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Augmentation Cystoplasty in the Management of Neurogenic Bladder Disease and Urinary Incontinence
0022-5347 /86/1355-0969$02,00/D THE JOURNAL
VoL PrintEd in_
UROLOGY
C0pyright © 1986 by The \iVilliams & V{ilkins Co.
AUGMENTATION CYSTOPLASTY IN THE MANAGEMENT OF NEUROGENIC BLADDER DISEASE AND URINARY INCONTINENCE J. L. LOCKHART, D. BEJANY
AND
V. A. POLITANO
From the Department of Urology, University of Miami School of Medicine and Jackson Memorial Hospital, Miami, Florida
ABSTRACT
Vesical augmentation procedures were performed on 15 patients for neurogenic bladder disease and urinary incontinence. Enterocystoplasty with ileum, cecum and sigmoid was used associated with different operations to prevent upper tract deterioration or urinary incontinence. The small bowel stored larger amounts of urine at a lower maximal detrusor pressure at capacity than the large bowel. All ureterointestinal and ureterovesical reimplantations were successful, including 5 ureteroileal with the Camey procedure. The 2 failures, characterized by persistent urinary incontinence, included a male patient who refused intermittent catheterization and a girl with persistent hypersecretion of mucus and recurrent urinary tract infections. Management of patients with a small capacity, high pressure bladder and deteriorating upper tracts has improved markedly in the last few years. Previously, these patients were followed conservatively for some time, and a great majority ended in renal failure or supravesical diversion. Improvement in care is secondary to new pharmacological therapy, intermittent catheterization and vesical augmentation procedures. 1• 2 Such operations increase the functional bladder capacity and decrease the maximal detrusor pressure at capacity, improving urinary incontinence and facilitating ureteral drainage, thus, improving upper tract deterioration. Different authors have used large and small bowel but most prefer to use large bowel when ureteral reimplantation is indicated. 2- 5 Camey and LeDuc, 6 and Lilien and Camey7 reported good results with an antireflux ureteroileal reimplantation as part of an operation to substitute the bladder with ileum after radical cystectomy. We have performed 11 antireflux ureteroileal reimplantations with an 82 per cent success rate. 8 Careful construction of the mucosal sulcus for a distance of 3 cm. without creating a tunnel is satisfactory to prevent reflux and to avoid ureteroileal obstruction. We have treated 15 patients with urinary incontinence secondary to neurogenic bladder disease. All patients presented with a small capacity bladder, with or without high maximal detrusor pressure during filling, and had failed previous therapy with pharmacological agents and intermittent catheterization. We used small and large bowel to augment the bladder capacity, associated with a variety of operations to prevent ureteral reflux or obstruction and urinary incontinence. MATERIALS AND METHOD§
Vesical augmentation procedures were performed in 15 patients with neurogenic bladder disease and urinary. incontinence. Patient age ranged between 4 and 48 years. The only adult was a woman with multiple sclerosis and the remaining patients were children or adolescents. There were 6 female and 9 male subjects. Preoperatively, all patients had been followed conservatively for many years, and all had failed previous treatment with pharmacological therapy and intermittent catheterization. Drugs most commonly used were propantheline bromide, oxybutynin and imipramine alone or in different combinations. Ephedrine sulfate in children more than 5 years old also was used without success. When some vesical residual urine was present or had develAccepted for publication December 3, 1985. Read at annual meeting of Southeastern Section, American Urological Association, Marco Island, Florida, March 17-20, 1985. 969
oped after the use of pharmacological therapy, a program of clean, intermittent self-catheterization was initiated. However, 15 of our patients failed such therapy since the incontinence persisted and they were then considered for vesical augmentation procedures. The patients with low urethral closure pressures also received either urethral reconstructive or compressive interventions. Some patients also required correction of vesicoureteral reflux or ureterovesical obstruction, Two patients were undiverted, and the bladder was augmented after a period of bladder cycling failed to improve its capacity. All 15 patients presented with a small capacity bladder (less than 150 cc) and 13 (86 per cent) also presented with elevated detrusor pressure at capacity (greater than 40 cm. water). The other 2 female patients had low intravesical pressure during filling (less than 10 cm. water) and suffered leakage at early bladder capacity (less than 100 ml.) due to urethral sphincter incompetence (13 per cent). The maximal detrusor pressure at capacity of 40 cm. water has been considered the "pressure limit" above which the upper tracts present risk of damage. 9 Of the patients 8 (53 per cent) presented with detrusor-sphincter dyssynergia preoperatively and 5 (33 per cent) voided without external sphincter interference but with poor detrusor contractility, leaving vesical residual urine. The major etiology of neurogenic bladder disease was myelomeningocele in 10 patients. Other causes included cord lipoma, Riley-Day syndrome, multiple sclerosis (the only adult patient) and spinal cord injury. In l case the etiology was unknown. The enterocystoplasty was done with ileum in 9 patients, cecum in 3 and siirmoid in 3. The vesical augmentation consisted of several associated procedures in different patients (table 1). The ileocystoplasty included 5 ureteroileal reimplantations, 7 modified ureterovesical reimplantations, 2 female urethral lengthening techniques and 5 psoas Hitch procedures. The ileocecocystoplasty was combined with 2 ileocecal nipples intussuscepting the ileocecal valve into the ileum. Concomitantly with the sigmoid cystoplasty 2 ureterosigmoid reimplantations were performed into a sigmoid conduit before undiversion and 1 periurethral polytetrafluoroethylene (Teflon) injection was done because of persistent urinary incontinence after the initial reconstruction. There were no surgical complications in any of these cases. RESULTS
Of the 9 patients in the ileocystoplasty group 8 (88 per cent) are free of incontinence (table 2). These patients perform intermittent catheterization every 4 to 8 hours successfully. No patient requires anticholinergics or detrusor relaxants to main-
970
LOCKHART, BEJANY AND POLITANO
tain urinary continence. The only incontinent patient, a 6year-old girl, has improved from the preoperative status but she still suffers leakage between catheterizations and, presently, she is considered a candidate for a periurethral polytetrafluoroethylene injection. This patient is the only one who has had persistent mucous secretion and recurrent urinary tract infections. Among all of the ureteroileal and ureterovesical reimplantations postoperative reflux or obstruction has not ocTABLE
1. Neurogenic b/,a,dder incontinence procedures associated with
enterocystoplasty No. Ileum: Antireflux ureteroileal reimplantation (Camey) Ureterovesical reimplantation Urethral lengthening (female pts.) Psoas hitch Cecum: Direct ureteroileal reimplantation with ileocecal valve nipple Sigmoid: Antireflux ureterosigmoid reimplantation Periurethral polytetrafluoroethylene injection
TABLE 2.
5 7
2 5 2
curred. All patients have satisfactory upper tract drainage without dilatation. Of the 6 patients in the cecum or sigmoid cystoplasty group 5 (83 per cent) are free of incontinence (table 2). All 5 patients are on intermittent catheterization and require anticholinergics to maintain continence. The remaining patient (17 per cent) has recurrent urinary tract infections and is the only one on chronic suppressive therapy. The 2 ureterosigmoid reimplantations have been successful but 1 of the 2 ileocecal valve intussusceptions has failed and will require further surgery to correct reflux. The incontinent patient had the bladder augmented with sigmoid and has refused intermittent catheterization (figs. 1 and 2). The mean postoperative maximum bladder capacity in 7 ileocystoplasties studied urodynamically was 480 ml. and the mean maximum bladder pressure at capacity was 18 cm. water. The mean postoperative maximum bladder capacity in all large bowel cystoplasties was 330 ml. and the mean maximum bladder pressure at capacity was 38 cm. water.
2
1
Results No. Pts. (%)
Ileocystoplasty, 9 pts.: Free of incontinence Intermittent catheterization Anticholinergics Problems with mucus Recurrent urinary tract infections Reflux or obstruction at ureteroileal or ureterovesical reimplantation Cecum or sigmoid cystoplasty, 6 pts.: Free of incontinence Intermittent catheterization Anticholinergics Recurrent urinary tract infections Reflux at ileocecal valve Reflux or obstruction at ureterosigmoid reimplantation Problems with mucus
* One of only 2 ileocecal value intussusceptions performed.
8 8 0 1 1 0
(88) (88) (0) (11) (11) (0)
5 (83) 6 (100) 6 (100) 1 (16.6)
1 (50)* 0 (0)
0 (0)
FIG. 2. Same case as in figure 1 after ileocystoplasty, left psoas hitch and bilateral ureterovesical reimplantation. A, residual bilateral caliceal clubbing, no obstruction and smooth-walled bladder. B, cystogram shows no reflux.
FIG. 1. Seventeen-year-old male youth with myelomeningocele. A, preoperative cystogram in 1980 shows bilateral grade III vesicoureteral reflux and trabeculated bladder. B, preoperative excretory urogram in 1980 reveals bilateral caliceal clubbing and no obstruction. Patient was placed on anticholinergic therapy and intermittent catheterization. C, preoperative cystogram in 1984 demonstrates bilateral vesicoureteral reflux.
971
AtJGl'V[EI.JTAT!ON CYSTOPLASTY DISCUSSION
The popularization of vesical augmentation procedures has improved markedly the care of small capacity, high pressure, neurogenic and nonneurogenic bladders. These operations were initiated more than 30 years ago in Europe but their indications were not established clearly until recently. 1- 4 The acceptance of intermittent catheterization, particularly in the management of patients with spinal cord injury, has allowed the development of several lower urinary tract reconstructive procedures that had been condemned previously. 10 However, the initial treatment of a small capacity, hyperreflexic bladder should still consist of a trial of anticholinergics and/or detrusor relaxants with or without intermittent catheterization. Among our patients with neurogenic bladder disease and inadequate bladder emptying acceptance of intermittent catheterization has been uniformly good. The initiation of an adequate intermittent catheterization program before surgical reconstruction may be of therapeutic value, and simultaneously allows the necessary training if a bladder augmentation operation might be required in the future. Persistent urinary incontinence and upper tract deterioration after treatment with pharmacological agents and intermittent catheterization have been our basic indications for bladder augmentation. Large and small bowel was used, depending on the availability and anatomy at the time of operation. Large bowel has been used more commonly by others, particularly when ureteral reimplantation was considered. 2- 5 • 11 Mitchell also believes that the anatomical blood supply of the sigmoid is better suited to his surgical technique. 2 In his experience sigmoid accommodates urine on a long-term basis well and preserves a sensation of fullness. 2 Absorption has not been reported as a major problem among different authors using large or small bowel for enterocystoplasty. Mucus production can be a problem the first 6 to 8 weeks postoperatively but in most patients this may be controlled with intermittent catheterization and vesical irrigations. Only l patient who underwent ileocystoplasty had persistent mucus hypersecretion and recurrent urinary tract infections. Since most authors have used large bowel for bladder augmentation, there is less information on the long-term value of ileum as a reservoir. Comparing our small and large bowel cystoplasties, the incidence of postoperative incontinence was similar in both groups (88 and 83 per cent), However, all of our patients with a cecum or sigmoid cystoplasty required anticholinergics and l required periurethral polytetrafluoroethylene injection to achieve continence. The maximum bladder capacities have increased markedly postoperatively and the bladder pressure at capacity has decreased in both groups of patients, In a larger series Rink and ]Mitchen obtained similar results using predominantly large boweL 3 However, the average bladder pressure was higher in the large bowel reservoir group and the small bowel stored larger amounts of urine. This is of clinical importance, since high intravesical pressure could cause upper tract damage or recurrent vesicoureteral reflux, All patients with persistently high intravesical pressure postoperatively have been started on a program of anticholinergics, intermittent catheterization and careful followup. If such therapy should fail and urinary incontinence or upper tract damage would develop, an external sphincterotomy with the placement
of an artificial urinary sphincter should be considered. 11 Only 1 female patient has had recurrent urinary tract infections and we believe that this is secondary to persistent secretion of mucus by the ileal patch. This girl is being treated with intermittent catheterization accompanied by daily bladder irrigations with sterile water. The satisfactory results reported with the ureteroileal reimplantation have created a renewed interest in the procedure. 6 • 7 We have used this operation in 11 ureteroileal reimplantations in children and adults, with an 82 per cent success rate. 8 Three children were included in the ileocystoplasty group and none has reflux or obstruction to date. If this result can be reproduced on a long-term basis in a larger number of patients, it would be an excellent alternative to the ureterosigmoid reimplantation. An important point is that we have not had to use the artificial urinary sphincter in these patients. Our male patients are continent after the enteroplasty with a program of intermittent catheterization. However, 50 per cent of our female subjects underwent a second procedure to achieve continence (2 urethral lengthening operations and 1 periurethral polytetrafluoroethylene injection). This preliminary report suggests that placement of an artificial sphincter in these patients may not be necessary, and it should be considered only if the enterocystoplasty, with the aid of intermittent catheterization and anticholinergics, fails to provide continence. Even in that situation we elect to perform periurethral polytetrafluoroethylene injection, which is technically an easier operation with fewer complications. 12
REFERENCES
l. Couvelaire, R.: Le reservoir ilea! de substitution apres la cystectomie total chez l'homme. J, d'Urol., 57: 408, 1951.
2. Mitchell, M. E.: Augmentation cystoplasty and bowel use. DiaL Ped. Urol., 7: 7, September 1984. 3, Rink, R. C. and Mitchell, M. E.: Surgical correction of urinary incontinence, J. Ped. Surg., 19: 637, 1984, 4, Turner Warwick, R. T. and Ashken, M. H.: The functional results of partial, subtotal and total cystoplasty with special reference to ureterocaecocystoplasty, selective sphincterotomy and cystocystoplasty. Brit. J. Urol., 39: 3, 1967, 5. Webster, G. D,: Unpublished data. 6, Camey, M, and LeDuc, A.: L'enterocystoplastie avec cystoprostatectomie totale pour cancer de la vessie. Ann. Urol., 13: 114, 1979. 7. Lilien, 0, M, and Camey, M,: 25-Year experience with replacement of the human bladder (Camey procedure), J. Urol., 132: 886, 1984. 8, Lockhart, J, L. and Bejany, D.: The antireflux uretero-ileal reimplantation in children and adults. J. Urol., 135: 576, 1986, 9. McGuire, K J., Woodside, J, R., Borden, T, A. and Weiss, R. M,: The prognostic value of urodynamic testing in myelodysplastic patients. J. UroL, 126: 205, 1981. 10, Lapides, J., Diokno, A. C,, Silber, S. J. and Lowe, R S,: Clean, intermittent self-catheterization in the treatment of urinary tract disease, J. UroL, 107: 458, 1972. 1 L Stephenson, T, P. and Mundy, A. R.: Treatment of the neuropathic bladder by enterocystoplasty and selective sphincterotomy or sphincter ablation and replacement. Brit. J. Urol., 57: 27, 1985. 12. Lewis, R L, Lockhart, J. L. and Politano, V. A.: Periurethral polytetrafluorethylene injection in incontinent female subjects with neurogenic bladder disease. J. Urol., 131: 459, 1984.
VoL PrintEd in_
UROLOGY
C0pyright © 1986 by The \iVilliams & V{ilkins Co.
AUGMENTATION CYSTOPLASTY IN THE MANAGEMENT OF NEUROGENIC BLADDER DISEASE AND URINARY INCONTINENCE J. L. LOCKHART, D. BEJANY
AND
V. A. POLITANO
From the Department of Urology, University of Miami School of Medicine and Jackson Memorial Hospital, Miami, Florida
ABSTRACT
Vesical augmentation procedures were performed on 15 patients for neurogenic bladder disease and urinary incontinence. Enterocystoplasty with ileum, cecum and sigmoid was used associated with different operations to prevent upper tract deterioration or urinary incontinence. The small bowel stored larger amounts of urine at a lower maximal detrusor pressure at capacity than the large bowel. All ureterointestinal and ureterovesical reimplantations were successful, including 5 ureteroileal with the Camey procedure. The 2 failures, characterized by persistent urinary incontinence, included a male patient who refused intermittent catheterization and a girl with persistent hypersecretion of mucus and recurrent urinary tract infections. Management of patients with a small capacity, high pressure bladder and deteriorating upper tracts has improved markedly in the last few years. Previously, these patients were followed conservatively for some time, and a great majority ended in renal failure or supravesical diversion. Improvement in care is secondary to new pharmacological therapy, intermittent catheterization and vesical augmentation procedures. 1• 2 Such operations increase the functional bladder capacity and decrease the maximal detrusor pressure at capacity, improving urinary incontinence and facilitating ureteral drainage, thus, improving upper tract deterioration. Different authors have used large and small bowel but most prefer to use large bowel when ureteral reimplantation is indicated. 2- 5 Camey and LeDuc, 6 and Lilien and Camey7 reported good results with an antireflux ureteroileal reimplantation as part of an operation to substitute the bladder with ileum after radical cystectomy. We have performed 11 antireflux ureteroileal reimplantations with an 82 per cent success rate. 8 Careful construction of the mucosal sulcus for a distance of 3 cm. without creating a tunnel is satisfactory to prevent reflux and to avoid ureteroileal obstruction. We have treated 15 patients with urinary incontinence secondary to neurogenic bladder disease. All patients presented with a small capacity bladder, with or without high maximal detrusor pressure during filling, and had failed previous therapy with pharmacological agents and intermittent catheterization. We used small and large bowel to augment the bladder capacity, associated with a variety of operations to prevent ureteral reflux or obstruction and urinary incontinence. MATERIALS AND METHOD§
Vesical augmentation procedures were performed in 15 patients with neurogenic bladder disease and urinary. incontinence. Patient age ranged between 4 and 48 years. The only adult was a woman with multiple sclerosis and the remaining patients were children or adolescents. There were 6 female and 9 male subjects. Preoperatively, all patients had been followed conservatively for many years, and all had failed previous treatment with pharmacological therapy and intermittent catheterization. Drugs most commonly used were propantheline bromide, oxybutynin and imipramine alone or in different combinations. Ephedrine sulfate in children more than 5 years old also was used without success. When some vesical residual urine was present or had develAccepted for publication December 3, 1985. Read at annual meeting of Southeastern Section, American Urological Association, Marco Island, Florida, March 17-20, 1985. 969
oped after the use of pharmacological therapy, a program of clean, intermittent self-catheterization was initiated. However, 15 of our patients failed such therapy since the incontinence persisted and they were then considered for vesical augmentation procedures. The patients with low urethral closure pressures also received either urethral reconstructive or compressive interventions. Some patients also required correction of vesicoureteral reflux or ureterovesical obstruction, Two patients were undiverted, and the bladder was augmented after a period of bladder cycling failed to improve its capacity. All 15 patients presented with a small capacity bladder (less than 150 cc) and 13 (86 per cent) also presented with elevated detrusor pressure at capacity (greater than 40 cm. water). The other 2 female patients had low intravesical pressure during filling (less than 10 cm. water) and suffered leakage at early bladder capacity (less than 100 ml.) due to urethral sphincter incompetence (13 per cent). The maximal detrusor pressure at capacity of 40 cm. water has been considered the "pressure limit" above which the upper tracts present risk of damage. 9 Of the patients 8 (53 per cent) presented with detrusor-sphincter dyssynergia preoperatively and 5 (33 per cent) voided without external sphincter interference but with poor detrusor contractility, leaving vesical residual urine. The major etiology of neurogenic bladder disease was myelomeningocele in 10 patients. Other causes included cord lipoma, Riley-Day syndrome, multiple sclerosis (the only adult patient) and spinal cord injury. In l case the etiology was unknown. The enterocystoplasty was done with ileum in 9 patients, cecum in 3 and siirmoid in 3. The vesical augmentation consisted of several associated procedures in different patients (table 1). The ileocystoplasty included 5 ureteroileal reimplantations, 7 modified ureterovesical reimplantations, 2 female urethral lengthening techniques and 5 psoas Hitch procedures. The ileocecocystoplasty was combined with 2 ileocecal nipples intussuscepting the ileocecal valve into the ileum. Concomitantly with the sigmoid cystoplasty 2 ureterosigmoid reimplantations were performed into a sigmoid conduit before undiversion and 1 periurethral polytetrafluoroethylene (Teflon) injection was done because of persistent urinary incontinence after the initial reconstruction. There were no surgical complications in any of these cases. RESULTS
Of the 9 patients in the ileocystoplasty group 8 (88 per cent) are free of incontinence (table 2). These patients perform intermittent catheterization every 4 to 8 hours successfully. No patient requires anticholinergics or detrusor relaxants to main-
970
LOCKHART, BEJANY AND POLITANO
tain urinary continence. The only incontinent patient, a 6year-old girl, has improved from the preoperative status but she still suffers leakage between catheterizations and, presently, she is considered a candidate for a periurethral polytetrafluoroethylene injection. This patient is the only one who has had persistent mucous secretion and recurrent urinary tract infections. Among all of the ureteroileal and ureterovesical reimplantations postoperative reflux or obstruction has not ocTABLE
1. Neurogenic b/,a,dder incontinence procedures associated with
enterocystoplasty No. Ileum: Antireflux ureteroileal reimplantation (Camey) Ureterovesical reimplantation Urethral lengthening (female pts.) Psoas hitch Cecum: Direct ureteroileal reimplantation with ileocecal valve nipple Sigmoid: Antireflux ureterosigmoid reimplantation Periurethral polytetrafluoroethylene injection
TABLE 2.
5 7
2 5 2
curred. All patients have satisfactory upper tract drainage without dilatation. Of the 6 patients in the cecum or sigmoid cystoplasty group 5 (83 per cent) are free of incontinence (table 2). All 5 patients are on intermittent catheterization and require anticholinergics to maintain continence. The remaining patient (17 per cent) has recurrent urinary tract infections and is the only one on chronic suppressive therapy. The 2 ureterosigmoid reimplantations have been successful but 1 of the 2 ileocecal valve intussusceptions has failed and will require further surgery to correct reflux. The incontinent patient had the bladder augmented with sigmoid and has refused intermittent catheterization (figs. 1 and 2). The mean postoperative maximum bladder capacity in 7 ileocystoplasties studied urodynamically was 480 ml. and the mean maximum bladder pressure at capacity was 18 cm. water. The mean postoperative maximum bladder capacity in all large bowel cystoplasties was 330 ml. and the mean maximum bladder pressure at capacity was 38 cm. water.
2
1
Results No. Pts. (%)
Ileocystoplasty, 9 pts.: Free of incontinence Intermittent catheterization Anticholinergics Problems with mucus Recurrent urinary tract infections Reflux or obstruction at ureteroileal or ureterovesical reimplantation Cecum or sigmoid cystoplasty, 6 pts.: Free of incontinence Intermittent catheterization Anticholinergics Recurrent urinary tract infections Reflux at ileocecal valve Reflux or obstruction at ureterosigmoid reimplantation Problems with mucus
* One of only 2 ileocecal value intussusceptions performed.
8 8 0 1 1 0
(88) (88) (0) (11) (11) (0)
5 (83) 6 (100) 6 (100) 1 (16.6)
1 (50)* 0 (0)
0 (0)
FIG. 2. Same case as in figure 1 after ileocystoplasty, left psoas hitch and bilateral ureterovesical reimplantation. A, residual bilateral caliceal clubbing, no obstruction and smooth-walled bladder. B, cystogram shows no reflux.
FIG. 1. Seventeen-year-old male youth with myelomeningocele. A, preoperative cystogram in 1980 shows bilateral grade III vesicoureteral reflux and trabeculated bladder. B, preoperative excretory urogram in 1980 reveals bilateral caliceal clubbing and no obstruction. Patient was placed on anticholinergic therapy and intermittent catheterization. C, preoperative cystogram in 1984 demonstrates bilateral vesicoureteral reflux.
971
AtJGl'V[EI.JTAT!ON CYSTOPLASTY DISCUSSION
The popularization of vesical augmentation procedures has improved markedly the care of small capacity, high pressure, neurogenic and nonneurogenic bladders. These operations were initiated more than 30 years ago in Europe but their indications were not established clearly until recently. 1- 4 The acceptance of intermittent catheterization, particularly in the management of patients with spinal cord injury, has allowed the development of several lower urinary tract reconstructive procedures that had been condemned previously. 10 However, the initial treatment of a small capacity, hyperreflexic bladder should still consist of a trial of anticholinergics and/or detrusor relaxants with or without intermittent catheterization. Among our patients with neurogenic bladder disease and inadequate bladder emptying acceptance of intermittent catheterization has been uniformly good. The initiation of an adequate intermittent catheterization program before surgical reconstruction may be of therapeutic value, and simultaneously allows the necessary training if a bladder augmentation operation might be required in the future. Persistent urinary incontinence and upper tract deterioration after treatment with pharmacological agents and intermittent catheterization have been our basic indications for bladder augmentation. Large and small bowel was used, depending on the availability and anatomy at the time of operation. Large bowel has been used more commonly by others, particularly when ureteral reimplantation was considered. 2- 5 • 11 Mitchell also believes that the anatomical blood supply of the sigmoid is better suited to his surgical technique. 2 In his experience sigmoid accommodates urine on a long-term basis well and preserves a sensation of fullness. 2 Absorption has not been reported as a major problem among different authors using large or small bowel for enterocystoplasty. Mucus production can be a problem the first 6 to 8 weeks postoperatively but in most patients this may be controlled with intermittent catheterization and vesical irrigations. Only l patient who underwent ileocystoplasty had persistent mucus hypersecretion and recurrent urinary tract infections. Since most authors have used large bowel for bladder augmentation, there is less information on the long-term value of ileum as a reservoir. Comparing our small and large bowel cystoplasties, the incidence of postoperative incontinence was similar in both groups (88 and 83 per cent), However, all of our patients with a cecum or sigmoid cystoplasty required anticholinergics and l required periurethral polytetrafluoroethylene injection to achieve continence. The maximum bladder capacities have increased markedly postoperatively and the bladder pressure at capacity has decreased in both groups of patients, In a larger series Rink and ]Mitchen obtained similar results using predominantly large boweL 3 However, the average bladder pressure was higher in the large bowel reservoir group and the small bowel stored larger amounts of urine. This is of clinical importance, since high intravesical pressure could cause upper tract damage or recurrent vesicoureteral reflux, All patients with persistently high intravesical pressure postoperatively have been started on a program of anticholinergics, intermittent catheterization and careful followup. If such therapy should fail and urinary incontinence or upper tract damage would develop, an external sphincterotomy with the placement
of an artificial urinary sphincter should be considered. 11 Only 1 female patient has had recurrent urinary tract infections and we believe that this is secondary to persistent secretion of mucus by the ileal patch. This girl is being treated with intermittent catheterization accompanied by daily bladder irrigations with sterile water. The satisfactory results reported with the ureteroileal reimplantation have created a renewed interest in the procedure. 6 • 7 We have used this operation in 11 ureteroileal reimplantations in children and adults, with an 82 per cent success rate. 8 Three children were included in the ileocystoplasty group and none has reflux or obstruction to date. If this result can be reproduced on a long-term basis in a larger number of patients, it would be an excellent alternative to the ureterosigmoid reimplantation. An important point is that we have not had to use the artificial urinary sphincter in these patients. Our male patients are continent after the enteroplasty with a program of intermittent catheterization. However, 50 per cent of our female subjects underwent a second procedure to achieve continence (2 urethral lengthening operations and 1 periurethral polytetrafluoroethylene injection). This preliminary report suggests that placement of an artificial sphincter in these patients may not be necessary, and it should be considered only if the enterocystoplasty, with the aid of intermittent catheterization and anticholinergics, fails to provide continence. Even in that situation we elect to perform periurethral polytetrafluoroethylene injection, which is technically an easier operation with fewer complications. 12
REFERENCES
l. Couvelaire, R.: Le reservoir ilea! de substitution apres la cystectomie total chez l'homme. J, d'Urol., 57: 408, 1951.
2. Mitchell, M. E.: Augmentation cystoplasty and bowel use. DiaL Ped. Urol., 7: 7, September 1984. 3, Rink, R. C. and Mitchell, M. E.: Surgical correction of urinary incontinence, J. Ped. Surg., 19: 637, 1984, 4, Turner Warwick, R. T. and Ashken, M. H.: The functional results of partial, subtotal and total cystoplasty with special reference to ureterocaecocystoplasty, selective sphincterotomy and cystocystoplasty. Brit. J. Urol., 39: 3, 1967, 5. Webster, G. D,: Unpublished data. 6, Camey, M, and LeDuc, A.: L'enterocystoplastie avec cystoprostatectomie totale pour cancer de la vessie. Ann. Urol., 13: 114, 1979. 7. Lilien, 0, M, and Camey, M,: 25-Year experience with replacement of the human bladder (Camey procedure), J. Urol., 132: 886, 1984. 8, Lockhart, J, L. and Bejany, D.: The antireflux uretero-ileal reimplantation in children and adults. J. Urol., 135: 576, 1986, 9. McGuire, K J., Woodside, J, R., Borden, T, A. and Weiss, R. M,: The prognostic value of urodynamic testing in myelodysplastic patients. J. UroL, 126: 205, 1981. 10, Lapides, J., Diokno, A. C,, Silber, S. J. and Lowe, R S,: Clean, intermittent self-catheterization in the treatment of urinary tract disease, J. UroL, 107: 458, 1972. 1 L Stephenson, T, P. and Mundy, A. R.: Treatment of the neuropathic bladder by enterocystoplasty and selective sphincterotomy or sphincter ablation and replacement. Brit. J. Urol., 57: 27, 1985. 12. Lewis, R L, Lockhart, J. L. and Politano, V. A.: Periurethral polytetrafluorethylene injection in incontinent female subjects with neurogenic bladder disease. J. Urol., 131: 459, 1984.