WHAT IS AN AUGMENTATION CYSTOPLASTY?
An operation where a segment of bowel is isolated from the rest of the bowel and sewn as a patch onto the bladder to increase the size of the bladder.
WHY IS IT DONE?
- To increase the amount of urine the bladder can hold so patients don’t need to go to the toilet as often.
- To stop involuntary bladder contractions which are causing urge incontinence.
- To lower the pressure at which the bladder stores urine when high bladder pressures have caused, or are at risk of causing, kidney damage.
- When other treatments such as anticholinergic medication (e.g. Ditropan) and intermittent self catheterization has failed.
WILL I NEED TO SELF CATHETERISE AFTERWARDS?
Yes, you will usually need to pass a catheter yourself to empty the bladder usually 4-5 times a day for the rest of your life. This is especially true for patients with neurological disease. There are some patients without a neurological disease who can still pass urine on their own after the procedure although at least 30% of these patients will still be totally catheter dependant. It is very important patients continue to catheterize as required. Failure to do so can result in the bladder bursting which can be fatal.
WHAT IS THE LIKELIHOOD OF THE OPERATION WORKING?
- 75% of patients have an excellent result
- 20% are improved
- 5% have major ongoing problems
- 13% have incontinence but only half of these require surgery
- 16% chance of needing revision surgery over next 3-5 years, [1].
In addition to accepting the need to catheterise afterwards it essential patients also realize that following this procedure they will need lifelong follow-up and further surgical procedures are often required.
COULD I STILL HAVE INCONTINENCE AFTERWARDS?
- This occurs in about 13% of patients and is more common at night or if patients don’t catheterize often enough.
- Some patients have stress incontinence as well as urge incontinence. Patients with stress incontinence may require another procedure for this done at the same time as the augmentation cystoplasty or done at a later date.
WILL I STILL NEED ANTICHOLINERGIC MEDICATION AFTERWARDS?
This may be required to inhibit bladder contractions or contractions of the bowel patch.
WHAT TESTS MIGHT BE REQUIRED BEFOREHAND?
- Urine test for infection.
- Blood test of kidney and liver function.
- Fluoroscopic Urodynamic Studies (FUDS).
- Cystoscopy – telescope examination in the bladder.
- Kidney ultrasound or IVP X-Ray.
- 24 hour urine collection to check urine volume and kidney function.
- Patients with bowel disease or older patients may need tests on their bowel such as a Barium enema or colonoscopy.
- A Pre-op anaesthetic assessment will be arranged with the anaesthetist.
- You will need to be taught to self catheterize if you are not doing this already.
WHO IS THIS OPERATION NOT SUITABLE FOR?
- Patients who are unable to self catheterise.
- Some patients with severe kidney failure.
- Patients who produce excessive volumes of urine which would mean they would have to catheterize too frequently to manage.
- Patients who produce extremely small volumes of urine.
- Patients with liver failure.
- Patients with bowel disease or who have had large volumes of bowel removed.
- Some patients who have had radiotherapy to their bladder and bowel.
JUST BEFORE SURGERY
You will need a bowel prep to clear out and prepare the bowel for surgery. If there is kidney failure you may need to have intravenous fluids in hospital whilst the bowel preparation is done.
WHAT IS DONE AT THE OPERATION?
- A General anaesthetic is required and the operation takes about 3 hours.
- A midline incision extends from the umbilicus (belly button), straight down to the pubic bone. It may also extend upwards from the umbilicus as far as the rib cage.
- A segment of bowel is isolated to sew onto the bladder as a patch. Usually some of the Ileum, (small bowel) is used but occasionally this is not suitable and an alternative such as colon, (large bowel) or stomach is used.
AFTER THE OPERATION
- You will have a Nasogastric Tube – a tube inserted via the nostril down the oesophagus into the stomach which drains the fluid produced by the stomach, allowing the bowel to rest and heal. This is usually removed on the ward after a couple of days.
- A suprapubic catheter – a catheter from the bladder which comes out through the overlying skin, directly out of the abdominal wall.
- A Urethral catheter – a catheter coming out of the urethra.
- A wound drain coming out of the abdomen through the abdominal wall. This is usually removed on the ward after a few days.
- Nil by mouth until bowel activity returns, usually within 3-5 days.
- Fluids and antibiotics are given intravenously.
- Pain killers are given to control pain.
- Gentle washouts are performed 2-3 times a day of the bladder via the catheter to remove any mucus secreted by the bowel patch.
- Injections daily to thin the blood and prevent blood clots in the leg veins.
- Chest physiotherapy to prevent chest infection.
- You are discharged with the catheters on free drainage into a bag for 3 weeks.
AFTER DISCHARGE FROM HOSPITAL
- You will need to perform washouts via the catheter up to 3 times a day to clear any mucus produced by the bowel.
- You will need to empty the urine form the catheter bag.
- At 3 weeks from surgery you will be readmitted to hospital and a cystogram, (X-Ray) will be performed to test if the bladder is watertight.
- If this X-Ray is Okay the suprapubic catheter will be clamped and the urethral catheter removed.
- You will need to self catheterize every 2-3 hours initially and 1-2 times overnight.
- Bladder Washouts continue daily or as required, usually 2-3 times a day.
- Gradually with time you should be able to increase the intervals between passing the catheter to a maximum of every 4-5 hours as the bladder and bowel patch gradually stretches over time and more urine can be held. The bladder capacity usually continues to improve for up to a year afterwards.
- Some of your other medications may need the dose reduced if they are eliminated from the body by the kidneys. After this procedure the medications can then get reabsorbed from the urine by the gut on the bladder.
WHAT IF YOU DON’T CATHETERISE AS OFTEN AS REQUIRED?
- The bladder can rupture or burst which can be serious and even fatal.
- You can get; kidney failure, urine infections, or stones forming in the bladder or kidneys.
- A build up of mucus in the bladder that can cause blockages.
WHAT ARE THE POTENTIAL RISKS AND COMPLICATIONS?
- Death is rare, < 1/1000.
- There is a small risk of a major event like a heart attack, stroke, heart failure, leg vein clots and pulmonary embolus, (clots dislodging to the lungs), or pneumonia .
- Damage to adjacent organs such as: ureters, (tubes from kidney to bladder), bowel, blood vessels or nerves which may require further surgery to correct.
- Inability to use the bowel segment as planned and an alternative bowel segment is used or rarely being unable to perform the procedure at all.
- Bleeding; 5% risk of needing a blood transfusion.
- Wound infection, wound breakdown or infection within the abdomen.
- Ileus – a delay in the return of bowel activity requiring gastric drainage via a nasogastric tube, intravenous fluids, nil by mouth and even intravenous feeding, sometimes requiring re-exploration of the abdomen by returning to surgery.
- A small bowel obstruction; this can occur up to many years later and may require an operation/laparotomy and further bowel resection/removal.
- A leak of urine from the bladder requiring prolonged catheter/tube drainage or even return to theatre.
- Dying of the bowel patch requiring its removal and possibly replacement with another bowel patch at that time or at a later date.
- Failure to give adequate bladder capacity or contractions of the bowel segment or bladder resulting in continuing incontinence. Contractions may require ongoing medical therapy with anticholinergic medication, Imodium or even a second augmentation cystoplasty.
- Development of stress incontinence.
- Vitamin B12 deficiency due to ileum segment removal requiring lifelong Vitamin B12 replacement injections.
- Removal of a bowel segment can result in a change in bowel habit and even chronic diarrheoa in some patients.
- Kidney infections; 11%.
- Urine infections are common but only need treating if symptomatic.
- Mucus production usually reduces over time. Some patients continue to require regular washouts via a catheter to prevent mucus causing infections, stone formation or blockage which could result in bladder rupture.
- Stones requiring surgery to remove occur in up to 50% of patients.
- Metabolic disturbances may require ongoing medication and can cause osteoporosis. Rarely are they severe enough to require removal of the augmentation.
- Bleeding or discomfort passing urine
- Delayed rupture, <5% may be due to mucus blockage, infection, chronic bladder over distension. It requires laparotomy to repair with subsequent increased risk of another rupture. Sometimes complete replacement of the augment is required.
- Cancer – rare; 1.5% risk. The average time to cancer is > 20 years. It occurs at the join of the bladder to the bowel. After 10 years a screening cystoscopy is required every 1-2 years for the rest of your life.
It is often not possible to warn patients of every possible risk or potential complication with surgery especially if very rare. Yet it is important that you are aware of what risks are involved, especially the more common ones. This information is not meant to alarm you but allow you to make an informed consent to have surgery. It is very rare but unfortunately some patients can suffer complications and end up worse off as a result of their surgery.
LIFE LONG FOLLOW UP IS REQUIRED
- Blood test for kidney function and urine test for infection every 3 months for the first year
- An IVP X-Ray is sometimes required at 6 weeks.
- Review appointment at 6 weeks, 3 months, 6 months and then annually thereafter.
- Ultrasound of kidneys annually.
- Vitamin B12 levels if indicated and replacement injections if deficient.
- Flexible cystoscopy every 1-2 years after 10 years.
BLADDER RUPTURE
- This usually results from overfilling of the bladder but could also result from chronic infection or a blow to the lower abdomen.
- The symptoms are abdominal pain, nausea, vomiting or abdominal distension and eventually sepsis.
- Immediate presentation to a hospital emergency department is required.
- Treatment is surgery to repair the rupture. Sometimes replacement of the augment is required.
References
1. Flood, H.D., et al., Long-term results and complications using augmentation cystoplasty in reconstructive urology. Neurourol Urodyn, 1995. 14(4): p. 297-309.
Version: V2, July 2013
