Enterocystoplasty and Urinary Diversion Hann-Chorng Kuo Department of Urology Buddhist Tzu ChiGeneral Hospital Hualien

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

Surgical technique of Enterocystoplasty (1)

Surgical technique of Enterocystoplasty (2)

Surgical technique of Enterocystoplasty (3)

Surgical technique of Enterocystoplasty (4)

Surgical technique of Enterocystoplasty (5)

Surgical technique of Enterocystoplasty (6)

Surgical technique of Enterocystoplasty (7)

Surgical technique of Enterocystoplasty (8)

Results of Augmentation cystoplasty

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

Changes of intestinal mucosa

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

Ileal mucosa in enterocystoplasty

Muscular degeneration at 1 month after Enterocystoplasty

Active peristalsis at initial stage of enterocystoplasty

Muscular degeneration at 6-month after Enterocystoplasty

Decrease in peristaltic pressure in enterocystoplasty

Muscular degeneration at 1-year after Enterocystoplasty

Silence of peristaltic waves after enterocystoplasty

Contracture of anastomosis of enterocystoplasty in TB patient

Changes in bladder compliance in enterocystoplasty

Persistent DESD and poor compliance in enterocystoplasty

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

Technique of gastrocystoplasty

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 for bladder 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

Bladder autoaygmentation

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

Contracted bladder with a non-functioning urethra

Technique of formation of a Kock pouch

Intraluminal pressure and anti-incontinence mechanism

Cystoscopic finding of Anti-reflux nipple valve

Sonography of anti-incontinence efferent loop

Urodynamic results after augmentation cystoplasty Cystometric capacity cmH2O End filling pressure cmH2O Bladder compliance ml/cmH2O MUCP cmH2O Preoperative 165±97 50±23 10.8±2.7 62±28 Postoperative 760±289 13±4.7 75±43 － Statistics p<0.005 MUCP= Maximal urethral closure pressure.

Changes in pressure and capacity after enterocystoplasty

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

Technique of Seromuscular enterocystoplasty

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%

Orthotopin Neobladder in woman after radical cystectomy

Contraindication for enterocystoplasty in NVD Azotemia with elevated creatinine (>2.5mg%) and BUN, CCr <10ml/min Severely damaged or incompetent urethra Low abdominal straining ability and poor hand function for catheterization Severe intestinal dysfunction and diarrhea Low social status and far to reach medical resources