Augmentation ileocystoplasty

Introduction

Augmentation cystoplasty is traditionally indicated for small-capacity, poorly compliant bladders, refractory to more conservative treatment strategies. Aggressive pharmacological therapies with anticholinergics or β3-mimetic drugs, intradetrusor injections of botulinum toxin, and sacral neuromodulation have reduced the need for augmentation cystoplasty over the past two decades. While ileocystoplasty with a preterminal segment of ilium is by far the most widely adopted augmentation procedure, other gastrointestinal segments such as stomach, cecum and colon have also been successfully used to augment the bladder. Experience with other native (e.g., fascial grafts, peritoneum, skin) or synthetic tissue grafts has been disappointing. The introduction of robot-assisted surgery has accelerated the transition to minimally invasive ileocystoplasty with complete intracorporeal reconstruction.

Indications and contraindications for augmentation cystoplasty

Augmentation cystoplasty is indicated for patients with neurogenic detrusor overactivity and poor bladder compliance refractory to more conservative treatments such as pharmacotherapies, intravesical botulinum toxin, or sacral neuromodulation. Augmentation cystoplasty can also be indicated in patients with congenital bladder abnormalities, such as bladder exstrophy, and rare infective and inflammatory disorders of the bladder such as tuberculous bladder, schistosomiasis and radiation-induced cystitis resulting in a poorly compliant and low-capacity bladder.

In patients with intrinsic bowel disease, such as Crohn disease or short-bowel syndrome, in which removal of an extra bowel segment may increase the risk of intestinal/malabsorption consequences, augmentation cystoplasty is contraindicated. Renal insufficiency and the inability to perform intermittent self-catheterization due to decreased dexterity or cognitive impairment are also considered as contraindications for bladder augmentation.

Preoperative assessment

Standard preoperative workup includes a urine culture to exclude urinary tract infection, a renal tract ultrasound to exclude hydronephrosis or other unanticipated structural abnormalities, and a cystoscopy to exclude significant urethral stricture disease or intravesical abnormalities (stones, TCC). All patients considered for augmentation cystoplasty should undergo videourodynamics to record bladder capacity, compliance, outlet resistance, and the presence of vesicoureteral reflux. The potential need to surgically increase bladder outlet resistance and provide continence can also be appraised from the urodynamic exam.

It is important that patients and family members are clearly informed preoperatively about the potential need for intermittent catheterization as noncompliance with this may result in significant complications including recurrent urinary tract infections, stone formation and even rupture of the augmented bladder.

Stages of the procedure