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  • Robotic Bladder Augmentation in the Adult

    About the Author

    Ali Moinzadeh MD

    Introduction

    Mikulicz was likely the first surgeon to describe the use of small intestine for bladder augmentation, around 1900. Goodwin described the cup patch technique which is most similar to the procedure used today. (1)

    Indications/Alternatives

    Patients with small capacity bladders may have two problems. First the inability to hold urine therefore issues with incontinence. The second, increased bladder pressures which may have a negative effect on upper tract function. Bladder augmentation involves increasing the capacity of the. By increasing the size of the bladder with an intestinal portion, the capacity is increased and bladder pressure lowered. Patients may also have issues with urinary frequency, urgency, and sometimes, urinary tract infections.

    Work up generally includes video urodynamic testing to assess bladder compliance, capacity, reflux, and sphincter function.

    Patients must be motivated to perform clean intermittent catheterization (CIC).

    It is assumed that patients who are candidates for surgery have maximally utilized and failed anticholinergic medications and CIC. Alternatives to surgery include the use of Botulinium A Toxin injected into the detrusor muscle.(2) The lack of long term effect and need for sequential injection is really the major limitation to Botulinum A toxin (in addition to the cost). Finally, autoaugmentation has been reported as an alternative to using bowel for augmentation.(3) The technique involves the creation of multiple incisions into the bladder detrusor muscle (but not the mucosa) to allow for expansion. Unfortunately, the increased capacity may be overall small compared to what may be needed for patients with small capacity bladder.

    Contraindications

    Patients with multiple prior bowel surgeries or those with short gut syndrome, may not be able to lose any further portion of their intestine and hence not be suitable surgical candidates.

    -Complications

    Complications specific to ileal augmentation of the bladder include the continued production of mucous from the bowel segment. This may cause blockage of the bladder outlet. The issue is more prevalent in the first several months after the procedure and improves.

    Metabolic changes are second consideration. The bowel segment retains the ability to absorb products and water from the urine.  Vitamin B 12 deficiency has been reported with long term follow up.(4)

    Other complications include: stone formation, bladder perforation, and rarely cancer production the urinary system. This latter complication is difficult to directly associate with the augmentation procedure as it occurs in adult population already at risk for the development of cancer.

    Patient preparation

    Patient preparation includes bowel preparation. Depending on baseline intestinal function (may be impaired in spina bifida patients) we may use manesium citrate or Go-Lytely bowel preparation.

    Patients should be fully aware of the tubes and drains they will have after surgery. Some surgeons advocate the use of suprapubic tubes. In addition, of often nasogastric tubes (NGT) are placed during surgery and maintained after surgery. A large sized Foley catheter is placed and kept in place in the post operative period to allow for bladder to intestinal augment healing.

     

    Procedure details:

    Trocar placement for robotic bladder augmentation with ileum:

    Trocar placement robotic bladder augmentation on urologybook.com

    Note, the 5mm assistant trocar is often changed to a 12 mm trocar to allow the assistant direct angle for firing the Endo-Gia Stapler.

    References:

    1.            Goodwin WE, Winter CC, Barker WF. “Cup-patch” technique of ileocystoplasty for bladder enlargement or partial substitution. J Urol 2002;168(2):667-70; discussion 671.

    2.            Schurch B, Stohrer M, Kramer G, Schmid DM, Gaul G, Hauri D. Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results. J Urol 2000;164(3 Pt 1):692-7.

    3.            Marte A, Di Meglio D, Cotrufo AM, Di Iorio G, De Pasquale M, Vessella A. A long-term follow-up of autoaugmentation in myelodysplastic children. BJU Int 2002;89(9):928-31.

    4.            Gilbert SM, Hensle TW. Metabolic consequences and long-term complications of enterocystoplasty in children: a review. J Urol 2005;173(4):1080-6.

    For a great review article on this topic Visit:http://www.indianjurol.com/  LINK