Cystoplasty is also known as bladder augmentation or augmentation cystoplasty, ileocystoplasty, bladder augmentation surgery. The aim of this surgery is to increase the severely reduced bladder capacity and to enable the patient to hold their urine longer. Ileocystoplasty surgery can be performed on both men and women. It is a procedure that can also be performed for pediatric patients when appropriate and necessary. Since a piece taken from the patient’s own body (small intestine) is used to increase the bladder volume, no reaction occurs by the body.

In this article, I will provide general and up-to-date information about bladder augmentation surgery in the light of our own experience and literature.

What is bladder augmentation (ileocystoplasty) surgery?

One of the most important functions of the bladder is to ensure that the urine filtered from the kidneys is stored until urination. Bladder capacity/volume in normal adults is 350-400 cc on average. In some diseases, bladder volume decreases and patients need to urinate frequently. Bladder augmentation surgery is an operation to enlarge the bladder volume in cases where the bladder capacity is reduced for various reasons.

Preparation before ileocystoplasty surgery

Ileocystoplasty is a major surgery. Therefore, before deciding on surgery, a detailed evaluation should be made and patients and their relatives should be informed about the surgery. Procedures to be done before surgery;

• Patients should be evaluated in general and it should be determined whether this surgery is really necessary.
• Bladder and ureter orifices are evaluated by cystoscopy.
• Urodynamic evaluation is done
• Neurological examinations should be performed if necessary
• Since the operation will be under general anesthesia, routine blood tests are taken from the patients before the operation.
• If patients are taking blood thinners, they should be stopped one week in advance.
• If there are any medicines that they take because of other diseases, they should be taken.
• By a pediatrician in children and an internist in adults; If necessary, patients are evaluated by a cardiologist.
• Liquid food is started 2-3 days in advance, if necessary, an enema can be made before the operation.
• Preventive antibiotic treatment is started against infection.
• Oral liquid and solid food intake is stopped 5-6 hours before the operation.

How is ileocystoplasty surgery performed?

Augmentation cystoplasty is performed under general anesthesia. The bladder volume is enlarged by patching a piece of the bladder taken from the small intestine by surgery. Surgery can be performed with different methods. These methods are:

• Open surgery method
• Laparoscopic method
• Robotic method

The procedure is the same for all three methods. They are not superior to each other in terms of long-term results.

What should be considered after cystoplasty surgery?

Bladder augmentation surgery is a long major surgery. This procedure, which is done under general anesthesia, can take 3-5 hours. Postoperative;

• After the surgery, patients can stay under close follow-up in the intensive care unit for 1 night, depending on the situation.
• Vascular access is established for the patients and painkillers and antibiotic treatment are started.
• As early as possible, patients are up and walking. We usually walk patients after 5-6 hours.
• There is no oral feeding for 2-3 days after the operation, during this period the patients are fed intravenously. Then, depending on the bowel movements, liquid food is started and gradually passed to normal food.
• Intravenous feeding is given to meet the daily fluid and calorie needs of the patients.
• The catheters placed during the operation are followed and the patient’s intake and removal are recorded.
• Washing is done from the urethral catheter at regular intervals against the obstruction of the mucus secreted from the intestine.
• The bowel sounds of the patients are followed.
• If there is no problem, we usually send our patients 5-6. We discharge on the day, the urethral catheter is removed after 2-3 weeks.
• Patients do not lift heavy for 4-6 weeks, do not do heavy sports, and return to their normal lives after 3 months.

When should a doctor be called after surgery?

Patients should always be in contact with the operating doctor. Patients discharged after surgery should call their doctor if:

• If there is a high fever, chills, chills
• If fluid comes from the surgery and drain site
• In case of obstruction of the urethral tube
• If patients who have the catheter removed cannot urinate, if there is swelling in the abdomen

Who can have bladder expansion surgery?

The most important purpose in performing bladder expansion / augmentation surgery is to expand the decreased bladder capacity. Generally, this surgery is performed in the following cases:

• Patients with severely reduced bladder capacity
• Patients who have problems with bladder capacity expansion due to neurogenic reasons
• Patients with overactive bladder and painful bladder syndrome that do not respond to other treatments

Apart from this common indication:

• Patients with urinary incontinence
• Patients with very small bladder capacity (volume)
• Cases in which bladder functions are severely impaired
• If you have advanced spastic bladder disease
• Painful bladder syndrome (interstitial cystitis)
• Overactive bladder disease that does not respond to treatment
• Cases where bladder capacity is severely reduced due to inflammatory reasons.
• Radiation cystitis

Conditions requiring ileocystoplasty surgery in children;

• Spina bifida/meningomyelocele
• Posterior urethral valve
• Bladder esctrophy
• Cloacal exstrophy

Who cannot have this surgery?

Before performing ileocystoplasty, patients should be evaluated in detail. If the result of the evaluation is suitable for this surgery, the results are quite successful. We can summarize some situations in which bladder expansion surgery should not be performed as follows:

• Patients with problems in their hands. Postoperative patients may sometimes have bladder emptying problems, and the need for evacuation by urethral catheterization may occur. In this regard, patients should be able to use their hands actively. If the patient cannot do this, other methods should be tried.
• Those with severe kidney damage: Kidney functions should be normal in this type of surgery. If there is serious deterioration in kidney function, these patients should be more careful.

Can children undergo cystoplasty surgery?

This surgery can be performed on both adult and pediatric patients. In children, we mostly do it for those with small bladder capacity. It is done by both genders, male or female. Since the surgery is a major operation, it should be performed after it has been proven that it is really necessary. In the surgeries we performed on our pediatric patients, an increase in bladder capacity and an improvement in urinary leakage (VUR) to the kidneys were achieved. It is an application with successful results in suitable patients.

Should VUR surgery be performed at the same time as cystoplasty surgery?

Some patients with small bladder capacity may also have vesicoureteral reflux (VUR) at the same time. The reason for this is that due to the high intra-bladder pressure, urine flows backwards from the bladder to the ureters, towards the kidney. Studies have shown that simultaneous VUR surgery is not required during cystoplasty. It has been reported that there is no need for surgery even in high-grade VUR cases, and VUR resolves spontaneously over time.

Is augmentation cystoplasty successful in patients with overactive bladder?

There are different treatment options in overactive bladder surgery. We first start drug therapy (anticholinergic drugs) for these patients. Then, if there is no response to drug treatment, botox (botox) application or neuromodulation treatment is applied into the bladder. If these are not answered, we perform augmentation cystoplasty as the last option. In cases where the bladder volume is severely reduced, drug treatments are generally not effective and surgery is required.

Is augmentation cystoplasty successful in neurogenic bladder patients?

This surgery can be performed on suitable patients who have reduced bladder capacity and impaired storage functions of the bladder. In spastic type neurogenic bladder disease, bladder capacity is severely reduced and vesicoureteral reflux (VUR, leakage of urine from the bladder to the kidneys) may occur in these. In these cases, ileocystoplasty may be required to expand the bladder volume. The results of the surgeries performed in these patients are quite successful. After this surgery, bladder volume increases and VUR improves.

Can a kidney transplant be performed for those who have undergone augmentation cystoplasty surgery?

It is a matter of debate whether kidney transplantation can be performed in patients who have previously undergone augmentation cystoplasty due to bladder problems. If there is severe renal dysfunction in patients after this surgery and kidney transplantation is the last option, transplantation should be performed in experienced centers. Infection is a serious problem in these patients, as immunosuppressive therapy (immunosuppressive drugs) is used after kidney transplantation. When the literature on this subject is examined, there is a series of 9 patients. Catheter use should be very careful in these patients. Appropriate antibiotic prophylaxis should be done. In this way, it is possible to prevent serious complications.

How long does the surgery take, how long is the hospital stay?

Bladder augmentation surgery takes 3-5 hours on average. During this period, removal of the small intestine, re-anastomosis and patching of the bladder are performed. We usually keep our patients in the hospital for 4-6 days. The urethral catheter remains for 2-3 weeks. After 4-6 weeks, patients start their normal work. However, it is necessary to wait up to 3 months for full recovery.

What is the difference between artificial bladder and bladder expansion surgery?

In artificial bladder surgery, the entire bladder is removed. If there is bladder cancer, prostate, lymph nodes and seminal vesicle are also removed in men. In women, the uterus (womb), tubes, ovaries (ovaries), lymph nodes are removed along with the bladder. After the bladder is removed, it is replaced by a small bowel bladder. However, since there is no cancer in ileocystoplaty surgery, there is no need to remove lymph nodes and adjacent organs. The bladder remains in place. Only a piece of the small intestine is taken and the existing bladder is patched and the bladder volume is increased in this way.

What are the long-term risks of ileocystoplasty surgery?

Some serious complications develop quite rarely after a long period of ileocystoplasty surgery. Because with this surgery, we are transplanting a tissue from another system to the urinary system. As a result, some complications develop in the small intestine, where a patch is applied to the bladder, which is in contact with urine for a long time. Complications that can be seen long after ileocystoplasty, that is, augmentation surgery, are as follows:

• Urinary system stones
• Bladder cancer
• Metabolic disorders
• Bacteriuria
• Urinary incontinence
• Perforation (perforation of the urinary bladder)
• Inability to urinate and the need for a catheter
• Malabsorption
• Impairment and deficiency in the absorption of vitamin B12 and bile acids

Cancer development after augmentation cystoplasty surgery

One of the most frequently asked questions after this surgery is whether bladder cancer will develop later. In the literature, it has been reported that cancer may develop in the bladder after a long time in patients who underwent ileocystoplasty. In one study, cancer developed in the bladder 26 years after surgery. In another study, 483 bladder augmentation patients were followed for a long time and it was observed that 3 of them developed bladder muscle cancer after an average of 19 years.

These patients require close follow-up after surgery. If the cancer is detected in the early period, the cancer is completely cleared with TUR surgery. In delayed and advanced cancers, the bladder may need to be removed.

What is the success rate of bladder augmentation surgery?

This surgery is a surgery that has been performed in the world for a long time and the success rate is quite high. 90% success is achieved in surgeries performed by an experienced surgeon. In our 19-year follow-up, we have patients who are uneventful and continue their normal lives. In the studies conducted, positive results were obtained in long-term follow-ups. We can summarize them as follows:

• Urinary incontinence complaints improved
• Increased bladder capacity
• Decreased intra-bladder pressure

How long is the recovery period of the surgery?

Since this procedure is a major surgery, the recovery process is a little long. After an average of 4-6 weeks, patients return to their normal lives. Full recovery takes 12 weeks. During this period, heavy lifting and excessive exercise should be avoided.

In summary: Surgical treatment is the last option for people with advanced bladder capacity (volume) for various reasons, severely impaired and frequent need to urinate, and overactive bladder patients who cannot get results with current treatments. The most effective method of surgical treatment in these patients is ileocystoplasty. The success rate of this surgery is very high. In our patients who underwent surgery, the results were very good in long-term follow-ups and no serious complications were encountered. Since they have late complications, these patients should be regularly checked throughout their lives.

Prof. Dr. Emin OZBEK

Urology Specialist

Istanbul- TURKEY