Augmentation cystoplasty

Question 1

short term complications

Answer 1

<5%
bowel ob
infection
bleeding
fistula
VTE

Question 2

long term

Answer 2

CISC 38%
metabolic 16%
mucus
renal failure 2%
risk bladder perforation <1%
diarrhoea 25-30%
stones 15%
cancer 10 years

Question 3

patient counselling

Answer 3

• This is a complex operation and the patient needs extensive preoperative workup and counselling including time with the specialist nurse, stoma nurse.
• The patient is likely to need more than one appointment, I would provide written information.
• Understanding of personal responsibilities including need to do bladder washouts, need lifelong follow-up and surveillance
• Patients who are not motivated to perform CISC urethrally or mitrofanoff are not candidates for augmentation
• In patients who cannot perform CISC an incontinent diversion is preferable

Question 4

baseline investigations

Answer 4

Consider baseline renal function
Upper tract imaging check no dilatation and no scarred kidney
If in doubt may need MAG4 and CT urogram
Check if there is VP shunt as risk of infection
MUST have WORKING URETERS

Question 5

contraindications

Answer 5

short bowel
IDB severe
previous irradiation 
not willing do ISC
renal scarring
hepatic impairment

Question 6

procedure

Answer 6

• Preop consent, stoma marking, adequately draped and prepped
• AVOID latex, beware positioning in SB to avoid skin ulcers
• Catheter
• Midline laparotomy
• Peritoneum dissected from posterior bladder wall for later coverage of posterior anastomosis between bladder and bowel
• Select 20cm of bowel, 60cm from ileocaecal junction, bowel resection, open antimesenteric border, close mesenteric defect
• Make sure mesentery of excluded ileum has more than one arcade and can reach down to bladder
• Assess for size of plasty needed
• Flush ileal segment with saline and open lengthwise at opposite side of mesentery
• Posterior wall of ileal pouch made with side to side anastomosis of the two opposed margins
• Open bladder coronally or sagitally as far as able to ureteric orifices as possible, catheters in ureters during op unless reimplanting
• Use vicryl 1/0 or 2/0
• Make U shaped patch from bowel
• Suture ileal plate to posterior margin of bladder remnant
• Make sure do interrupted stitches in corners, this is where most likely to leak, then do back and then front continuous stitches
• Full thickness on bladder and seromuscular on the bowel, wider bites on the bowel
• Check leaks with saline solution
• Can insert SPC to irrigate or do 6 hourly saline flushes, pelvic drain

Question 7

indications cystoplasty

Answer 7

Refractory NDO to medications & Botox.
Unable to tolerate medications or Botox.
Dilated upper tracts
Uncontrolled ureteric reflux