Enterocystoplasty

1. 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

2. 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

3. 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

4. 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

5. Surgical technique of Enterocystoplasty (1)

6. Surgical technique of Enterocystoplasty (2)

7. Surgical technique of Enterocystoplasty (3)

8. Surgical technique of Enterocystoplasty (4)

9. Surgical technique of Enterocystoplasty (5)

10. Surgical technique of Enterocystoplasty (6)

11. Surgical technique of Enterocystoplasty (7)

12. Surgical technique of Enterocystoplasty (8)

13. Results of Augmentation cystoplasty

14. 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

15. 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

16. Late complications of Enterocystoplasty • Mucus production and obstruction • Bacteriuria • Stone formation • Metabolic alteration • Bowel dysfunction • Secondary malignancy

17. Changes of intestinal mucosa

18. 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

19. Ileal mucosa in enterocystoplasty

20. Muscular degeneration at 1 month after Enterocystoplasty

21. Active peristalsis at initial stage of enterocystoplasty

22. Muscular degeneration at 6-month after Enterocystoplasty

23. Decrease in peristaltic pressure in enterocystoplasty

24. Muscular degeneration at 1-year after Enterocystoplasty

25. Silence of peristaltic waves after enterocystoplasty

26. Contracture of anastomosis of enterocystoplasty in TB patient

27. Changes in bladder compliance in enterocystoplasty

28. Persistent DESD and poor compliance in enterocystoplasty

29. 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

30. Large capacity and compliance in enterocystoplasty for 5 years

31. Changes in peristaltic pressure and com-pliance before and after enterocystoplasty

32. 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

33. Technique of gastrocystoplasty

34. 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

35. 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

36. 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

37. Bladder autoaygmentation

38. 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

39. Contracted bladder with a non-functioning urethra

40. Technique of formation of a Kock pouch

41. Intraluminal pressure and anti-incontinence mechanism

42. Cystoscopic finding of Anti-reflux nipple valve

43. Sonography of anti-incontinence efferent loop

44. Urodynamic results after augmentation cystoplasty

45. Changes in pressure and capacity after enterocystoplasty

46. 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

47. 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

48. Technique of Seromuscular enterocystoplasty

49. 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%

50. Orthotopin Neobladder in woman after radical cystectomy