct stroma had greater vascularization with gently folded, interwoven connective tissue elements. Scaffold stroma was dense, haphazardly organized connective tissue. Urothelium regenerated in response to construct and scaffold implantation. However, only construct had normal stroma, well developed detrusor and abundant alpha-smooth muscle actin (Vector Laboratories, Burlingame, California) cell staining at early time points, leading to a structurally and functionally complete regenerated bladder wall at 9 months. Early cellular and stromal events distinguish healing processes that lead to bladder wall regeneration or repair. Construct implants containing cells elicit early healing processes that culminate with the regeneration of complete mucosal and muscular components, whereas the response to scaffold implantation is consistent with reparative healing, that is with mucosal growth but incomplete tissue layer development.

Tumor in Bladder Reservoir After Gastrocystoplasty

To our knowledge the risk of malignancy in patients with previous bladder augmentation with stomach is unknown. We report 3 cases of gastric adenocarcinoma and 1 of transitional cell carcinoma after augmentation cystoplasty with stomach with long-term followup. Between August 1989 and August 2002, 119 patients underwent augmentation cystoplasty with stomach at our 2 institutions (University of Miami School of Medicine, and Seattle Children's Hospital and Regional Medical Center). Medical records, urodynamic studies, radiographic imaging and laboratory evaluations were reviewed retrospectively and cases of malignancy were analyzed in detail. Four male patients had carcinoma after augmentation gastrocystoplasty. Preoperative diagnosis was neurogenic bladder in 3 patients and posterior urethral valve in 1. Three patients had gastric adenocarcinoma, while the other had poorly differentiated transitional cell carcinoma. Each case progressed to malignancy more than 10 years after augmentation (11, 12, 14 and 14 years, respectively). Patients who undergo bladder augmentation with a gastric remnant are at increased risk for malignancy, probably similar to that in patients with enterocystoplasty. Therefore, they require close long-term followup. Patients should be followed annually with ultrasound, and cystoscopy should be performed annually starting 10 years after gastrocystoplasty unless they have abnormal ultrasound, hematuria or another cancer risk factor. Any suspicious lesions should be biopsied, especially at the gastrovesical anastomotic site.

INTRAVESICAL JACKSON-PRATT DRAIN FOR URINARY DIVERSION AFTER AUGMENTATION CYSTOPLASTY

Augmentation cystoplasty has become a primary form of bladder management in children with a noncompliant bladder. Excellent urinary drainage is required for anastomotic healing and the removal of mucous buildup. Suprapubic drainage traditionally involves a Malecot catheter, although poor irrigation and dislodgment of this type of catheter are well-known complications. We report the placement of an intravesical Jackson-Pratt drain for urinary diversion in augmented bladders. We reviewed our use of an intravesical Jackson-Pratt drain for urinary diversion between 1995 and 1999 in 17 patients. Postoperative catheter drainage and irrigation characteristics were assessed as well as catheter related complications. Average patient age was 13 years (range 3 to 27). The majority of patients underwent ileal (11) or sigmoid (4) cystoplasty and 1 each underwent composite and ureteral cystoplasty. Drains remained in place an average of 27 days (range 6 to 57). All patients had excellent drainage during the postoperative period. Irrigation was subjectively easier than with a Malecot catheter. Average cost of a latex-free Malecot catheter was 2.7-fold that of a Jackson-Pratt drain. No catheters became nonfunctional before removal, although 1 was inadvertently pulled during patient transfer. A Jackson-Pratt drain provides excellent urinary drainage in patients undergoing augmentation cystoplasty. Multiple openings along the tube seem to improve irrigation in contrast to the single opening in a Malecot catheter, which often aspirates a region of the augmented bladder. The ready availability, decreased cost, ease of irrigation, increased pliability with decreased chance of dislodgment and lack of latex make an intravesical Jackson-Pratt drain a superior choice for augmented neurogenic bladder.

Long-Term Results of Augmentation Cystoplasty

Objectives: To present the long-term results and complications of augmentation cystoplasty. Methods: 267 patients underwent augmentation cystoplasty with a minimum follow-up of 3 years. Results: Patients with neuropathic bladders had a 78% continence rate with cystoplasty alone increasing to 90% with the addition of an artificial urinary sphincter. Patients undergoing cystoplasty for detrusor instability had a 93% continence rate. The complications of this procedure include bacteriuria, absorption disorders, stones and the potential risk of malignancy. Discussion: The overall results of continence with augmentation cystoplasty are excellent. Long-term follow-up is required to ensure prompt treatment of the complications.

Combined Use of Bowel and the Artificial Urinary Sphincter in Reconstruction of the Lower Urinary Tract: Infectious Complications

Combined use of the artificial urinary sphincter and bowel in reconstruction of the lower urinary tract is currently being performed with increasing frequency. We reviewed our experience with 31 patients undergoing augmentation cystoplasty and insertion of the artificial urinary sphincter with respect to device infections to determine if a single operation was associated with increased morbidity compared to staged procedures. Of the patients who underwent simultaneous reconstruction 50% had prosthetic infections as opposed to 9.5% when the procedure was staged. More than half of the infections presented longer than 1 year after placement of the artificial urinary sphincter. The lowest incidence of device infection occurred in patients who underwent a staged procedure with implantation of the artificial urinary sphincter initially followed by augmentation cystoplasty. The discrepancy in infection rates between single and staged procedures is dramatic in this series and, therefore, a staged approach is recommended to decrease infectious complications.

The Gastric Augment Single Pedicle Tube Catheterizable Stoma: A Useful Adjunct to Reconstruction of the Urinary Tract

Since 1990 we have used stomach for bladder augmentation and continent urinary diversions in 73 patients, of whom 15 received a gastric tube catheterizable stoma and are the subject of this report. The gastric tube receives its blood supply from the same vascular pedicle as the gastric patch and, therefore, it can be moved anywhere along with the patch. The tube is then reimplanted in the reservoir or bladder following the Mitrofanoff principle and brought to the skin as a catheterizable stoma. Patient age ranged from 12 to 60 years. Three patients underwent augmentation cystoplasty and 12 received a composite gastrointestinal continent reservoir (in 10 a prior bowel conduit was detubularized and used as part of the reservoir). The appendix was either previously removed (10 patients) or not suitable as a catheterizable limb (4). All patients are continent. Catheters used to empty the reservoir varied from 12F to 18F. Complications included an early traumatic perforation of the tube in 1 patient, distal stenosis in 1 and mucosal redundancy in 1. Of these patients 2 required revision. Two patients had mild peristomal skin irritation without ulceration. Anatomical and technical aspects of this procedure are presented. In summary, we believe the gastric augment single pedicle tube to be a useful tool for the reconstructive urologist, which in select cases may obviate the need for additional bowel anastomosis to create a tapered intestinal catheterizable limb.

Continence in the Myelodysplastic Patient Following Enterocystoplasty

To evaluate the ability of augmentation cystoplasty alone to provide a low pressure bladder and an adequate degree of continence in the myelodysplastic patient, the clinical records and urodynamic data of the last 18 consecutive such patients undergoing augmentation cystoplasty at our institution were reviewed. Two patients underwent colocystoplasty and 16 underwent ileocystoplasty. No patient underwent any procedure on the bladder neck or urethra. The 2 colocystoplasty patients exhibited episodic dampness attributed to contractions of the augmentation but all of the ileocystoplasty patients were dry during the day except 1 who had a urethral resistance of only 19 to 22cm. water. On the basis of this review, ileocystoplasty alone appears to be sufficient for satisfactory continence in patients with a neurogenic bladder undergoing vesical augmentation if bladder outlet resistance exceeds 25 to 30cm. water.