Surgical treatment of urinary incontinence

Tetronic(®)-based composite hydrogel scaffolds seeded with rat bladder smooth muscle cells for urinary bladder tissue engineering applications

Natural hydrogels such as collagen offer desirable properties for tissue engineering, including cell adhesion sites, but their low mechanical strength is not suitable for bladder tissue regeneration. In contrast, synthetic hydrogels such as poly (ethylene glycol) allow tuning of mechanical properties, but do not elicit protein adsorption or cell adhesion. For this reason, we explored the use of composite hydrogel blends composed of Tetronic (BASF) 1107-acrylate (T1107A) in combination with extracellular matrix moieties collagen and hyaluronic acid seeded with bladder smooth muscle cells (BSMC). This composite hydrogel supported BSMC growth and distribution throughout the construct. When compared to the control (acellular) hydrogels, mechanical properties (peak stress, peak strain, and elastic modulus) of the cellular hydrogels were significantly greater. When compared to the 7-day time point after BSMC seeding, results of mechanical testing at the 14-day time point indicated a significant increase in both ultimate tensile stress (4.1-11.6 kPa) and elastic modulus (11.8-42.7 kPa) in cellular hydrogels. The time-dependent improvement in stiffness and strength of the cellular constructs can be attributed to the continuous collagen deposition and reconstruction by BSMC seeded in the matrix. The composite hydrogel provided a biocompatible scaffold for BSMC to thrive and strengthen the matrix; further, this trend could lead to strengthening the construct to match the mechanical properties of the bladder.

Single surgeon experience of augmentation ileocystoplasty in the management of refractory idiopathic detrusor overactivity

Background:

Until a decade ago, augmentation ileocystoplasty (AIC) was the only major advancement over anti-muscarinics for intractable idiopathic detrusor overactivity (IDO). Clam ileocystoplasty has been proposed to restore continence and preserve urethral voiding. While intravesical botulinum and neuromodulation have revolutionised the treatment of this condition, arguably there remains a place for bladder augmentation in the surgical armamentarium.

Objective:

This study presents a single surgeon experience of clam ileocystoplasty performed for intractable IDO at our institution.

Methods:

A retrospective case-note review was performed over a 9-year period. Data on basic patient demographics, urodynamic findings, pre-operative treatments administered, post-operative complications and response to surgery were documented.

Results:

In total, 22 patients were identified with a median age of 42.4 years. The predominant symptoms were urgency (100%) and urge incontinence (96%). All our patients were incontinent pre-operatively with 59% using pads. Ambulatory cystometry was helpful in 27% patients in whom standard +/- video studies were inconclusive. Of the cohort, 100%, 82% and 55% had one, two and three anticholinergics, respectively. Only 18% received intravesical botulinum toxin A pre-operatively. Some 77% were cured of their storage symptoms and incontinence; 18% had residual incontinence. Of these, genuine urodynamic stress incontinence was demonstrated in 9% and improved with tension-free vaginal tape. Some 9% had Clavien 3b complications requiring laparotomy. Mortality was nil.

Conclusion:

In young patients with refractory IDO, clam ileocystoplasty serves as a permanent, effective technique for symptom reduction and restoration of continent urethral voiding with few complications.

Complications after bladder augmentation or substitution in children: a prospective study of 86 patients

OBJECTIVE

• To evaluate complications after urinary bladder augmentation or substitution in a prospective study in children.

PATIENTS AND METHODS

• Data of 86 patients who underwent urinary bladder augmentation (80 patients) or substitution (6 patients) between 1988 and 2008 at the authors' institute were analysed. • Ileocystoplasty occurred in 32, colocystoplasty in 30 and gastrocystoplasty in 18. Urinary bladder substitution using the large bowel was performed in six patients. • All patients empty their bladder by intermittent clean catheterization (ICC), 30 patients via their native urethra and 56 patients through continent abdominal stoma. Mean follow-up was 8.6 years. • Rate of complications and frequency of surgical interventions were statistically analysed (two samples t-test for proportions) according to the type of gastrointestinal part used.

RESULTS

• In all, 30 patients had no complications. In 56 patients, there were a total of 105 complications (39 bladder stones, 16 stoma complications, 11 bowel obstructions, 5 reservoir perforations, 7 VUR recurrences, 1 ureteral obstruction, 4 vesico-urethral fistulae, 4 orchido-epididymitis, 4 haematuria-dysuria syndrome, 3 decreased bladder capacity/compliance, 3 pre-malignant histological changes, 1 small bowel bacterial overgrowth and 7 miscellaneous). • In 25 patients, more than one complication occurred and required 91 subsequent surgical interventions. Patients with colocystoplasty had significantly more complications (P < 0.05), especially more stone formation rate (P < 0.001) and required more post- operative interventions (P < 0.05) than patients with gastrocystoplasty and ileocystoplasty.

CONCLUSIONS

• Urinary bladder augmentation or substitution is associated with a large number of complications, particularly after colocystoplasty. • Careful patient selection, adequate preoperative information and life-long follow-up are essential for reduction, early detection and management of surgical and metabolic complications in patients with bladder augmentation or substitution.