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Augmentation Cystoplasty Periprocedural Care

  • Author: Pravin K Rao, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Nov 12, 2014
 

Preprocedural Planning

Preoperative evaluation

Urine analysis, urine culture, and cytology (in adults) allow proper preoperative treatment of infection and investigation of potential occult malignancy. Sterile urine at the time of surgery is crucial in all patients, especially those with ventriculoperitoneal shunts.

Obtain a serum chemistry panel to rule out metabolic acidosis and to allow for assessment of renal failure with and without surgical therapy. Conduct a complete blood cell count to identify anemia or infection.

The kidneys and upper urinary tract should be imaged with renal ultrasonography to identify any upper tract anomalies and assess the renal parenchyma. In the presence of hydronephrosis, upper tract obstruction (eg, ureteropelvic junction obstruction) should be ruled out in addition to lower tract pathology.

Voiding cystourethrography should be performed to evaluate bladder size and contour, the presence of any diverticula, the anatomy of the bladder neck, and the presence of vesicoureteral reflux. This can also be performed as part of videourodynamic evaluation.

Assess urinary continence with a voiding diary and Valsalva leak point pressure.

Urodynamic evaluation should be performed if the patient has a history of dysfunctional voiding, though some surgeons perform this test in all patients in whom augmentation cystoplasty is being considered. Consider fluoroscopic video monitoring to assess for vesicoureteral reflux and to determine the bladder pressures at which reflux occurs.

Twenty-four–hour urine-volume assessment helps in planning the final reservoir size.

Cystoscopy, which can be performed immediately before augmentation cystoplasty under the same anesthesia, is useful for identifying occult urethral valves, strictures, or unsuspected bladder pathology.

Colonoscopy or barium enema may be considered in an older patient who has the potential for diverticular disease or colon cancer. This is even more important if the large intestine is the planned segment for augmentation cystoplasty.

Planning for concomitant procedures

Some patients who are candidates for augmentation cystoplasty also have ureteral reflux. Patients who have bladder exstrophy and who require augmentation cystoplasty should undergo simultaneous ureteral reimplantation. These patients have abnormal ureteral insertions to the bladder, and with bladder neck repair for continence, they often have elevated bladder pressures. Thus, tunneled reimplantation is almost universally performed, usually in a cephalad manner toward the bladder dome so as to follow the course of the ureter.

The role of ureteroneocystostomy in other patients is less clear. In patients with reflux at high bladder pressures, the augmentation procedure ideally resolves the issue. However, if low pressure causes reflux, the problem may persist after augmentation.

If a patient has grade 4 or 5 ureteral reflux at bladder-filling pressures lower than 40 cm H2 O, tunneled ureteral reimplantation into the native bladder tissue should be more strongly considered. Patients with low-grade reflux (ie, grade 1 or 2) at higher bladder pressures may undergo augmentation in the hope that the reflux will resolve with decreased bladder storage pressures.

A history of renal scarring, a history of pyelonephritis, the level of renal function, and the patient’s willingness to undergo future surgery should all be considered in counseling patients and parents and deciding whether to perform concomitant ureteral reimplantation at the time of augmentation cystoplasty.

In adult patients for whom a continent catheterizable stoma is planned, some surgeons routinely perform bladder-neck closure; however, if the outlet is intact and continent, it should be maintained to provide an alternative route for catheterization. Many surgeons feel that surveillance endoscopy is much easier in patients with an open bladder neck.

Associated urologic or gastrointestinal (GI) issues arising from congenital anomalies or acquired neurologic impairment may necessitate concomitant procedures. Urinary continence can be achieved with an artificial urinary sphincter (in males) or a urethral sling placement (in females). Construction of a continent catheterizable stoma assists with urinary emptying. A Malone antegrade catheterizable enema (MACE) procedure is used for neurogenic constipation.

In a small uncontrolled study, De et al discussed augmentation cystoplasty as an ancillary procedure to salvage prostatectomy after failed radiation therapy for localized prostate cancer; continence was improved, and 7 of 9 patients responding to a quality-of-life questionnaire stated that they would undergo the operation again.[16, 17] Because of the risk of high-bother urinary incontinence, the authors studied salvage prostatectomy with concomitant ileal augmentation, bladder neck closure, and creation of a catheterizable appendicovesicostomy.

In patients undergoing retropubic prostatectomy as primary treatment for prostate cancer who are at high risk for bladder dysfunction due to longstanding outlet obstruction, concomitant bladder augmentation is also an option.

Selection of tissue for augmentation cystoplasty

Proper selection of the optimal tissue for augmentation cystoplasty (see Table 1 below) begins with analysis of the patient’s anatomy and comorbidities but also requires consideration of intraoperative anatomic findings. One should always be prepared to use alternatives to the planned augmenting segment if the patient’s anatomy is unfavorable for the planned procedure.

Table 1. Comparison of Tissues for Augmentation Cystoplasty (Open Table in a new window)

Tissue Segment Advantages Disadvantages
Stomach Decreases mucus, infection, and stones; better for short gut and acidosis/azotemia Hemolytic dysuria syndrome
Jejunum None (used only if other segments are contraindicated/unavailable) Electrolyte disturbances; malabsorption
Ileum Usually available, well-tolerated Electrolyte disturbances; mucus
Large intestine Usually available, well-tolerated Electrolyte disturbances; mucus; sigmoid: strong contractions
Ureter Minimizes mucus, infection, stones and electrolyte effects Rarely available

Gastrocystoplasty may be considered in patients with renal insufficiency (creatinine level > 2 mg/dL) or significant metabolic acidosis. Using a gastric segment does not appear to worsen the acidosis and may preserve renal function. However, this procedure can be difficult to perform, it does not eliminate the risk of severe electrolyte abnormalities, and a significant number of these patients experience dysuria.

Patients who have a reduced amount of intestine (eg, anomalous short gut, previous intestinal removal, or cloacal exstrophy) may also be considered for augmentation cystoplasty with stomach rather than intestine. In patients with short gut or cloacal exstrophy, ileum is also commonly used for Mitrofanoff channel and augmentation, with GI consultation.

Ureterocystoplasty is a favorable option in patients with a massively dilated ureter; the use of ureteral tissue curbs the electrolyte imbalance and mucus production observed with intestinal segments. If the ipsilateral kidney is minimally functional, nephrectomy can be performed at the time of surgery.

With removal of the ileocecal valve, patients with neuropathic causes of bladder dysfunction (eg, spina bifida) may experience severe diarrhea that can cause fecal incontinence; thus, the combined use of distal ileum and cecum is discouraged in these patients.

In general, ileum and large intestine both handle well surgically and make excellent intestinal segments for augmentation. However, they both produce mucus and can have problematic peristalsis if not properly detubularized. Both types of augmentation segment have been well tested, and the choice of one over the other is largely a matter of individual surgical preference.

Some patients with neurogenic bowel dysfunction have a redundant sigmoid colon, which is therefore the segment of choice. In addition, this is the preferred segment in patients who do not require a continent catheterizable stoma.

Jejunal augmentation segments are rarely used, because of the importance of the jejunum in nutritional absorption and the severity of electrolyte abnormalities associated with the use of jejunal tissue.

If a patient or their caretaker is poorly compliant, an incontinent ileovesicostomy (ie, an ileal chimney with stoma) may be considered as a means of reducing the risk of perforation. This can be reversed when the patient can responsibly and independently manage the catheterization schedule.

Alternative tissue sources

Desai et al used ureteral tissue balloon expanders before laparoscopic bladder augmentation in a porcine model.[18] Basic science researchers continue to investigate potential alternatives to autologous tissues for augmentation cystoplasty. Small-intestine submucosa and synthetic polymeric substances are being studied. Tissue-engineering efforts continue, though reproducing the elastic and contractile properties of the bladder is challenging. Tissue engineering with nanostructured polymeric scaffolds appears promising.[19]

The use of any such surfaces could expand bladder volume and decrease bladder compliance without the morbidity and potential complications of intestinal harvesting. Potential benefits would include decreases in complications, operating time, metabolic derangements, and deleterious effects on bowel function.

Bowel preparation

All patients undergoing augmentation cystoplasty require preoperative mechanical and antibiotic bowel preparation.[20] Patients stay on a clear liquid diet for 2 days prior to the operation and take magnesium citrate the night before surgery.

Preoperative inpatient hospital admission should be planned for patients with renal insufficiency, chronic constipation, or a high risk of dehydration so that intestinal evacuation can be performed with concomitant monitoring and treatment of serum electrolytes and fluid status.

Scheduled oral erythromycin base and neomycin are often administered the night before surgery, and intravenous antibiotics are given 1 hour before the incision.

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Monitoring and Follow-up

The patient should be seen for follow-up visits at 6 weeks, 3 months, and 6 months, then yearly thereafter. The focus is on preventing complications by monitoring with appropriate laboratory and radiologic studies.

Serum electrolytes and renal panel should be monitored to assess the level of acidosis and the potential need for correction with alkali therapy. Renal and bladder ultrasonography is used to monitor for occult obstruction or calculi formation and to confirm appropriate renal growth in pediatric patients.

Screening urine culture tests are used to check for bladder colonization with urease-producing bacteria; these species should be treated because they may cause bladder stones and have been associated with upper tract damage.

Begin bladder malignancy screening 10 years after surgery with annual cystoscopy, cytology, and biopsy if appropriate. Educate the patient about the symptoms of bladder perforation and the need for urgent treatment.

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Contributor Information and Disclosures
Author

Pravin K Rao, MD Assistant Professor, Director of Reproductive Medicine and Surgery, Brady Urological Institute at Bayview Medical Center, Johns Hopkins Medicine

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.

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 of Andrology, Society of Reproductive Surgeons, Society for the Study of Male Reproduction, American Society for Reproductive Medicine, American Urological Association, SWOG

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, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Acknowledgements

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.

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

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Augmentation cystoplasty. Isolate segment of ileum chosen for augmentation on adequate mesentery, and reestablish intestinal continuity. Close ends of segment with suture, and open antimesenteric surface.
Augmentation cystoplasty. Fold ileal segment, and sew it upon itself. This detubularizes segment, reduces enteric contractions, and maximizes volume that segment contributes to urinary storage.
Augmentation cystoplasty. Anastomose augmenting segment to prepared bladder. Perform wide-mouthed anastomosis to ensure that augmentation is spherical. If this is not carried out properly, augmenting segment can exist only as poorly draining diverticulum that is prone to complications.
Table 1. Comparison of Tissues for Augmentation Cystoplasty
Tissue Segment Advantages Disadvantages
Stomach Decreases mucus, infection, and stones; better for short gut and acidosis/azotemia Hemolytic dysuria syndrome
Jejunum None (used only if other segments are contraindicated/unavailable) Electrolyte disturbances; malabsorption
Ileum Usually available, well-tolerated Electrolyte disturbances; mucus
Large intestine Usually available, well-tolerated Electrolyte disturbances; mucus; sigmoid: strong contractions
Ureter Minimizes mucus, infection, stones and electrolyte effects Rarely available
Table 2. Metabolic Changes Caused By the Use of Various Tissues in Augmentation Cystoplasty
Intestinal Segment Acid-Base Effect K+ Cl+ Notes
Stomach Alkalosis Respiratory insufficiency, seizure, arrhythmia
Jejunum Acidosis Hyponatremia, azotemia, malabsorption
Ileum/colon Acidosis Diarrhea with loss of colon, ileocecal valve
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