Female Pelvic Surgery

12. Augmentation Cystoplasty

Geneviève Nadeau  and Sender Herschorn 

(1)

Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada

(2)

Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada

Geneviève Nadeau

Email: Genevieve.nadeau.6@ulaval.ca

Sender Herschorn (Corresponding author)

Email: s.herschorn@utoronto.ca

Introduction

Augmentation cystoplasty (AC) is a surgical procedure used to increase bladder storage capacity or improve detrusor compliance. Performed by urologists for more than a century, the technique has evolved over the years, using different segments of the gastrointestinal (GI) tract. It is frequently combined with other procedures depending on the need for correction of associated problems (bladder outlet correction, ureteral obstruction, etc.), and more recently has been performed laparoscopically or robotically. Even though its role has declined over the years, decreasing from 192 operations in 2000 in the United Kingdom to 120 in 2010 [1], it remains of paramount importance for the reconstructive urologist to be proficient with this procedure. This chapter will outline the indications and technique of bladder augmentation as well as focus on the short- and long-term complications.

History

First described in dogs in 1888 by Tizzoni and Foggi [2] and in 1899 in humans by von Mikulicz [3], augmentation cystoplasty was reported by Couvelaire in 1950 to treat tuberculosis cystitis [4]. The use of different segments of the GI tract has been described: colon in 1912 by Charghi [5], sigmoid by Bisgard in 1943 [6], cecum by Couvelaire [4], stomach in 1956 by Sinaiko [7], and finally the classic detubularized ileal patch by Goodwin in 1959 [8]. A wide variety of other organic tissues (peritoneum, omentum, gallbladder, skin, etc.) have also been unsuccessfully attempted and abandoned [9]. Finally, the introduction of clean intermittent catheterization (CIC) by Lapides in 1972 allowed the procedure to gain widespread acceptance [10].

Indications

Considering that AC is an invasive procedure, it should be offered only after more conservative interventions such as behavioral modification, anticholinergics, botulinum toxin (BTX-A), or sacral neuromodulation have been considered and failed, as recommended by the 4th International Consultation on Incontinence [11]. Many conditions may necessitate AC (Table 12.1), whether in the setting of upper tract deterioration due to high bladder storage pressures (detrusor leak point pressure over 40 cm H2O) or unacceptable incontinence secondary to contracted bladder volume and decreased compliance or overactivity [12].

Table 12.1

Indications for augmentation cystoplasty

 

Indications

Congenital

Myelodysplasia

Tethered spinal cord

Exstrophy (classic, cloacal, epispadias)

Sacral agenesis

Caudal regression

Posterior urethral valves

Acquired neurogenic

Spinal cord injury

Spinal tumors

Myelitis

Multiple sclerosis

Idiopathic

Acquired non-neurogenic

Detrusor overactivity

Defunctionalized bladder in patients on dialysis

Infectious

Tuberculosis

Schistosomiasis

Inflammatory

Interstitial cystitis

Radiation cystitis

Chemotherapy-induced cystitis

Iatrogenic

Intraoperative loss of bladder wall (after extirpative surgery for malignancy)

Urinary undiversion

Neurogenic conditions caused by congenital, acquired, or traumatic etiologies, especially myelodysplasia in children and spinal cord injuries in adults, are probably the most frequent indications. Although there is considerable variation in institutional rates, it has been estimated that 5–30 % of patients with spina bifida will undergo AC [1314]. Multiple sclerosis, with its inherent progressive neuromuscular deterioration that may make intermittent self-catheterization difficult [15], is preferably managed with medical therapy such as anticholinergics and botulinum toxin but occasional cases may be amenable to AC.

Patients with severe refractory idiopathic overactive bladder (OAB) or rarely interstitial cystitis can also be offered such a procedure, but this should be a last resort option for carefully selected cases, as pointed out by the American Urological Association guidelines [1617].

Benign diseases with decrease in compliance from collagen deposition in the bladder wall are other indications. Tuberculosis cystitis, which used to be the number one indication in the past, is now a rarity [15]. Schistosomiasis, an endemic parasitic infection found primarily in the Middle East and Africa, may cause bladder wall fibrosis in 2 % of cases [1]. Reduced bladder capacity may be improved by AC.

Pelvic radiation therapy or surgical resection for colorectal, gynecological, or urological malignancies may also compromise the urinary tract and necessitate AC.

Finally, a defunctionalized bladder in a patient on dialysis awaiting renal transplantation might warrant AC to restore proper lower urinary tract function and protect the allograft, although its timing (before, after, or even concomitantly with the transplantation) is controversial [18], the concern being the risk of severe sepsis in the immunosuppressed patient [1].

Contraindications

Poor baseline renal function may potentially expose patients to severe electrolyte abnormalities and worsening renal function and is a relative contraindication. However, in patients with renal dysfunction that is a direct result of bladder dysfunction with elevated storage pressure, AC may be appropriate and help stabilize renal function [19]. Other relative contraindications include inflammatory bowel disease (Crohn’s disease), irradiated bowel, short gut syndrome, bladder tumors, and liver failure [20].

Preoperative Surgical Considerations

Extensive history and physical exam, serum chemistries (complete blood count, electrolyte and creatinine levels, coagulation factors), urine cytology, urinalysis, and cultures are required. All patients should also undergo anatomic and functional assessment of the urinary tract with cystoscopy (to exclude intravesical abnormalities such as tumors), urodynamics (to characterize bladder capacity, compliance, or uninhibited detrusor contractions, to assess detrusor and Valsalva leak point pressures, and to rule out infravesical obstruction), cystography (to rule out vesicoureteral reflux), and upper tract imaging (ultrasound or computerized tomography; to document the presence of hydronephrosis or stone disease). A history of bowel disease may require preoperative bowel imaging studies or colonoscopy. A voiding diary can help in planning for the final reservoir size by assessing 24-h urine volume [21], although the augmentation usually enlarges with time. The need for latex precautions for at-risk patients with spinal dysraphism should also be kept in mind. Planning for other concomitant procedures such as a continent catheterizable stoma (using the Mitrofanoff or Monti principles), ureteral reimplantation, or bladder neck management is an essential prerequisite before considering the intervention [22]. Finally, since CIC is frequently a necessary adjunct, adequate manual dexterity and cognitive abilities are prerequisites to be considered an adequate surgical candidate and it is crucial, in the preoperative visits, to reinforce the importance of compliance with CIC postoperatively [23].

Bowel Preparation and Antibiotic Coverage

Preoperative mechanical bowel preparation continues to be an issue of controversy. In the colorectal surgery literature, it does not lower the rate of postoperative complications (wound infection, intraperitoneal abscess, or anastomotic leak) [2425] and some patients have reported adverse events from it [2628]. There are two pediatric studies that have reported no increase in complications after AC following no preoperative mechanical bowel preparation [2930]. However, there are no prospective randomized trials so caution should be exercised especially in patients with ventriculoperitoneal shunts that may be exposed to fecal contamination intraoperatively [31]. Even though there is no consensus among the studies with the duration, the dosage, and the type of bowel preparation to use, we agree with the most recent CDC guidelines (published in 1999) [32] and still routinely prescribe mechanical bowel preparation and clear fluids diet the day prior to the intervention.

The periprocedural systemic administration of an antimicrobial agent to reduce infectious risks in contaminated urology surgery [33] is an evidence-based supported concept, but the literature is not clear about the optimal therapeutic regimen (type of medication, dosage, and route of administration). Available practice guidelines recommend a combination of either second- or third-generation cephalosporin with an aminoglycoside and metronidazole, with special caution for patients with prosthetic devices such as ventriculoperitoneal shunts or orthopedic hardware [3233].

Choice of Intestinal Segment

Different parts of the GI tract from stomach to sigmoid have been used for bladder augmentation, each having its pros and cons (Table 12.2), but none being the ideal segment.

Table 12.2

Advantages and disadvantages of different tissues used for augmentation cystoplasty

Tissue

Advantages

Disadvantages

Stomach

Produces less mucus

Lower incidence of bacteriuria

Rich blood supply

More appropriate for patients with renal insufficiency

Risk of bladder ulcers and perforation

Hematuria–dysuria syndrome

Vit B12 malabsorption

Jejunum

 

Severe electrolyte abnormalities

Risk of profound dehydration

Iron and calcium deficiencies

Ileum

Mobile, small diameter, easy to handle

Well-defined, reliable blood supply

Less severe metabolic complications

Lipid malabsorption (Vit A, D, E, K)

Vit B12 deficiency (anemia)

Incidence of bowel obstruction more common than colon

Lack of bile salt reabsorption (diarrhea)

Metabolic acidosis

Sometimes short mesentery

Colon

Transverse colon safer if prior pelvic radiation

Fewer nutritional problems

Redundant in spina bifida patients

Antireflux tunnels easily made

Metabolic acidosis

Produces more mucus than ileum (increased risk of UTIs and stones)

Ureter

Urothelial lined

Requires no intestinal resection

Limited availability (need for hydroureter)

Autoaugmentation

Urothelial lined

Requires no intestinal resection

Technically demanding

Limited gain in capacity and compliance

Risk of perforation

Tissue engineering

Theoretically unlimited donor tissue

Still experimental

Data from Abou-Elela A. Augmentation cystoplasty: in pretransplant recipients. In: Ortiz J, Andre J, eds. Understanding the Complexities of Kidney Transplantation. Rijeka, Croatia: InTech; 2011:279–330; and Duel BP, Gonzalez R, Barthold JS. Alternative techniques for augmentation cystoplasty. J Urol. 1998;159(3):998–1005

Ileum is unquestionably the most widely used bowel segment in reconstructive urology. The versatility it provides allows the surgeon to refashion it in a multitude of different techniques that have been elaborated over the years [34]. With overall fewer complications than other bowel segments, it is mobile, easy to handle, with a constant blood supply, and available in large quantity [35]. However, ileum might not be ideally suited in situations where the mesentery is short, or for those with significant adhesions or prior small bowel resections [23]. Caution should be also exercised when considering ileocystoplasty for patients who underwent prior pelvic radiation therapy [36].

If functional or anatomic factors preclude the use of ileum, colon is often the second choice. Advantages of colocystoplasty include a thick muscular wall, large lumen, and abundant mesentery guaranteeing adequate bladder capacity and maneuverability [37], while disadvantages include more mucus production with increased risk of urinary tract infections (UTI) and stone formation [38]. More specifically, the sigmoid is sometimes redundant in patients with neurogenic bowel dysfunction which makes it an attractive alternative for this population [22]. Finally, the cecum, in conjunction with the terminal ileum, can be used as a continent catheterizable channel [39]. The ileocecal valve provides the continence mechanism, but its resection renders the patient vulnerable to diarrhea [40], which occasionally may be severe and difficult to manage. This may render the patient at risk for malabsorption and fecal incontinence [35].

Gastrocystoplasty as an alternative has been mostly reported in the pediatric literature [4142]. Despite clear advantages to the use of the stomach such as less mucus production, a lower incidence of bacteriuria, and a rich blood supply, the technique has declined in popularity due to significant limitations, mostly from debilitating hematuria–dysuria syndrome [43].

The use of jejunum results in severe metabolic disorders in 25–40 % of cases and therefore should not ordinarily be utilized [4445]. Although not formerly contraindicated, its use should be limited to those extremely rare cases where any other segment of the GI tract is not available for the augmentation, a situation we have not yet encountered.

Alternative tissues have also been described. Several series have reported satisfactory outcomes with ureterocystoplasty [384647]. This necessitates a hydroureter from a nonfunctioning renal unit and is practically rarely applicable [4748]. In autoaugmentation (or detrusor myectomy) of the bladder, the creation of a urothelial pseudodiverticulum is technically demanding and usually only provides a slight gain in capacity and compliance [49]. With such disappointing efficacy, the technique is rarely reported.

Finally, none of the bowel segments has been shown to be clearly superior to another in all circumstances so the reconstructive urologist needs to be proficient in several techniques making use of various segments in order to individualize the decision and optimize results.

Technique

With the ultimate goals of lowering urinary storage pressures, preserving renal function, maximizing continence, and hopefully maintaining volitional voiding, the clam ileocystoplasty is the most commonly reported technique.

With the patient supine or in the low lithotomy position, a midline infraumbilical incision is usually adequate to gain intraperitoneal access, but a short Pfannenstiel incision has also been described [50]. With a Foley catheter in the surgical field, the native bladder is distended. The loose areolar tissue is bluntly dissected to expose the anterior and perivesical spaces [51]. With stay sutures on either side, the bladder is bivalved in the coronal or sagittal plane [11]. A “smile” incision has also been described [52]. The bladder incision should be a broad opening to create a large anastomosis and prevent an hourglass deformity [35]. Occasionally, supratrigonal cystectomy can be done for conditions such as severe interstitial cystitis [53].

A 15–40 cm segment of ileum is then harvested approximately 20 cm proximal to the ileocecal valve on a broad well-vascularized pedicle that may be identified by transillumination. A side-to-side stapled or hand-sewn ileoileostomy reestablishes bowel continuity cephalad to the isolated segment and the mesenteric defect may be closed to prevent internal hernias, or alternatively left open if judged to be wide enough. The isolated segment is irrigated thoroughly until return is clear to prevent intraperitoneal soiling as much as possible. It is then detubularized on its antimesenteric side to prevent intraluminal pressure rises from peristaltic contractions. The segment is reconfigured into a U, S, or W shape [3654] (Figs. 12.1 and 12.2). The surgeon should make sure that the segment reach down into the pelvis without tension or twist on the mesentery. The ileal patch can then be reapproximated to the edges of the cystotomy, starting posteriorly, with one to two layers of 2-0 continuous absorbable sutures. The vesico-intestinal anastomosis is tested for watertightness and drains are inserted prior to closing the abdominal wall in a standard fashion. The goal is to create a new reservoir in as spherical a configuration as possible to maximize the surface area as per Laplace’s law.

A307466_1_En_12_Fig1_HTML.gif

Fig. 12.1

(ac) (a) Ileocystoplasty. A 20- to 40-cm segment of ileum at least 15 cm from the ileocecal valve is removed and opened on its antimesenteric border. Ileoileostomy reconstitutes the bowel. (b) The opened ileal segment should be reconfigured. This can be done in a U, S, or W configuration. It can be further folded as a cup patch. (c) The reconfigured ileal segment is anastomosed widely to the native bladder

A307466_1_En_12_Fig2_HTML.jpg

Fig. 12.2

A 40 cm length of ileum is shown. The segment has been isolated from the GI tract and reconfigured. The antimesenteric border was incised and the bowel segment was detubularized into an inverted U shape. It will be anastomosed to the bladder

More recently, minimally invasive (laparoscopic and robot-assisted) approaches have become more frequently reported from a number of institutions. Depending on the surgeon’s experience and expertise, most of the suturing can be performed intra- or extracorporeally [55]. More technically demanding, these minimally invasive techniques have the advantages of reduced perioperative pain and morbidity, shorter hospital stay, and cosmetic superiority, with outcomes similar to the open surgery [205658].

Postoperative Care

As for any major abdominal surgery, intravenous fluids and bowel rest are maintained for several days with close monitoring of inputs and outputs. Routine nasogastric tube drainage is not required as it has not been shown to lead to faster bowel function recovery [59]. Antibiotic prophylaxis for 24 h [60], thromboprophylaxis, and early ambulation are also recommended. A closed-suction pelvic drain is kept until output tapers off or once peritoneal fluid is confirmed with fluid chemistries [21].

Proper drainage and irrigation of the augment, initially several times a day with 50–100 mL of sterile saline and then gradually reduced to an as-needed basis, are necessary to prevent mucus from accumulating, plugging the catheters and disrupting the fresh anastomosis. We usually favor a Foley urethral catheter (16–18 Fr) and a suprapubic (SP) Malecot catheter (20–22 Fr). Both tubes are kept for approximately 4 weeks, after which a cystogram is performed. The Foley is then removed if there is no extravasation and patients resume spontaneous voiding. Post-void residuals are closely monitored initially as well as on a long-term basis, and CIC is initiated when needed. The SP tube may be kept for 1–2 more weeks longer and used for daily bladder irrigation. Although there is no evidence to support it, antimicrobial prophylaxis can be administered at the time of catheter removal since bacterial colonization has likely occurred [33].

Complications

Flood and colleagues reported an overall 28 % early and 44 % late complication rate in this difficult group of patients, with a chance of requiring a reintervention ranging from 15 % to 40 % [6163]. Table 12.3 lists the possible consequences of such procedure.

Table 12.3

Complications of augmentation cystoplasty

Early

Late

Infection

Wound infection

Intraperitoneal abscess

UTI

Ventriculoperitoneal shunt sepsis

Metabolic disturbances

Metabolic acidosis

Hypokalemia

Hypocalcemia

Hypomagnesemia

Hyperammonemia (encephalopathy)

Wound dehiscence

Mucus accumulation

Prolonged ileus

Urolithiasis

Peroneal nerve palsy

Bacteriuria/Pyelonephritis

Anastomotic leak

Urinary

Intestinal

Bowel dysfunction

Diarrhea

Fecal incontinence

Bowel obstruction

Fistula

Neoplasia

Hemorrhage

Bladder perforation

Death

Upper tract deterioration/Renal dysfunction

 

Malabsorption

Vitamins A, D, E, K deficiencies

Bile salts (gallbladder stones)

Vitamin B12 deficiency (megaloblastic anemia)

 

Hematuria–dysuria syndrome (gastric)

 

Drug absorption toxicities

 

Bone demineralization/Impaired growth

 

Urinary retention/Diverticularization

 

Incontinence

Data from Herschorn S WB. Bladder augmentation. In: HB G, ed. Complications of female incontinence and pelvic reconstructive surgery. Cleveland, OH: Humana Press; 2013:171–187; Flood HD, Malhotra SJ, O’Connell HE, Ritchey MJ, Bloom DA, McGuire EJ. Long-term results and complications using augmentation cystoplasty in reconstructive urology. Neurourol Urodyn. 1995;14(4):297–309; and de Petriconi R. Metabolic aspects of bowel use in urologic surgery. Ann Urol (Paris). 2007;41(5):216–236

Early Complications

Cardiovascular, respiratory, thromboembolic, and gastrointestinal complications can occur in the early postoperative course, as for any major abdominal surgery. The most common ones include wound infection or dehiscence (5–6 %), prolonged ileus (5 %), anastomotic leakage (2–4 %), catheter obstruction from mucus, ventriculoperitoneal shunt sepsis (0–20 %) [64], and peroneal nerve palsy [19]. Contemporary publications in the literature report a mortality rate of 0–3.2 % [19].

Late Complications

Bacteriuria

Asymptomatic bacteriuria in patients on CIC is nearly universal regardless of the segment considered and should not be treated except for infection with urease-splitting organisms [65]. Recurrent episodes of symptomatic cystitis do require treatment, but symptoms may be nonspecific. Risk factors predisposing to UTI include mucus accumulation, stasis, and CIC [66]. Symptomatic urinary tract infection which occurs in 5–40 % of patients [196768] requires antibiotic treatment. With regard to prophylaxis, as recommended by the European Association of Urology, low-dose, long-term, antibacterial prophylaxis may be an option for patients with recurrent UTI, but there is a risk of emergence of multiresistant organisms [69].

Urolithiasis

The incidence of calculi in augmented bladders ranges from 10 % to 50 % [7071]. Stone composition is more commonly struvite or calcium oxalate [72]. Stasis, incomplete emptying, excessive mucus production, and chronic bacteriuria, especially if urease-splitting organisms, predispose to stone formation [7374]. Patients with a continent catheterizable channel (which may not drain the bladder completely), those using urethral CIC (compared to those voiding spontaneously), and patients with urease-splitting bacteriuria are at increased risk [1975]. Permanent sutures can serve as a nidus and should be avoided as much as possible [35]. Prevention strategies include increased fluid intake, routine bladder irrigation, prompt treatment of UTI, and staple exclusion at the time of surgery [74].

Perforation

Bladder perforation is a potentially life-threatening complication and is due to either overdistension or trauma from catheterization. It has been reported up to 13 % [76]. Patients with neurogenic bladders, those with competent bladder necks, those without a catheterizable channel, and those who abuse alcohol appear to be at an increased risk [197779]. Patients can present with an acute abdomen, but symptoms can be more subtle in neurologically impaired patients. The diagnosis can be made with a CT cystogram but requires a high index of suspicion [76] and low threshold for exploratory laparotomy [79]. The area of perforation is usually at the vesico-intestinal anastomosis or within the weaker bowel wall [80]. Emphasizing the importance of compliance with regular CIC can help obviate the risk of early perforation [76].

Mucus Production

The average daily mucus production is about 40 g and does not taper off with time despite villous atrophy [181]. With time, accumulated proteinaceous material can become a nidus for infection and stone or impair adequate bladder emptying [19]. Colonic segments produce more mucus than ileum [82]. Daily irrigation can help reduce mucus retention [83]. These can be augmented with acetylcysteine or urea irrigations which help dissolve mucus [82] or oral ranitidine which may help to reduce mucus production [84].

Renal Function

Renal function deterioration can occur in about 20 % of patients after AC [23]. The etiology of renal dysfunction may be urinary stone disease, bacteriuria, high detrusor pressures, vesicoureteral reflux, unrecognized obstruction, and lack of compliance with CIC [85]. The patient’s initial kidney function predicts long-term outcome, but in all cases close postoperative monitoring is warranted with periodic ultrasound imaging and laboratory studies.

Neoplasia

Bladder cancer following AC is a recognized risk, but remains a rare complication, with an incidence of approximately 1 % [86]. The risk may be similar in patients with CIC and bladder dysfunction due to neurologic abnormalities, exstrophy, and posterior urethral valves [87]. Tumors are usually adenocarcinomas that occur at the vesico-intestinal junction [86]. The exact etiologic mechanism of the development of neoplasia is not well understood, but proposed hypotheses include chronic inflammation from prolonged exposure of the intestinal epithelium bathed in urine, the production of carcinogenic nitrosamines by chronic bacteriuria, and/or mixed cell-to-cell interactions from juxtaposition of tissues from two different origins: intestinal and urothelial [8890]. We do advocate routine surveillance with endoscopy and urine cytology on a long-term basis despite inconsistent evidence to support it, considering the long latency period of about 15 years [9192]. Although there is currently no consensus, we begin surveillance about 5–10 years after initial surgery and follow patients every year or every other year thereafter.

Metabolic Disturbances

Translocation of functional enteric epithelium into the urinary tract can result in electrolyte and acid–base abnormalities which are directly related to the segment of intestine used, the amount of time urine spends in contact with the bowel mucosa, and renal function [3893]. The length of bowel segment used in AC is usually relatively short which partly reduces the incidence of metabolic disorders compared to other types of diversion [94]. The classic electrolyte pattern for ileum and colon is hyperchloremic metabolic acidosis [39], from net absorption of NH4 and to a lesser extent bicarbonate losses [95]. Low serum potassium as well as hypocalcemia and hypomagnesemia can also occur, but they are less common.

Nutritional disorders are rare if the surgeon spares the terminal ileum, which is the sole site of absorption for vitamin B12. Resection of the distal 20 cm should be avoided to prevent such deficiency which may cause megaloblastic anemia and neurologic changes [95]. If more than 100 cm of ileum is resected, lipid malabsorption is virtually inevitable and there is also fat-soluble vitamin (A, D, E, and K) malabsorption [96].

When stomach is used, a hypokalemic hypochloremic metabolic alkalosis can occur [97]. The exclusion of a jejunal segment is rarely used in urology due to the severe hyponatremic hypochloremic hyperkalemic metabolic acidosis that may result [98].

Other consequences from metabolic disturbances include hyperammonemia secondary to the inability of the liver to clear it, which could lead to encephalopathy [95], and bone demineralization in adults or impaired bone growth in children [99] from chronic acidosis. Finally, certain drugs (digoxin, methotrexate, phenylalanine, antibiotics, theophylline) can be reabsorbed by the intestinal segment and cause toxicity [94].

Bowel Dysfunction

Patients can present a prolonged paralytic ileus, especially in those with neurological impairment as they often already suffer from slow transit [100]. Intestinal obstruction from adhesions can occur in the early or late postoperative setting and usually resolves with conservative management [83]. With time, removal of the ileocecal valve may yield a decreased stool transit time and result in intractable diarrhea, steatorrhea (from fat malabsorption), or distressing fecal incontinence [21].

Pregnancy

Successful pregnancies and deliveries after AC have been reported and are becoming more common. There is a substantial rate of obstetrical complications, mostly preterm labor and preeclampsia, the latter being more challenging to diagnose considering the inaccuracy of urinalysis for proteinuria due to mucus from the enteric segment [101]. Antenatal close monitoring is recommended and should include regular midstream urine cultures [102] in order to treat any UTI and minimize the risk of renal scarring and impairment. In spite of this increased risk of ascending bacteria, pyelonephritis, and upper tract obstruction over the general population [103], lower urinary tract function is usually not adversely affected by pregnancy or delivery, as reported by Greenwell et al. [104]. Unless the patient has had bladder neck reconstruction or insertion of an artificial urinary sphincter [105], vaginal delivery seems preferable. If an elective cesarean section is necessary, a classical upper-segment rather than a lower-segment section should be favored [19], with urologic assistance to avoid the potential risk of damaging the vascular pedicle of the bowel segment, in which case eventual ischemic enteric contraction could occur [39].

Outcomes

From a clinical standpoint, we aim for patients to be free of symptomatic UTIs, continent, and with a stable renal function without hydronephrosis or stones. Only a few small retrospective case series (Level 4 evidence) have reported outcomes, but comparisons are difficult due to lack of standard terminology and the use of non-validated questionnaires [83]. The success rate, defined as achieving continence with or without CIC, has ranged from 67 % to 100 % [6163106]. The average rate for CIC after AC is 54 % (range 14–100 %) [104]. The improvement in quality of life for individuals undergoing enterocystoplasty is substantial. However, discrepancy exists between neuropathic and non-neuropathic patients regarding their satisfaction as assessed by means of a questionnaire. Indeed, the latter group is overall only 50–60 % satisfied on a long-term basis [11] compared to over 90 % satisfaction for the neuropathic patients [107], results that are probably largely influenced by the degree of unacceptability of the preoperative condition.

From a urodynamic standpoint, successful cases will have cystometrograms indistinguishable from normal, and on fluoroscopic studies, it has been demonstrated that the initial contraction occurs in the detrusor residue and subsequently in the intestinal segment [108]. Outflow resistance is also a critical factor to assess if patients have leakage postoperatively [108]. In any case, a delicate balance exists between continence and retention. Patients’ expectations and motivation highly influence their long-term satisfaction and sense of well-being after surgery.

The cost-effectiveness of AC has been compared to intradetrusor injections of botulinum toxin A (BTX-A) for refractory neurogenic OAB and favors BTX-A over a 5-year period. However, AC was deemed to be cheaper if the complication rate was below 14 % or if the efficacy of BTX-A was less than 5 months [109].

Overall, excellent outcomes can be expected with a combination of reliable surgical techniques in addition to careful patient selection as well as appropriate preoperative counseling and postoperative follow-up [110].

Follow-Up

Despite the fact that this surgery has been practiced for decades, no evidence-based guidelines are available to recommend what kind of follow-up should be performed. Nevertheless, if we transpose the recommendations for urinary diversions post-cystectomy, and consider the potential complications and underlying disease of the patients, annual monitoring appears reasonable. Thus, in addition to history (focused on continence, frequency of intermittent catheterization, UTI, mucus production, etc.) and physical exam, upper urinary tract surveillance (comprising serum electrolytes, renal function tests, and imaging) starting at 6 weeks, then at longer intervals, and then annually may be done. Adequate oral fluid intake should be emphasized and those voiding spontaneously should check their post-void residuals regularly. Urinary cytology may be misleading because of the presence of a variety of cells. As previously mentioned, we advocate an annual or biennial cystoscopy to screen bowel and bladder mucosa for any suspicious change (redness, growth) or foreign body (stone, mucus). Long-term follow-up is necessary because of the persisting potential for problems over the years.

Experimental Options

Augmentation cystoplasty using either enteric or urothelial tissues is not a panacea and experimentation is ongoing in the quest for alternative tissues to use.

Since its beginning in the early 1990s, the field of tissue engineering has made tremendous progress [111]. Currently, there are two types of technologies that have been investigated. These are unseeded and seeded technologies [112]. Unseeded technology involves implantation of bioactive or resorbable synthetic matrices into the host organ and allowing the body’s natural capability to use the matrix as a scaffold for cell growth or tissue regeneration [111]. In comparison, seeded technology involves cells derived from biopsy that are expanded in vitro, seeded onto a natural (porcine small intestinal submucosa) or synthetic (polyglycolic acid) scaffold, and the composite is then placed back into the host for continued regeneration. Among the most exciting results, Kurokawa et al. have reported utilizing cultured oral mucosal epithelial cell sheets grafted on demucosalized seromuscular colonic flaps [113], while Atala et al. described a model created with autologous urothelial and muscle cells obtained from bladder biopsy seeded on collagen-polyglycolic acid scaffolds, and wrapped in omentum after implantation [114]. Unfortunately, despite significant advances in the field of bioengineering, the search for a perfect material remains experimental and ongoing, with few published trials on humans available yet [114].

Conclusion

Although intradetrusor botulinum toxin and sacral neuromodulation have emerged as competing minimally invasive therapeutic options, AC remains an essential component to the reconstructive urologist’s armamentarium, with the most popular technique using a detubularized patch of ileum. It provides satisfactory clinical outcomes and acceptable morbidity, but the potential for long-term complications warrants prolonged follow-up and monitoring.

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