Augmentation Cystoplasty

Augmentation cystoplasty

Bladder augmentation, also known as augmentation cystoplasty, is a surgical procedure in which the bladder is expanded with a patch of tissue, most often a segment of the intestine or, in some cases, other tissues. This increases bladder capacity, decreases pressure and improves urine storage. 

Indications

This process is normally discussed in patients with:

• Small bladder capacity or high pressure (neurogenic bladder e.g., SCI, spina bifida).low pressure-low capacity bladder
• Bladder exstrophy or birth defects.
• Painful bladder syndrome
• Bladder damaged from radiation.
• Infection, tuberculosis or chronic inflammation in the bladder can lead to bladder contracture.
• Failed conservative/medical management of the bladder dysfunction.

Augmentation cystoplasty surgery

Preparation before Surgery

Patient evaluation:

• Blood tests and renal functioning.
• Urine culture
• Imaging of the urinary tract.
• Urodynamics of the bladder.
• Preparation of the bowel
• Antibiotics
• Informed consent 

Anaesthesia

• General anaesthesia is given. 
• Patient positioned supine.

Surgical Steps

Step 1: Abdominal Access 

• Incision in the lower midabdomen 
• Expose the bladder.

Step 2: Bladder Mobilization

• Free dissection of bladder is done.
• Measure bladder capacity and tissue caliber.

Step 3: Bowel Segment Selection

• Ileum or colon is normally used.
• Isolation of segment 1520 cm with intact blood supply.
• The bowel is re-anastomosed at both ends of the bowel to retain intestinal continuity.

Step 4: Bowel segment Detubularization

• This is opened through the anti-mesenteric border of the bowel.
• This decreases peristaltic and enables it to act as a low-pressure reservoir.

Step 5: Augmentation and Bladder Incision

• Opening of the bladder in a vertical incision or clam-shell.
• The detubularized bowel segment is attached to the edges of the bladder using absorbable sutures.
• Close the watertight to avoid spills.

Step 6: Ureteral Reimplantation (if required)

• For reflux or obstruction of the ureters the ureters are reimplanted into the augmented bladder. 

Step 7: Drain Placement

• Suprapubic catheter and/or Foley catheter. 
• To check leaks, abdominal drain can be undertaken.

Step 8: Closure

• Abdomen is closed in layers.
• Provide preoperative hemostasis.

Postoperative Care

• Hospital stay: 7–14 days.
• Catheter drainage of the bladder: 2 -3 weeks of continuous catheterization.

Monitor for:

• Urinary leakage
• Infection
• Electrolyte disturbance (particularly where bowel is employed)
• Pain treatment: IV, then oral analgesics.
• Slow food intake resumes upon bowel recovery.

Long-term Management

• In the meantime, should be clean, intermittent self-catheterization for partial bladder emptying.

Routine visits: 

• Kidney and electrolytes.
• Imaging of UTIs in stones or hydronephrosis.
• Urine culture as a follow up of infection.

Augmentation cystoplasty recovery

The following is an elaborate recovery plan following augmentation cystoplasty:

Postoperative Period (First 1-3 Days)

• Patient is followed up in hospital.

Catheters:

• Foley catheter inserted in the bladder to allow the bladder to be continuously drained.
• Suprapubic catheter can also be inserted in case of necessity.
• IV fluids to maintain hydration of the body.
• Analgesia: IV analgesics 
• Observation: Vital signs, urine output, bleeding or sepsis. 
• Bowel care: Nasogastric tube can be provisional in case there has been bowel segment use; resumed gradually on fluids when the bowel activity returns to normal.

Early Recovery (1–2 Weeks)

• Inpatient: An average of 7-14 days based on recovery.
• Catheter care: Bladder drainage continuous; guarantees bowel and augmented bladder healing.
• Diet: A progressive advancement of liquids to soft food.
• Mobility: Mobilization promoted to avoid such complications as DVT.

Intermediate Recovery (2 -6 Weeks)

• Removal of catheter: The Foley catheter is usually removed in 2-3 weeks; the suprapubic catheter can be maintained for an unlimited time.
• Bladder training: The patient may start to fill up the bladder gradually; Some patients require clean intermittent self-catheterization to empty the bladder.
• Restoration: Repeat urinalysis, renal function, and electrolytes. 
• Exercise: Mild activity; avoid heavy lifting or vigorous exercise.

Long-Term Recovery (6 weeks later) 

• Full bladder function: Weeks to months the bladder adjusts to the increased capacity.
• Intermittent catheterization: Many patients require this procedure for the rest of their life if they are unable to completely empty their bladder.

Follow-up:

• Imaging to determine the presence of stones or hydronephrosis.
• Blood tests
• Urine tests: observes infection and mucus.

Changes in lifestyle:

• Stay hydrated to help prevent stones and infections. 
• Watch out on evidence of metabolic disturbances.

Augmentation cystoplasty complications

The following is an in-depth description of complications of augmentation cystoplasty:

Early/Postoperative Complications

• UTI: This is most likely a result of catheters and surgery.
• Urine leakage: Bladder or bowel anastomosis.
• Bleeding: Uncommon, but can lead to transfusion.

Bowel complications:

• Ileus (blockage of the bowel, but only for a short time) 
• Bowel anastomosis leak. 
• Wound infection or dehiscence.

Metabolic Complications

Hyperchloric metabolic acidosis:

• Routine: When a loop of bowel is positioned in the bladder.
• Because of the absorption of urinary ammonia and chloride by intestinal mucosa.
• May be given as oral bicarbonate supplement.

Disturbance of Electrolutes:

• Hypokalemia or hyponatremia may also occur.

Long-Term Complications

Urinary stones: 

• Habitual because of secretions by bowel length.
• May needs to have her endoscopically removed.

Mucus production in urine:

• Bowel segment releases mucus; can cause catheter obstruction or stones.

The patient has incomplete bladder emptying:

• May needs to do self-catheterization at times.

Urinary incontinence:

• Especially at night or when the pressure on the bladder is higher.

Ureteral/Upper Tract Complications

• Hydronephrosis: Obstructed or refluxed if the ureters are reimplanted too tightly.
• Reflux nephropathy: High pressure can cause irreversible renal damage. 

Uncommon yet Severe Complications

Augmentation segment malignancy:

• Uncommon, can arise many decades later.
• Risk was higher for long-term infection or inflammation.
• Bowel obstruction: Septations or strictures.
• Bladder perforation: It is rare but life-threatening. 

Best hospital for augmentation cystoplasty India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Augmentation cystoplasty is a very efficient reconstructive surgery that is applicable to increase the size of the bladder, lower the bladder pressure and preserve the kidney functioning, particularly when patients have neurogenic bladder, congenital deformity, or extreme damage of the bladder. Although it has considerable long-term outcomes, including enhanced continence and improved quality of life, it is a major procedure, and important considerations have to be made. The surgery is characterized by the insertion of a bowel segment to enlarge the bladder and even though the results are usually satisfactory, patients should be cautious of the complications that may arise short and long-term such as infections, mucus secretion, metabolic imbalance and the presence of stones. Proper catheter care, lifelong follow-up, hydration and periodic renal-function monitoring are vital components of the postoperative care.

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FAQ

How long does the surgery last?

• The surgery is generally about 3 to 5 hours long depending on the complexity of the case, the surgery may be longer if ureteral reimplantation is necessary.

Is this done laparoscopically?

• Yes, it can in certain patients be performed laparoscopically or via robotic assisted techniques but open is still very much used.

Do I need a catheter after surgery?

• Yes. A Foley catheter or suprapubic one is kept for 2–3 away for continuous drainage, enabling the bladder and bowel parts to heal.

After surgery, Will I be able to urinate normally?

• Some can empty the bladder normally, yet many need to do intermittent self-catheterization (CIC) to get the bladder completely empty.

Will the bowel segment continue to produce mucus?

• Yes. The intestinal segment continues producing mucus. Adequate hydration and periodic bladder irrigation may be necessary.

Is augmentation cystoplasty a permanent procedure?

• It is a permanent reconstruction. The augmented bladder does not shrivel up.

Will kidney function improve?

• Yes – by reducing bladder pressure, it is kidney-protective and may stabilise kidney function.