Early clinical experience with adult bladder auto-augmentation

Validation of a culturally compliant voiding platform for urodynamics in African vesicovaginal fistula patients

INTRODUCTION AND HYPOTHESIS

Most patients in regions where obstetric vesicovaginal fistulas (VVF) are endemic void using a squatting posture. Additionally, many patients continue to have lower urinary tract symptoms (LUTS) following fistula closure. We designed and validated a prototype platform that allows urodynamic studies to be performed in a squatting position and conducted a pilot study to assess uroflowmetry in this patient population.

METHODS

Sixteen patients with persistent LUTS following fistula surgery were recruited. Posture measurements were taken in each patient's natural voiding posture on the ground and were then repeated using the platform. Nine patients with persistent urinary incontinence also underwent uroflowmetry. The data were compared with normal values in different nomograms. Paired t tests were used to determine significant differences in posture. One-way ANOVA was used to determine statistical significance between flow rate values.

RESULTS

Only the heel-to-heel distance (H-H) measure of posture was significantly increased on the platform compared with on the ground. The mean corrected Qmax was 0.89 ± 0.46. Flow rate values were significantly lower than mean normal flow rates obtained from the nomograms. In general, the patients' uroflowmetry patterns were similar to those indicative of impaired detrusor function.

CONCLUSION

A platform for conducting urodynamic studies in a squatting posture was successfully validated in the VVF patient population. The finding of increased H-H on the platform is expected, since the patient must accommodate a large funnel for urine collection. The pilot data suggest that patients with persistent urinary incontinence following VVF closure may also have significant voiding dysfunction.

Long-term outcomes of urinary tract reconstruction in patients with neurogenic urinary tract dysfunction

The advent of specialized spinal units and better understanding of the pathophysiology of neurogenic urinary tract dysfunction has made long-term survival of these patients a reality. This has, in turn, led to an increase in quality and choice of management modalities offered to these patients including complex anatomic urinary tract reconstructive procedures tailored to the unique needs of each individual with variable outcomes. We performed a literature review evaluating the long-term outcomes of these reconstructive procedures. To achieve this, we conducted a world-wide electronic literature search of long-term outcomes published in English. As the premise of this review is long-term outcomes, we have focused on pathologies where evidence of long-term outcome is available such as patients with spinal injuries and spina bifida. Therapeutic success following urinary tract reconstruction is usually measured by preservation of renal function, improvement in quality-of-life, the satisfactory achievement of agreed outcomes and the prevention of serious complications. Prognostic factors include neuropathic detrusor overactivity; sphincter dyssynergia; bladder over distension; high pressure storage and high leak point pressures; vesicoureteric reflex, stone formation and urinary tract infections. Although, the past decade has witnessed a reduction in the total number of bladder reconstructive surgeries in the UK, these procedures are essentially safe and effective; but require long-term clinical and functional follow-up/monitoring. Until tissue engineering and gene therapy becomes more mainstream, we feel there is still a place for urinary tract reconstruction in patients with neurogenic lower urinary tract dysfunction.

Prerequisite for successful surgical outcome in urothelium lined seromuscular colocystoplasty

PURPOSE

Urothelium lined seromuscular colocystoplasty is an ideal method of augmentation cystoplasty that avoids various complications caused by the use of gastrointestinal segments. We reviewed the long-term outcomes using this technique at a single institution.

MATERIALS AND METHODS

We retrospectively analyzed 34 patients who underwent urothelium lined seromuscular colocystoplasty between January 1996 and December 2007. A total of 33 patients, excluding 1 who had previously undergone artificial urinary sphincter implantation, were included in the study. Changes in urodynamic parameters, duration of anticholinergic use, incontinence and surgical complications were analyzed.

RESULTS

Mean±SD age at surgery was 10.0±5.7 years (range 3.0 to 26.0) and duration of followup was 6.0±2.3 years (2.7 to 13.4). A total of 17 patients (51.5%) underwent simultaneous anti-incontinence surgery and urothelium lined seromuscular colocystoplasty. Mean bladder capacity increased by a factor of 2.96 and mean percentage of expected bladder capacity for age increased by a factor of 1.96 postoperatively. Of patients who underwent anti-incontinence surgery 4 of 10 whose abdominal leak point pressure was less than 40 cm H2O required additional surgery, whereas none whose abdominal leak point pressure was 40 to 60 cm H2O required reoperation. Two of 16 patients who did not undergo anti-incontinence surgery eventually required continence surgery. A total of 13 patients (39.4%) were able to discontinue anticholinergics at 47.3 months postoperatively. There were no bladder perforations, bowel obstructions or metabolic abnormalities.

CONCLUSIONS

Urothelium lined seromuscular colocystoplasty can be primarily considered in patients without prior bladder mucosal injury. Constant high bladder outlet pressure to facilitate adhesion of bladder mucosa and seromuscular patch is critical for the best results. We recommend abdominal leak point pressure 60 cm H2O or less as an indication for simultaneous anti-incontinence surgery and urothelium lined seromuscular colocystoplasty.

Use of an inflatable silicone balloon improves the success rate of bladder autoaugmentation at long-term followup

PURPOSE

Most groups have reported disappointing results with autoaugmentation or detrusor myectomy for low capacity/compliance neuropathic bladders. Failure may be due to an ischemic diverticulum or mucosal shrinkage. We investigated whether a Silimed® silicone balloon placed in the bladder after autoaugmentation could prevent these problems, improving surgical results.

MATERIALS AND METHODS

We compared the results of standard bladder autoaugmentation in 12 children (group 1) with those in 10 (group 2) who underwent the same surgery using a bladder conformer. The conformer was a silicone balloon filled with saline that remained in the bladder for 2 weeks. All patients had a neuropathic bladder with poor capacity and compliance, resulting in urinary leakage between catheterizations. Preoperative and postoperative evaluation included a voiding diary, ultrasound, voiding cystourethrogram and urodynamics.

RESULTS

In group 1 only 1 patient became dry, 4 had little improvement in continence, 4 remained unchanged and 3 became worse. In group 2, 6 patients (60%) become continent without medication, 2 (20%) become continent with oxybutynin and 2 remained unchanged. Bladder capacity and compliance did not change significantly in group 1. However, in group 2 capacity changed from a mean of 140 to 240 ml and mean ± SD compliance increased from 15.6 ± 16.8 to 34.3 ± 22.8 ml/cm H(2)O (p = 0.02).

CONCLUSIONS

The inflatable balloon improved our long-term results of bladder auto-augmentation. A larger series may be necessary to confirm procedure efficacy and safety.

Management of overactive bladder syndrome

Overactive bladder (OAB) syndrome is the term used to describe the symptom complex of urinary urgency with or without urge incontinence, usually with frequency and nocturia. Drug treatment continues to have an important role in the management of women with OAB. Other treatment options include conservative management with lifestyle interventions, modification of fluid intake, and physiotherapy including bladder retraining. Surgery remains the last resort in the treatment and is usually reserved for intractable detrusor overactivity, as it is associated with significant morbidity. This article reviews the management of the overactive bladder with specific focus on newer developments in the medical treatment of OAB in women.

Enterocistoplastia de ampliación laparoscópica: experiencia inicial

OBJECTIVE

To analyze the initial experience of our group in the realization of the augmentation enterocystoplasty by laparoscopyc approach.

METHODS AND PATIENTS

We describe the augmentation enterocystoplasty technique with ileal segment completely achieved by laparoscopyc approach. We present the cases of two patients suffering from hyperreflexic bladder refractory to medical treatment who underwent this surgery. In both cases the technique was realized without intraoperative complications although it was needed a surgical time of 6 and 4.5 hours respectively. The results after 12 and 5 months were satisfactory in both patients, obtaining a low pressure bladder with a good continence.

CONCLUSIONS

Laparoscopyc augmentation enterocystoplasty is a complicated technique that requires a great experience, mainly in laparoscopyc suture. It reproduces completely the open surgery and it offers all the advantages inherent to the laparoscopyc surgery.

Surgical management of overactive bladder

The majority of patients with overactive bladder (OAB) can be managed with office-based techniques. When medical therapy fails as treatment for OAB, surgical intervention ranging from electric stimulation administered in the office to extensive procedures, such as augmentation or urinary diversion, may be needed. Any surgical intervention should be tailored to the patient with consideration of the degree of his or her discomfort, underlying pathology, general health, and obviously, the patient's own motivation.

Detrusor myotomy: a 5-year review in unstable and non-compliant bladders

OBJECTIVE

To identify urodynamic factors that might determine the clinical outcome of detrusor myotomy in incontinent children.

PATIENTS AND METHODS

Six girls and three boys (aged 5-14 years) underwent detrusor myotomy for severe urinary incontinence. Seven children had spina bifida, one had traumatic paraplegia and one had low bladder compliance. The patients were followed for a minimum of 5 years.

RESULTS

Urodynamic studies before surgery showed that three patients had normal compliance with grossly unstable detrusor contractions, and six had low bladder compliance with few phasic detrusor contractions. Detrusor leak-point pressures were > 40 cmH2O in five patients and < 40 cmH2O in four. Only two patients, both with grossly unstable detrusor contractions and leak-point pressures of > 40 cmH2O, had a successful 5-year outcome. The other seven patients remained incontinent; six underwent further surgery and one died from unrelated causes.

CONCLUSION

Detrusor myotomy appears to have the best outcome in those patients with marked phasic unstable detrusor contractions with a competent urethral sphincter. In this group it may have distinct advantages over more commonly used procedures.

A long-term follow-up of autoaugmentation in myelodysplastic children

OBJECTIVE

To evaluate the long-term results of patients who underwent bladder autoaugmentation (BA) in whom BA was used to treat a neuropathic bladder secondary to myelomeningocele, and who presented with a high-pressure/poorly compliant bladder.

PATIENTS AND METHODS

Eleven patients (eight girls and three boys, mean age 12.8 years, mean follow-up 6.6 years) were selected who had undergone BA between June 1991 and June 1994. At surgery, the patients had a poorly compliant bladder with a mean leak point volume (LPV) of 94 mL and a mean leak point pressure (LPP) of 58 cmH2O. None of the patients had vesico-ureteric reflux (VUR) at BA; five with grade III or IV VUR had undergone endoscopic correction in a day-surgery procedure using a suburethral collagen injection 1-3 weeks before BA. The patients were evaluated using clinical, urodynamic, radiological and endoscopic assessments. The LPV, LPP and safe bladder capacity (SBC, the cystometric volume at an intravesical pressure of 40 cmH2O) were recorded.

RESULTS

At 1 year after surgery the mean LPV was 297 mL; none of the patients had VUR. The most recent mean LPV was 198 mL and the SBC 167 mL. The mean LPP remained stable at 60 cmH2O. At the last follow-up four patients had recurrent uni- or bilateral grade III-V VUR. At endoscopy the 'augmented' bladder portion had a smooth surface, compared with the grossly trabeculated lower half. From this finding all patients on clean intermittent catheterization were treated with oral oxybutynin. Some patients reported slightly less abdominal pain at maximum bladder volume; four needed pads to treat intermittent incontinence. On voiding cysto-urethrography, one patient had an hourglass-shaped bladder. Five patients recently underwent ileocystoplasty because of recurrent urinary tract infection, high-grade VUR and incontinence.

CONCLUSION

These results do not justify the routine use of BA in hypertonic/poorly compliant bladders secondary to myelomeningocele. The mean follow-up of 6.6 years showed that this procedure failed in seven of 11 patients. Further studies might be able to identify subgroups in which this approach may be more appropriate.

Detrusor myectomy for detrusor overactivity: a minimum 1-year follow-up

OBJECTIVE

To evaluate the clinical and urodynamic outcome of partial detrusor myectomy in patients with idiopathic detrusor instability and neuropathic hyper-reflexia.

PATIENTS AND METHODS

Seventeen patients with idiopathic detrusor instability and 10 with hyper-reflexia and symptoms not responding to non-surgical treatment underwent partial detrusor myectomy. The clinical and urodynamic results before and after myectomy were compared and the patient's subjective assessment of the outcome documented.

RESULTS

There was an overall improvement in 17 of 27 patients (63%) but the success rate was higher in those with idiopathic instability (12 of 17) than in those with neuropathy (five of 10). There was urodynamic evidence of reduced bladder contractility and an improvement in the storage characteristics of the bladder in most of the patients treated.

CONCLUSIONS

Partial detrusor myectomy is relatively simple and is associated with minimum morbidity and an acceptable success rate. The procedure alters the urodynamic behaviour of the bladder and leads to symptomatic and objective improvement, giving better results with idiopathic than with neuropathic detrusor overactivity. Detrusor myectomy may be offered to patients with detrusor overactivity unresponsive to conventional management. The option of enterocystoplasty is still open to patients with an unsuccessful outcome. However, the long-term results and surgical variations of the technique should be evaluated further.

Augmentation cystoplasty

The past 15 years have been witness to an explosion in the number of reconstructive procedures using bowel in the urinary tract. As with many concepts in medicine, one must rely on clinical experience while laboratory models and other advancements develop. This article attempts to address bladder reconstruction by enterocystoplasty, as well as the indications for augmentation, types of procedures available, and the early and late complications.

Urge incontinence

This article discusses the management of patients presenting with urge incontinence as the main symptom. The etiological factors, though not understood completely, are grouped into logical subsets and discussed. The incidence and the implications of urge incontinence on the quality of life of patients is considered. A summary of available treatment methods is presented in an algorithm.

Comparison of bladder rupture pressure after intestinal bladder augmentation (ileocystoplasty) and myomyotomy (autoaugmentation)

OBJECTIVES

To compare the risk of bladder rupture of bladder augmentation using ileocystoplasty versus that of autoaugmentation with myomyotomy in a rat model.

METHODS

Bladder rupture pressure and volume of three groups of female Sprague-Dawley rats were determined by cystometry. The first group of 11 rats had undergone ileocystoplasty using a detubularized 1 -cm segment of ileum. A second group of 9 rats had undergone autoaugmentation with myomyotomy. One month after surgery the animals were studied cystometrically to determine the bladder rupture pressure, then killed. A third group, consisting of 10 nonoperated rats, was studied and served as controls.

RESULTS

Nonoperated, control rat bladders were able to sustain 154 +/- 43 mm Hg pressure and 2.5 +/- 2.0 mL volume prior to bladder rupture. Conventional ileocystoplasty was noted to increase bladder capacity to 4.0 +/- 1.9 mL, but decrease rupture pressure to 111 +/- 49 mm Hg. Myomyotomy resulted in a mean bladder rupture volume of 1.2 +/- 0.4 mL, with a rupture pressure of 101 +/- 13 mm Hg. The rupture pressure after myomyotomy is significantly lower than that of the native bladder (P < 0.001), whereas the rupture volume after myomyotomy is significantly lower than either after the ileocystoplasty or with the native bladder (P < 0.001). Bladder rupture occurred at the augmented ileal bladder dome in 7 of 11 ileocystoplasty animals and at the anastomotic suture line in 4 animals. Bladder rupture occurred at the area of bladder diverticulum in all 9 myomyotomy animals. Among controls, no specific site pattern of bladder rupture was noted.

CONCLUSIONS

Bladder augmentation with myomyotomy increases vulnerability to urinary extravasation, evidenced by a significantly reduced rupture pressure and bladder volume at rupture when compared to the native bladder.

Laparoscopic bladder seromyotomy: laboratory experience

Twelve female microminipigs with normal bladder capacity underwent laparoscopic bladder seromyotomy. Three other female microminipigs were added to the study as controls. Urodynamic studies and cystograms were performed preoperatively and at 2 and 4 months after a laparoscopic bladder seromyotomy. Histologic studies of the treated bladders were performed when the animals were euthanized at 4 months. The operation was completed in all 12 test animals. There was no significant difference in bladder capacity or leak-point pressure between the 12 seromyotomy and the 3 control bladders at any time point. Histologically, over the seromyotomy site, the urothelium remained intact; however, the muscularis was attenuated, and a thin layer of fibrotic tissue replaced the normal serosal covering of the bladder. Laparoscopic bladder seromyotomy can be performed reliably in the porcine animal model. Not surprisingly, no significant changes in bladder capacity or bladder compliance were seen in our study of normal bladders. An animal model of a neuropathic contracted bladder is needed to assess more accurately the physiological impact of laparoscopic seromyotomy.

Bladder autoaugmentation

Autoaugmentation has proved effective in many patients in lowering bladder pressures, increasing bladder capacity, and improving their related symptoms. Patients with sever bladder hyperreflexia, uncontrolled with medications, have also benefited greatly from autoaugmentation procedures. Only patients who failed conventional medical management have undergone autoaugmentation at the authors' institution.

Ureterocystoplasty with renal preservation in young infants

To assess the outcome of ureterocystoplasty (UCP) with renal preservation in infants, three infants had a UCP with preservation of the ipsilateral kidney, including one who had a ureteropyeloplasty and one who had a UCP using a previously reimplanted ureter. All three had complication-free improvement in bladder volume and compliance. UCP thus produces an augmented bladder and can be performed as part of a transureteropyeloplasty and following ureteric reimplantation.

Experimental assessment of small intestinal submucosa as a bladder wall substitute

OBJECTIVES

This study determined the feasibility of promoting urinary bladder regeneration with porcine-derived small intestinal submucosa (SIS).

METHODS

Twenty-two Sprague-Dawley rats underwent partial cystectomy with immediate bladder augmentation with SIS. Bladders were harvested for histologic evaluation at 2, 4, 8, 12, 24, and 48 weeks.

RESULTS

Histologically at 2 weeks, there was infiltration of the graft material with viable host cells consisting of fibroblasts, macrophages, and blood vessels covered by complete mucosal urothelium comprised of transitional cells. During the next 10 weeks, collagen formation and maturation were noted, and by the end of 12 weeks, the SIS graft was comprised of a mature collagen matrix admixed with thinly scattered disorganized smooth muscle bundles and covered by normal urothelium. At 48 weeks, all three layers of the normal bladder (urothelium, smooth muscle, and serosa) were present and were grossly and microscopically indistinguishable from the normal rat urinary bladder.

CONCLUSIONS

This study further supports the concept of bladder regeneration and suggests that SIS may be a viable material for bladder augmentations.

Effect of seromuscular colocystoplasty lined with urothelium and partial detrusorectomy on a new canine model of reduced bladder capacity

We developed a canine model of reduced bladder capacity by spraying talc on the outer surface of the detrusor after peeling the peritoneum from the bladder. This method was effective to reduce bladder capacity to almost a third of normal and this reduction persisted for the 6-month followup. On this model we performed detrusorectomy (auto-augmentation) and seromuscular colocystoplasty, and compared the results. Following detrusorectomy in talc bladder dogs bladder capacity failed to increase significantly at 3 months and 6 months. In contrast, seromuscular colocystoplasty caused a significant increase in bladder capacity in talc bladder dogs that was sustained for the 6-month followup. We also performed detrusorectomy in dogs with normal bladders and observed a progressive decrease in bladder capacity, which became significant at 6 months. Histology of the bladders after sacrifice revealed that talc induces a desmoplastic reaction around the detrusor that limits bladder distensibility and reduces its capacity. With detrusorectomy the perivesical fibrotic layer induced by talc and the detrusor were effectively removed but a thin layer of fibrosis developed between the bladder mucosa and the peritoneum that may account for the lack of improvement in bladder capacity. Identical observations were made after detrusorectomy in normal bladders. In contrast, following seromuscular colocystoplasty the bladder mucosa was adjacent to the submucosa of the colonic patch without fibrosis, a finding that may account for the restoration of bladder capacity. These experiments confirm previous experimental and clinical observations about seromuscular colocystoplasty, and suggest that it may result in better long-term results than simple auto-augmentation.

Seromuscular colocystoplasty lined with urothelium: experience with 16 patients

OBJECTIVES

Report of initial clinical experience with seromuscular colocystoplasty lined with urothelium (SCLU), a new operation to increase bladder capacity and compliance without incorporating intestinal mucosa into the urinary tract. We have previously reported the technique and results of this procedure in a canine model.

METHODS

Sixteen patients underwent SCLU at two institutions. Their charts were reviewed retrospectively. The patients have been observed for a mean of 12 months.

RESULTS

Postoperatively, the bladder capacity increased an average of 2.4-fold from a mean of 139 mL (+/- 23.7 SEM) to 335 mL (+/- 38.9 SEM) in 14 patients (P < 0.001). Two patients required reaugmentation. Preoperative and postoperative bladder end filling pressures were available in 13 patients and decreased from a mean of 51.6 cm H2O (+/- 4.2 SEM) to 27.7 cm H2O (+/- 2.4 SEM) (P < 0.001). Of the 16 patients, 13 were incontinent preoperatively; 5 had renal insufficiency. Three patients have undergone renal transplantation following SCLU. After SCLU, 13 patients were dry day and night, 1 incontinent at night only, and 2 remained incontinent. Ten patients have undergone postoperative bladder biopsy. Seven demonstrate urothelium covering the augmented portion of the bladder, 2 have regrowth of colonic mucosa, and 1 shows a mixture of colonic mucosa and urothelium.

CONCLUSIONS

The results presented suggest that SCLU is a viable alternative to the more conventional forms of bladder augmentation in selected patients.