Augmentation Cystoplasty 

  • Author: Pravin K Rao, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS   more...
 
Updated: Nov 30, 2011
 

Background

Bladder augmentation, also called augmentation cystoplasty (AC), is a surgical procedure used in adults and children who lack adequate bladder capacity or detrusor compliance. Decreased bladder capacity or abnormal compliance may manifest as debilitating urgency, frequency, incontinence, recurrent urinary tract infections (UTIs), pyelonephritis, or progressive renal insufficiency. For many patients, augmentation cystoplasty can provide a safe functional reservoir that allows for urinary continence and prevention of upper tract deterioration.

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History of the Procedure

Augmentation cystoplasty with a segment of native tissue (usually an intestinal segment), was first performed in the late 1880s in animals and in the 1890s in humans. The original indication for the procedure was a small contracted bladder caused by tuberculous cystitis. Since that time, advances in surgical technique, perioperative care, and antibiotics have greatly improved outcomes.

Because the augmented bladder typically empties poorly, the introduction of clean intermittent catheterization by Lapides et al in the early 1970s was pivotal in allowing the widespread use of augmentation cystoplasty.[1] This allowed convenient, controlled bladder emptying of a safe, functional reservoir.

In 2005, 162 augmentation cystoplasty procedures were logged among Medicare patients.

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Etiology

Both neuropathic and non-neuropathic causes for severe bladder dysfunction exist in pediatric and adult populations.

Neuropathic causes include the following:

Non-neuropathic causes include the following:

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Presentation

Decreased bladder capacity or abnormal compliance may manifest as debilitating urgency, frequency, incontinence, recurrent UTIs, pyelonephritis, or progressive renal insufficiency.

Various studies used to evaluate such symptoms may reveal severe dysfunction.

  • Urodynamics demonstrate a low-volume, poorly compliant reservoir, placing the kidneys at risk from high-pressure urinary storage.
  • Simultaneous fluoroscopic videourodynamics may reveal vesicoureteral reflux.
  • Renal ultrasonography or other imaging modalities may show renal scarring or impaired renal growth due to high-pressure urinary storage.
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Indications

Any patient with marked reduction in bladder capacity or compliance may be a candidate for augmentation cystoplasty. Conservative management for these patients usually consists of intermittent self-catheterization and anticholinergic medications. Augmentation cystoplasty is considered when bothersome symptoms impair a patient’s lifestyle despite medical treatment or when high-pressure urinary storage places the upper urinary tracts at risk.

Neurogenic bladder in the pediatric population is often associated with congenital anomalies, including the following:

Patients with these conditions most commonly undergo augmentation cystoplasty when, despite behavioral and medical management, they experience continued incontinence, debilitating urgency, enuresis, complicated UTIs, vesicoureteral reflux, or impaired renal growth.

Some adult patients who underwent urinary diversion for an embryologic urinary defect as a child seek a healthier cosmetic and functional state. In other cases, adults have an acquired cause for bladder dysfunction, including some of those discussed in Etiology. Adults may present with symptoms very similar to those of children with congenital abnormalities. Again, surgery is indicated for adults with refractory symptoms and those with risk or progression of upper tract deterioration.

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Relevant Anatomy

The anatomy of the bladder forms an extraperitoneal muscular urine reservoir that lies behind the pubic symphysis in the pelvis. A normal bladder functions through a complex coordination of musculoskeletal, neurologic, and psychological functions that allow filling and emptying of the bladder contents. The prime effector of continence is the synergic relaxation of detrusor muscles and contraction of the bladder neck and pelvic floor muscles.

The normal adult bladder accommodates 300-600 mL of urine; a central nervous system (CNS) response is usually triggered when the volume reaches 400 mL. However, urination can be prevented by cortical suppression of the peripheral nervous system or by voluntary contraction of the external urethral sphincter.

See Bladder Anatomy for more information.

See Intraoperative details for a discussion of relevant anatomy.

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Contraindications

Patients who are unable or unwilling to perform life-long intermittent catheterization should not undergo augmentation cystoplasty because of the high likelihood of ultimately requiring catheterization.In addition, patients with inflammatory bowel disease (especially Crohn disease), short or irradiated bowel, bladder tumors, severe radiation cystitis, or severe renal insufficiency should not undergo augmentation cystoplasty.

Poor surgical candidates and patients with a short life expectancy should consider alternatives such as continued medical management or creation of a less complex, temporizing form of urinary drainage.

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Contributor Information and Disclosures
Author

Pravin K Rao, MD  Staff Physician, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

Disclosure: Nothing to disclose.

Coauthor(s)

Alan J Iverson, MD  Staff Physician, Department of Urology, David Grant Medical Center

Alan J Iverson, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

R Duane Cespedes, MD  Residency Program Director, Director of Female Urology and Urodynamics, Department of Urology, Wilford Hall Medical Center; Clinical Associate Professor, Department of Surgery, Division of Urology, University of Texas Health Science Center at San Antonio

R Duane Cespedes, MD is a member of the following medical societies: Alpha Omega Alpha and American Urological Association

Disclosure: Nothing to disclose.

Edmund S Sabanegh Jr, MD  Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

Edmund S Sabanegh Jr, MD is a member of the following medical societies: American Medical Association, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Society for the Study of Male Reproduction, Society of Reproductive Surgeons, and Southwest Oncology Group

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael Grasso III, MD  Director of Endourology, Lenox Hill Hospital; Professor and Vice Chairman, Department of Urology, New York Medical College

Michael Grasso III, MD is a member of the following medical societies: American Medical Association, American Urological Association, Endourological Society, Medical Society of the State of New York, National Kidney Foundation, Société Internationale d'Urologie (International Society of Urology), and Society of Laparoendoscopic Surgeons

Disclosure: Karl Storz Endoscopy Consulting fee Consulting; Boston Scientific Consulting fee Consulting; Cook Urologic Consulting fee Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS  Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists

Disclosure: Nothing to disclose.

References

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Augmentation cystoplasty. Isolate the segment of ileum chosen for augmentation on an adequate mesentery and re-establish intestinal continuity. Close the ends of the segment with suture and open the antimesenteric surface.
Fold the segment of ileum for augmentation cystoplasty and sew it upon itself. This detubularizes the segment, reduces enteric contractions, and maximizes the volume that the segment contributes to urinary storage.
Augmentation cystoplasty. Anastomose the augmenting segment to the prepared bladder. Perform a wide-mouthed anastomosis to ensure that the augmentation is spherical. If this is not carried out properly, the augmenting segment can exist only as a poorly draining diverticulum that is prone to complications.
Table 1. Comparison of Tissues for Augmentation Cystoplasty
Tissue SegmentAdvantagesDisadvantages
StomachDecreases mucus, infection, and stones; better for short gut and acidosis/azotemia Hemolytic dysuria syndrome
JejunumNone (used only if other segments are contraindicated/unavailable)Electrolyte disturbances; malabsorption
IleumUsually available, well-toleratedElectrolyte disturbances; mucus
Large intestineUsually available, well-toleratedElectrolyte disturbances; mucus; sigmoid: strong contractions
UreterMinimizes mucus, infection, stones and electrolyte effectsRarely available
Table 2. Metabolic Changes Caused By the Use of Various Tissues in Augmentation Cystoplasty
Intestinal SegmentAcid-Base EffectK+Cl+Notes
StomachAlkalosis↓↓Respiratory insufficiency, seizure, arrhythmia
JejunumAcidosis↑ ↓ Hyponatremia, azotemia, malabsorption
Ileum/colonAcidosis↓ ↑ Diarrhea with loss of colon, ileocecal valve
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