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Enterocystoplasty. Bladder augmentation – increase bladder capacity without (autoaugmentation) or with tissues such as stomach,intestine, or ureter Bladder substitution—total in situ replacement of bladder with anastomosis to bladder neck or urethra. Indication for augmentation cystoplasty.
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Enterocystoplasty • Bladder augmentation – increase bladder capacity without (autoaugmentation) or with tissues such as stomach,intestine, or ureter • Bladder substitution—total in situ replacement of bladder with anastomosis to bladder neck or urethra
Indication for augmentation cystoplasty • Intractable detrusor hyperreflexia – and incontinence refractory totreatment • Poor bladder compliance and hydronephrosis – compliance is more important than end-filling pressure • Contracted bladder and incontinence • Chronic interstitial cystitis causes bladder pain
Causes of contracted bladder for enterocystoplasty • Irradiation cystitis • Chronic non-bacterial cystitis • Tuberculosis granulomatous cystitis • Status post partial cystectomy • Unknown origin resulting contracted bladder – surgical trauma, frequent cystitis • Contracted bladder with vesicoureteral reflux
Surgical techniques • A 40-cm segment of terminal ileum • Detubularization and fashioned into a W-shaped or double-folded cup • Antireflux mechanism by a nipple valve or direct reimplantation with a submucosal segment of ureter • Bladder was opened as clam-shape • Double layer meticulous anastomosis
Complications of enterocystoplasty • Ureteral reimplantation stenosis 9-16% • Continence 27- 65% • Need for clean intermittent catheterization 8- 44% • Stone formation • Impairment of bone formation & mineralization
Stone formation after enterocystoplasty • More in intestinal reservoir than gastrocystoplasty • Staples, suture materials, metabolic abnormality, PH value • Mucus plays an important role • PH conducive to crystallization of uric acid • Calcium-phosphate ration is elevated in forming stone in intestinal reservoir
Late complications of Enterocystoplasty • Mucus production and obstruction • Bacteriuria • Stone formation • Metabolic alteration • Bowel dysfunction • Secondary malignancy
Mucosal alteration in ileal bladder • Started at 1 year and completed at 4 years • Reduction in microvilli and inflammatory infiltration of lamina propria • Flattening of mucosa with pseudourothelial morphology • Muscular degeneration and hypertrophy • Collagen deposition and fibrosis
Contracture of anastomosis of enterocystoplasty in TB patient
Significance in low compliance after enterocystoplasty • Persistent hydronephrosis after augmentation cystoplasty • Urinary incontinence at full bladder • Night time urinary incontinence due to high peristaltic pressure • Prone to urinary tract infection due to mucosal defects • Dysuria due to small bladder capacity
Large capacity and compliance in enterocystoplasty for 5 years
Changes in peristaltic pressure and com-pliance before and after enterocystoplasty
Gastrocystoplasty • Advantages of gastrocystoplasty– absence of mucus production, hydrogen ion absorption, bacteriuria, acidexcretion • Preferable in patients with chronic renal failure • Disadvantages – excessive acid depletion, metabolic alkalosis, hematuria, peptic ulceration, perforation, dumping syndrome
Ureterocystoplasty • Avoid performing gastroenteral surgery • Prevent mucus secretion, secondary malignancy, frequent infection • Indicated only in patients with megaloureter and contracted bladder • Tissue expansion may be another way in achieving a dilated ureter for harvest
Bladder autoaugmentation • Increase of bladder capacity is limited • Successful result in detrusor instability comparable with enterocystoplasty • May be indicated in chronic interstitial cystitis with bladder pain • The preoperative bladder capacity determines the final outcome • Minimal surgical morbidity
Surgical technique forbladder autoaugmentation • Extraperitoneal exploration of bladder • Inserting Foley catheter and tenting the draining tube to a pressure to keep the intravesical pressure and bladder volume • Dissection of detrusor muscle to mucosa • Dissect the detrusor muscles off mucosa (detrusor myomectomy) with perforation • Dissecting half of bladder wall • Covering with omentum or mucosectomized intestinal wall
Continent urinary reservoir (Kock pouch) • Indicated in quadriplegics with less good hand function • Women who cannot perform CISC • Severe urethral incompetence and inconti- nence after repeat surgical procedures • Patient with a severely damaged or scarred urethra
Continent cystostomy • Indicated for patients with a fair bladder compliance but a damaged urethra and incontinence • Closed the bladder outlet and augmented with anti-incontinence ileum or cecum with appendix • Avoid excessive intestinal surgery and prevent the need of ureteral reimplantation
Seromuscular enterocystoplasty • To avoid mucus secretion and complication from enterocystoplasty • To prevent secondary contracture of the bladder after autoaugmentation • Combined detrusor myomectomy and enterocystoplasty with a segment of mucosecomized ileum • Adequate myomectomy is necessary
Orthopedic neobladder in woman • Urinary incontinence is not a problem after neobladder formation without preserving bladder neck • Pelvic floor muscle exercises improve stress urinary incontinence • Pubovaginal sling procedure may help in achieving continence • Complete daytime and night time continence rates are 88% and 79-82%