Augmentation cystoplasty with ileum

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Who is offered it The small, poorly compliant or overactive bladder that has failed everything else: anticholinergics and beta-3 agonists, intermittent catheterisation, botulinum toxin more than once, neuromodulation where it was appropriate. Most are neuropathic, spina bifida and spinal injury, with a detrusor pressure that threatens the kidneys; a few are idiopathic overactivity or a contracted bladder after tuberculosis or radiation. The second condition is as important as the first: the patient who can and will catheterise for the rest of their life, with the hands, the eyesight, the urethra or the channel and the will, because a large floppy augmented bladder does not empty itself. Renal function, the upper tracts and the bowel are assessed before the decision.
2. Preparation and consent The consent is long and written down. Mucus in the urine and the need to irrigate; bladder stones in about one in ten to one in five over the years; infection; a hyperchloraemic metabolic acidosis from urine sitting on ileum, and B12 deficiency if the terminal ileum is used; spontaneous perforation, rare but life-threatening, presenting as an acute abdomen; intermittent catheterisation in most neuropathic patients and about a third of the idiopathic; bowel complications; and a small long-term risk of malignancy in the patch or at the anastomosis. Bowel preparation is not routine. Antibiotics at induction, calf compression, a urethral catheter on the field, and the stoma nurse involved if a channel is planned.
3. Lower midline, packs, the bladder filled A lower midline incision from symphysis to above the umbilicus, the layers as for any lower midline, the peritoneum opened high. The small bowel is packed into the upper abdomen under a Deaver, the table tipped head-down and a self-retaining retractor set. The bladder is mobilised: the urachus divided, the peritoneum swept off the dome and the lateral walls freed from the pelvic side wall enough to bring the dome up into the wound. It is then filled through the catheter with 200 to 300 millilitres of saline so that it stands up as a globe and the line of the bivalve can be marked on it with the diathermy. Stay sutures of 2-0 Vicryl go on either side of the marked line.
   where it bites: a scarred neuropathic pelvis may have the peritoneum stuck to the dome and small bowel adherent to it; the peritoneum is opened at the top of the wound and every adhesion is taken sharply.
4. The clam The bladder is bivalved in the sagittal plane with the diathermy, beginning on the dome and carried anteriorly down to about two centimetres above the bladder neck, then posteriorly down to a point short of the trigone, stopping about two centimetres above the interureteric ridge. The result is two half-shells joined at the base, opened like a clam, with a long ellipse to be filled. The orifices are looked at from inside and, if they lie close to the posterior limit of the cut, a ureteric catheter is passed up each before it is extended. The mucosal edges bleed; they are picked with the diathermy and the shells are left resting in the wound on their stay sutures.
   where it bites: the posterior limb of the bivalve stops above the interureteric ridge; a cut carried into the trigone takes the orifices and the closing mechanism of the neck with it.
5. The ileal segment The terminal ileum is delivered and a segment of twenty to twenty-five centimetres is chosen at least fifteen centimetres proximal to the ileocaecal valve, on a mesentery that reaches the pelvis without tension when the loop is dropped onto the bladder. The mesentery is held to the light so the arcades show and the segment is taken on a good arcade; windows are made between the arcades at each end and the mesentery divided between them with the LigaSure or between ties. The bowel is divided at each end with a linear stapler and continuity restored above the segment with a stapled side-to-side anastomosis, the mesenteric window closed with interrupted 3-0 Vicryl. The isolated loop is irrigated with saline through its open end until clear.
   where it bites: the loop has to reach the bladder base without pulling on its mesentery; a loop that lies tight at this stage is an ischaemic patch at the end.
6. Detubularising the segment The loop is laid on a swab and opened along its antimesenteric border, exactly opposite the mesentery, with the cutting diathermy or scissors, from one stapled end to the other, the staple lines excised as it goes. The purpose is to destroy the tube: a tube of ileum contracts as a ring and generates pressure, which is what the operation is trying to abolish. Opened flat it becomes a rectangle of mucosa about twenty centimetres long and eight to ten wide, its mesentery entering the back of the plate along one side. Bleeding from the cut edge is taken with the bipolar, the mucosa is wiped of mucus and the plate is measured against the open bladder.
7. Reconfiguring the patch The plate is folded on itself into a U, the two limbs lying side by side, and the adjacent inner edges are sewn together with a running 3-0 Vicryl, mucosa to mucosa, from the fold to the open ends. Folded again and sewn, if the length allows, the plate becomes a cup, and either shape has the same property: no line of ileum runs the full length of the patch as a tube, so no coordinated contraction can raise the pressure in it. The cup is oriented so that the mesentery enters from its convex side without twisting, and the free edge of the cup is now an ellipse of about the same length as the clam.
8. Sewing the patch to the clam The posterior edge first, because it is the deepest and hardest to see. Beginning at the posterior apex of the bivalve, one running 2-0 or 3-0 Vicryl is carried along each side, edge to edge, full thickness of ileum to full thickness of bladder, the bites close and the suture pulled just enough to appose, the assistant following. The two sutures meet and are tied at the anterior apex. At the corners the bites are placed carefully so the patch is not gathered. It is a watertight closure that is wanted, not a tight one, and any gap found on the fill is closed with a single interrupted suture rather than the whole line being redone.
   where it bites: the mesentery of the patch must lie flat with no twist under the bladder; a patch that turns blue before the wound is closed is taken down now.
9. Catheters, drain, the test fill A suprapubic catheter, 16 to 20 French, is brought through the native bladder, not through the patch, and out through a separate stab in the abdominal wall; the urethral catheter is left in as well, because mucus blocks one and the other will save the night. A tube drain is placed beside the suture line. The bladder is filled with 150 to 200 millilitres of saline and the suture line inspected all round: a leak is closed with an interrupted suture and the fill repeated. Omentum is brought down over the suture line if it reaches. The bowel is checked, the count confirmed, and the abdomen closed as a mass closure with looped 1 PDS.
10. After: mucus, catheters, the lifetime plan The catheters are flushed with 30 to 50 millilitres of saline three times a day from the first day, because mucus blocks them and a blocked augmented bladder leaks or bursts its suture line. The drain comes out when its output is low and clear. The catheters stay for two to three weeks and a cystogram before they come out is usual. Intermittent catheterisation is taught before discharge and the patient is told that they empty by the clock, not by sensation. Lifelong follow-up: irrigation for mucus, renal function and electrolytes, a bicarbonate for acidosis, B12 yearly after five years if terminal ileum was used, upper tract ultrasound, and a low threshold for cystoscopy for haematuria or infection, with the perforation warning repeated at every visit.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance