Augmentation cystoplasty is traditionally indicated for small-capacity, poorly compliant bladders, refractory to more conservative treatment strategies. Aggressive pharmacological therapies with anticholinergics or β3-mimetic drugs, intradetrusor injections of botulinum toxin, and sacral neuromodulation have reduced the need for augmentation cystoplasty over the past two decades. While ileocystoplasty with a preterminal segment of ilium is by far the most widely adopted augmentation procedure, other gastrointestinal segments such as stomach, cecum and colon have also been successfully used to augment the bladder. Experience with other native (e.g., fascial grafts, peritoneum, skin) or synthetic tissue grafts has been disappointing. The introduction of robot-assisted surgery has accelerated the transition to minimally invasive ileocystoplasty with complete intracorporeal reconstruction.
Patient positioning, access, pneumoperitoneum, and port placement
Ileal loop isolation and bowel reanastomosis
Indications and contraindications for augmentation cystoplasty
Augmentation cystoplasty is indicated for patients with neurogenic detrusor overactivity and poor bladder compliance refractory to more conservative treatments such as pharmacotherapies, intravesical botulinum toxin, or sacral neuromodulation. Augmentation cystoplasty can also be indicated in patients with congenital bladder abnormalities, such as bladder exstrophy, and rare infective and inflammatory disorders of the bladder such as tuberculous bladder, schistosomiasis and radiation-induced cystitis resulting in a poorly compliant and low-capacity bladder.
In patients with intrinsic bowel disease, such as Crohn disease or short-bowel syndrome, in which removal of an extra bowel segment may increase the risk of intestinal/malabsorption consequences, augmentation cystoplasty is contraindicated. Renal insufficiency and the inability to perform intermittent self-catheterization due to decreased dexterity or cognitive impairment are also considered as contraindications for bladder augmentation.
Standard preoperative workup includes a urine culture to exclude urinary tract infection, a renal tract ultrasound to exclude hydronephrosis or other unanticipated structural abnormalities, and a cystoscopy to exclude significant urethral stricture disease or intravesical abnormalities (stones, TCC). All patients considered for augmentation cystoplasty should undergo videourodynamics to record bladder capacity, compliance, outlet resistance, and the presence of vesicoureteral reflux. The potential need to surgically increase bladder outlet resistance and provide continence can also be appraised from the urodynamic exam.
It is important that patients and family members are clearly informed preoperatively about the potential need for intermittent catheterization as noncompliance with this may result in significant complications including recurrent urinary tract infections, stone formation and even rupture of the augmented bladder.
Stages of the procedure
|Laparoscopic scissors, suction device, grasper|
Patient preparation and positioning
Bowel preparation is not routinely performed, and patients are allowed to continue solid food intake until 6 hours and clear fluid intake until 2 hours before surgery. The patient is placed in supine position on a Trendelenburg positioning pad. After induction of general anesthesia, an 18 Fr urethral Foley catheter is inserted, both arms are strapped next to the body and all pressure points are carefully padded. A forced-air patient warming blanket is applied. A prophylactic antibiotic protocol of cefazolin and metronidazole is administered within 1 hour before skin incision and a nasogastric tube is placed for the duration of the procedure. Routine shaving, skin preparation and draping are performed.
Port placement and robot docking
The camera port is placed approximately 5 cm cranial of the umbilicus with the open Hasson technique and the abdomen is insufflated to 12 mm Hg pressure. After establishing pneumoperitoneum, two additional 8 mm robotic working ports are placed in the mid-clavicular line on either side of the camera port and a 12 mm robotic working port is placed in the left iliac fossa. A 5 mm assistant port is placed in the right upper quadrant, inferior to the costal margin, and finally a 10 mm assistant port is placed about 1 hand-breadth lateral to the most rightward working port ( Fig. 34.1 ). The patient is then placed in a 15 to 30 degree Trendelenburg position and the robot is side-docked from the right.
Release of the bladder
The bladder is released by incising the peritoneum medial of the medial umbilical ligaments and transecting the urachus. Anterior and lateral dissection of the bladder is continued to the endopelvic fascia to allow adequate mobilization ( Fig. 34.2 ). Next, the peritoneum is dissected off the bladder dome. Filling the bladder may help to identify the correct plane during this dissection ( Fig. 34.3 ).