排尿障礙治療中心版權所有 Enterocystoplasty and Urinary Diversion Hann-Chorng Kuo Department of Urology Buddhist Tzu ChiGeneral Hospital Hualien

排尿障礙治療中心版權所有

EnterocystoplastyEnterocystoplasty

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 Indication for augmentation cystoplastyaugmentation cystoplasty

Intractable detrusor hyperreflexia – and incontinence refractory totreatment

Poor bladder compliance and hydronephrosis – compliance is more important than end-filling pressure

Contracted bladder and incontinenceChronic interstitial cystitis causes bladder p

ain


Causes of contracted bladder Causes of contracted bladder for enterocystoplastyfor enterocystoplasty

Irradiation cystitisChronic non-bacterial cystitisTuberculosis granulomatous cystitisStatus post partial cystectomy Unknown origin resulting contracted bladde

r – surgical trauma, frequent cystitisContracted bladder with vesicoureteral reflu

x


Surgical techniquesSurgical techniques

A 40-cm segment of terminal ileum Detubularization and fashioned into a W-sh

aped or double-folded cupAntireflux mechanism by a nipple valve or

direct reimplantation with a submucosal segment of ureter

Bladder was opened as clam-shapeDouble layer meticulous anastomosis


Surgical technique of EnterocSurgical technique of Enterocystoplasty (1)ystoplasty (1)
















Results of Results of Augmentation cystoplastyAugmentation cystoplasty


Complications of enterocystopComplications of enterocystoplastylastyUreteral reimplantation stenosis 9-16%Continence 27- 65%Need for clean intermittent catheterization

8- 44%Stone formationImpairment of bone formation & mineraliza

tion


Stone formation after enterocyStone formation after enterocystoplastystoplastyMore in intestinal reservoir than gastrocysto

plastyStaples, suture materials, metabolic abnorm

ality, PH valueMucus plays an important rolePH conducive to crystallization of uric acidCalcium-phosphate ration is elevated in for

ming stone in intestinal reservoir


Late complications of EnterocLate complications of Enterocystoplastyystoplasty

Mucus production and obstructionBacteriuriaStone formationMetabolic alterationBowel dysfunctionSecondary malignancy


Changes of intestinal mucosaChanges of intestinal mucosa


Mucosal alteration inMucosal alteration in ileal bladder ileal bladder

Started at 1 year and completed at 4 yearsReduction in microvilli and inflammatory in

filtration of lamina propriaFlattening of mucosa with pseudourothelial

morphologyMuscular degeneration and hypertrophyCollagen deposition and fibrosis


Ileal mucosa in enterocystoplastyIleal mucosa in enterocystoplasty


Muscular degeneration at 1 mMuscular degeneration at 1 month after Enterocystoplastyonth after Enterocystoplasty


Active peristalsis at initial stagActive peristalsis at initial stage of enterocystoplastye of enterocystoplasty


Muscular degeneration at 6-mMuscular degeneration at 6-month after Enterocystoplastyonth after Enterocystoplasty


Decrease in peristaltic pressurDecrease in peristaltic pressure in enterocystoplastye in enterocystoplasty


Muscular degeneration at 1-yeMuscular degeneration at 1-year after Enterocystoplastyar after Enterocystoplasty


Silence of peristaltic waves after Silence of peristaltic waves after enterocystoplastyenterocystoplasty


Contracture of anastomosis of enContracture of anastomosis of enterocystoplasty in TB patientterocystoplasty in TB patient


Changes in bladder compliance iChanges in bladder compliance in enterocystoplastyn enterocystoplasty


Persistent DESD and poor compliPersistent DESD and poor compliance in enterocystoplastyance in enterocystoplasty


Significance in low compliancSignificance in low compliance after enterocystoplastye after enterocystoplasty

Persistent hydronephrosis after augmentation cystoplasty

Urinary incontinence at full bladderNight time urinary incontinence due to high

peristaltic pressureProne to urinary tract infection due to muco

sal defectsDysuria due to small bladder capacity


Large capacity and compliance in Large capacity and compliance in enterocystoplasty for 5 yearsenterocystoplasty for 5 years

排尿障礙治療中心版權所有Changes in peristaltic pressure and com-pliaChanges in peristaltic pressure and com-pliance before and after enterocystoplastynce before and after enterocystoplasty


GastrocystoplastyGastrocystoplasty

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 gastrocystoplastyTechnique of gastrocystoplasty


UreterocystoplastyUreterocystoplasty

Avoid performing gastroenteral surgeryPrevent mucus secretion, secondary malign

ancy, frequent infectionIndicated only in patients with megaloureter

and contracted bladderTissue expansion may be another way in ac

hieving a dilated ureter for harvest


Bladder autoaugmentationBladder autoaugmentation

Increase of bladder capacity is limitedSuccessful result in detrusor instability com

parable with enterocystoplastyMay be indicated in chronic interstitial cysti

tis with bladder pain The preoperative bladder capacity determin

es the final outcomeMinimal surgical morbidity


Surgical technique forSurgical technique forbladder autoaugmentationbladder autoaugmentation Extraperitoneal exploration of bladder Inserting Foley catheter and tenting the draining tub

e to a pressure to keep the intravesical pressure and bladder volume

Dissection of detrusor muscle to mucosa Dissect the detrusor muscles off mucosa (detrusor m

yomectomy) with perforation Dissecting half of bladder wall Covering with omentum or mucosectomized intestin

al wall


Bladder autoaygmentationBladder autoaygmentation


Continent urinary reservoir (KContinent urinary reservoir (Kock pouch)ock pouch)

Indicated in quadriplegics with less good hand function

Women who cannot perform CISCSevere urethral incompetence and inconti- n

ence after repeat surgical proceduresPatient with a severely damaged or scarred

urethra


Contracted bladder with a Contracted bladder with a non-functioning urethranon-functioning urethra

排尿障礙治療中心版權所有Technique of formation of a Kock pouchTechnique of formation of a Kock pouch


Intraluminal pressure and anti-Intraluminal pressure and anti-incontinence mechanismincontinence mechanism


Cystoscopic finding of Cystoscopic finding of Anti-reflux nipple valveAnti-reflux nipple valve


Sonography of anti-incontinenSonography of anti-incontinence efferent loopce efferent loop


Urodynamic results after augUrodynamic results after augmentation cystoplastymentation 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 p<0.005 p<0.005

MUCP= Maximal urethral closure pressure.


Changes in pressure and capacitChanges in pressure and capacity after enterocystoplastyy after enterocystoplasty


Continent cystostomyContinent 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 enterocystoplasSeromuscular enterocystoplastytyTo avoid mucus secretion and complication

from enterocystoplastyTo prevent secondary contracture of the bla

dder after autoaugmentationCombined detrusor myomectomy and enter

ocystoplasty with a segment of mucosecomized ileum

Adequate myomectomy is necessary


Technique of Seromuscular eTechnique of Seromuscular enterocystoplastynterocystoplasty


Orthopedic neobladder in woOrthopedic neobladder in womanman

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 womaOrthotopin Neobladder in woman after radical cystectomyn after radical cystectomy


Contraindication for enterocystContraindication for enterocystoplasty in NVDoplasty in NVD

Azotemia with elevated creatinine (>2.5mg%) and BUN, CCr <10ml/min

Severely damaged or incompetent urethraLow abdominal straining ability and poor h

and function for catheterizationSevere intestinal dysfunction and diarrheaLow social status and far to reach medical r

esources

Documents

排尿障礙治療中心 版權所有 Enterocystoplasty and Urinary Diversion Hann-Chorng Kuo Department of Urology Buddhist Tzu ChiGeneral Hospital Hualien

排尿障礙治療中心版權所有 Enterocystoplasty and Urinary Diversion Hann-Chorng Kuo Department of Urology Buddhist Tzu ChiGeneral Hospital Hualien