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Laparoscopic Retropubic Auto-Augmentation of the Bladder
0022-5347/95/1531-0123$03.00/0
THEJOURNAL OF UROLOGY Copyright 0 1995 by AMERICAN UROLOGICAL ASSOCIATION, INC
Vol. 153, 123-126, January 1995 Printed in U.S.A.
Urologists At Work LAPAROSCOPIC RETROPUBIC AUTO-AUGMENTATION OF THE BLADDER ELSPETH M. McDOUGALL, RALPH V. CLAMMAN, ROBERT S. FIGENSHAU AND MARGARET S. PEARLE From the Division of Urologic Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
ABSTRACT
The small capacity or contracted bladder is a difficult management problem. The goal of bladder augmentation is to create a storage structure with an adequate capacity and low pressure. Bladder auto-augmentation creates a large bladder diverticulum by partially excising the detrusor muscle. We report our initial experience with an extraperitoneal approach to laparoscopic auto-augmentation in a patient with a small contracted bladder. This is a technically feasible operation but longer clinical followup is necessary to determine its durability in the management of the small contracted bladder. KEY WORDS:bladder diseases, urinary diversion, peritoneoscopy The small capacity or contracted bladder can be a difficult management dilemma for the urologist. This clinical entity can be seen with neurological deficits, such as meningomyeloceles, traumatic spinal cord lesions and demyelinating diseases. However, nonneurogenic pathological conditions can also result in a contracted bladder, including interstitial cystitis, post-radiation therapy to the pelvis and occasionally idiopathic causes. Bladder augmentation attempts to create a bladder with adequate storage capacity and low storage pressure. Various surgical gastrointestinal segments have been used for this purpose. However, in 1989 Cartwright and Snow described the concept of creating a large bladder diverticulum by partially excising the detrusor muscle and thereby performing a bladder auto-augmentation.' More recently, Ehrlich and Gershman reported a transabdominal, laparoscopic seromyotomy (auto-augmentation) in a young boy with a nonneurogenic neurogenic bladder with good clinical results.2 We report our initial clinical experience with an extraperitoneal approach to laparoscopic auto-augmentation in a patient with a small contracted bladder.
monas aeruginosa, which was successfully treated with a course of parenteral gentamicin. Urodynamic assessment with a cystometrogram and pressure flow study revealed a poorly compliant bladder with a steady increase in intravesical pressure immediately upon filling. The initial bladder pressure was 6 to 8 cm.water, which increased rapidly to 40 cm. water at 85 cc of filling. Urine leakage occurred at 85 cc. The leak point pressure of the bladder was less than 60 cm. water. With the bladder neck occluded during filling, the bladder pressure increased to 70 to 80 cm. water with no uninhibited contractions (fig. 1). Urine leaked with coughing and Valsalva's maneuver. The post-void residual volume was 30 cc. Serum creatinine level was 0.7mg./dl. and serum electrolytes were all within normal limits. Excretory urography revealed normal upper tracts. Cystoscopy showed chronic bladder inflammation consistent with the indwelling catheter but no evidence of trabeculation, cellule formation or diverticula. The bladder neck and internal sphincter appeared intact. Management options were discussed extensively with the patient, who elected to undergo laparoscopic auto-augmenta-
CASE HISTORY
A 26-year-old white woman was involved in a motor vehicle accident 10 years ago in which she sustained a lower lumbar spinal injury requiring Hanington rod stabilization and L1 to L2 fusion. The rods were removed in 1984. Following the accident she experienced lower limb paralysis that lasted approximately 5 months before it gradually resolved. At presentation she was fully ambulatory but had residual neurological deficit in the sacral nerve distribution as evidenced by decreased perineal sensation and had been treated with an indwelling Foley catheter. During the months before presentation she had experienced increasing urine leakage around the Foley catheter and recurrent urinary tract infections. The remainder of the medical history was unremarkable. Physical examination was unremarkable except for decreased perineal sensation, decreased anal tone and an indwelling 18F Foley catheter. Urine culture revealed PseudoAccepted for publication July 22, 1994.
100
200
900
volurw, cc.
FIG.1. Preoperative urodynamics show that on initial bladder filling intravesical pressure was 6 to 8 cm. water, which increased rapidly to 70 to 80 em. water pressure at volume of 85 to 100 ~ e . 123
124
LAPAROSCOPIC RETROPUBIC AUTO-AUGMENTATION OF BLADDER
tion of the bladder. She understood that this would be our initial attempt at this procedure and that if difficulties were encountered a n enterocystoplasty would be performed. TECHNIQUE
Immediately before the planned laparoscopic procedure the patient underwent cystoscopy with bilateral double pigtail ureteral stent insertion. She was then placed in the supine position with the legs abducted on spreader bars. The abdomen and perineum were prepared in the sterile field. A 5F angiographic catheter was passed through the lumen of an 18F Council1 catheter. The small finger of a size 8, sterile, latex surgical glove was secured on the end of the 5F catheter with 2, 1-zero silk ligatures. The Foley catheter with the glove-covered tip of the 5F catheter protruding from the end was inserted into the bladder and placed to dependent drainage. The bladder was approached in a n entirely extraperitoneal manner. A skin incision was made in the midline midway between the umbilicus and symphysis pubis, and the subcutaneous tissue was bluntly dissected to expose the anterior abdominal fascia. Stay sutures of 1-zero polyglactin were placed on the superior and inferior aspects of the exposed anterior abdominal fascia, and a n incision was made in the fascia between the 2 stay sutures. Blunt finger dissection under the anterior fascia, between the bodies of the abdominis rectus muscles, allowed the retropubic space to be dissected bluntly along the posterior symphysis pubis to create a space within these fatty tissues. This space was further developed by balloon distention. A homemade dilating balloon catheter was constructed by tying the middle finger of a size 8 sterile, latex surgical glove onto the end of a 16F red rubber catheter with 2, 1-zero silk ligatures. This balloon catheter was back loaded into a 30F Amplatz sheath and the unit was inserted through the incision into the retropubic space. The Amplatz sheath, which assists in accurately directing the balloon, was withdrawn, leaving the balloon tip of the catheter in the retropubic space. The balloon was then inflated with 1 1. normal saline and emptied using suction, and the balloon catheter was removed. A blunt tip, disposable Hasson-type port was inserted into the retropubic space and secured to the incision by wrapping the 1-zero polyglactin stay sutures around the side arms of the port. Carbon dioxide insumation was then performed to 15 mm. Hg pressure. A 30-degree, 10 mm. laparoscope was inserted through this port and the retropubic space was examined. Our experience with laparoscopy has proved the 30-degree laparoscope to be a more versatile instrument, particularly for pelvic procedures. The posterior symphysis pubis with a small amount of adherent fatty tissue was easily identified. Gentle tugging on the Foley catheter at the urethral meatus allowed for identification of the urethra and catheter balloon at the bladder neck. Additional ports were then inserted under direct laparoscopic visualization: a 12 mm. port on the same horizontal level as the primary port at the lateral border of the left abdominis rectus muscle, a 5 mm. port at the same horizontal level as the primary port a t the lateral border of the right abdominis rectus muscle and a 5 mm. port approximately 2 cm. above the symphysis pubis at the lateral border of the left abdominis rectus muscle. The 12 mm. port is necessary for introduction of the laparoscopic clip applier. All ports were secured to the skin with a No. 2 polypropylene suture. Grasping forceps and electrocautery scissors were then used to dissect the anterior bladder from surrounding fatty tissues. This dissection was extended around both later-a1 walls of the bladder and over the dome to expose the back wall of the bladder. At the extreme lateral aspects of the dissection, electrocautew was used to achieve hemostasis at the point where the superior vesical vessels entered the bladder.
After the bladder was completely freed on the anterior, lateral and posterior aspects, the balloon on the end of the 5F angiographic catheter was inflated with 60 cc normal saline. Electrocautery was then used to score along the midline of the bladder from the bladder neck, over the dome and continuing along the back wall. A 3F right angle Greenwald electrode was used to incise the detrusor muscle down to but not through the mucosa (fig. 2, A). This dissection was continued laterally on both sides to free the detrusor muscle completely from the underlying bladder mucosa. The balloon inflated within the bladder facilitated this dissection, and allowed the plane between the mucosa and detrusor muscle to be easily identified. Detrusor flaps were developed bilaterally such that they could be loosely reflected back to the respective side wall of the pelvis in the region of Cooper’s ligament (fig. 2, B ) . A 6-inch length of 1-zero polyglactin on an SH needle was secured with a laparoscopic suture clip on the end of the suture. The needle and suture were passed through Cooper’s ligament on the right side of the pelvis. The suture was then passed through the edge of the right flap of the detrusor muscle and tightened down, drawing the edge of the detrusor flap against the pelvic side wall. A laparoscopic suture clip was placed on the suture as it exited the detrusor. This technique was repeated on the left side, tacking the left detrusor muscle flap onto the left pelvic side wall. This maneuver provided excellent exposure of the mucosa anteriorly and at the dome of the bladder. The retropubic space pressure was then decreased to 5 mm. Hg and the surgical sites were examined for hemostasis. The ports were removed un-
A
B
FIG. 2. A, detrusor muscle was incised down to but not through mucosa in midline. B . detrusor flaos were dissected from bladder mucosa and sutured back to respeciive side wall of pelvis.
LAPAROSCOPIC RETROPUBIC AUTO-AUGMENTATION OF BLADDER der laparoscopic visualization and the fascia of the 12 mm. ports was closed with a figure-of-8, 1-zero polyglactin suture. The blunt tip port was removed last under direct visualization and the fascia was approximated using the 2, 1-zero polyglactin stay sutures. The skin edges of the 12 mm. ports were approximated with a 4-2121-0absorbable subcuticular suture. The 5F angiographic catheter with the 80 cc inflated balloon was maintained postoperatively and the Foley catheter was placed to dependent drainage. Operating time was 6.5 hours. Estimated blood loss during the procedure was 75 cc. The patient resumed oral intake 12 hours postoperatively and was discharged home with both catheters and both ureteral stents in place on postoperative day 2, with a maintenance dose of ciprofloxacin. She received a total of 350 mg. meperidine hydrochloride and 8 tablets of oxycodone hydrochloride with acetaminophen in the hospital for control of postoperative discomfort. RESULTS
The patient returned for followup 2 weeks postoperatively. At that time the 5F catheter and balloon, and Foley catheter were removed. Flexible cystoscopy was performed t o remove the indwelling ureteral stents. The bladder appeared intact but exhibited some mild inflammation secondary to the catheters. We chose to wait 1month postoperatively before intermittent self-catheterization was begun. Therefore, a Foley bladder catheter was replaced for another 2 weeks. At 4 weeks postoperatively a cystogram revealed an intact bladder with no extravasation. The Foley catheter was removed and the patient began intermittent self-catheterization. She was also placed on 5 mg. oxybutynin 3 times a day. At 9 weeks Pseudomonas aeruginosa urinary tract infection recurred, which was treated with appropriate parenteral antibiotics. She was performing intermittent self-catheterization every 3 hours during the day and remained dry between catheterizations. She was experiencing some occasional nighttime leakage, which was resolved by limiting evening fluid intake. At 6 months the patient had a normal cystogram (fig. 3). Urodynamics revealed a compliant bladder with a bladder pressure of 4 cm. water at 200 cc that increased to 18 cm. water at 300 cc pressure (fig. 4). The patient had a strong sensation to void at 375 cc. Leakage occurred at 285 to 300 cc. The leak point pressure was tested and there was no leakage up to a bladder pressure of 80 cm. water. There were no involuntary detrusor contractions. Total bladder capacity was 350 cc and she voided by Valsalva’s maneu-
loo
125
200
vokme cc.
FIG. 4. Urodynamics 9 weeks following laparoscopic bladder autoaugmentation demonstrates intravesical pressure of only 4 cm. water on filling to 200 cc. Continued bladder filling to 300 cc increased intravesical pressure to 18 cm. water without any evidence of uninhibited detrusor contractions.
ver with a residual of 30 cc. The patient has discontinued intermittent self-catheterization and voids by Valsalva’s maneuver every 3 hours. She remains dry day and night. DISCUSSION
The small contracted bladder can present clinically in the pediatric or adult urological patient with associated debilitating urinary incontinence. In the most severe cases anticholinergic therapy provides minimal relief of symptoms for these patients. The goal of bladder augmentation is to create a storage structure with an adequate capacity and low pressure. Historically, enterocystoplasty has used various gastrointestinal segments, including the stomach, jejunum, ileum, cecum and colon. However, these operations have been complicated by significant electrolyte abnormalities, as well as urinary extravasation, abscess formation, abundant mucous production, enteric fistula and peritoneal adhesions. In an effort to preclude bowel interposition, laboratory and clinical studies have been completed with a variety of materials to augment the bladder (omentum, peritoneum, human dura and placental m e r n b r a n e ~ )These . ~ ~ materials have usually been placed on the incised or partially excised bladder wall. Unfortunately, none of these materials has been entirely successful and, therefore, clinical application has generally not occurred. Cartwright and Snow originally described the technique of partially excising the detrusor muscle in the dog to create a diverticular bulge of the bladder mucosa, thereby increasing urine storage volumes at low pressure.’ Their subsequent report of the clinical application of this same technique in 7 children showed significant urodynamic improvement in 5 (71%),with increased capacity and/or decreased storage pressures.l A recent report by Snow and Cartwright indicated that 3 months to 4 years following auto-augmentation of the bladder 80% of the patients in their expanded series were continent and another 10% had significant improvement in c~ntinence.~ Interestingly, a significant increase in bladder capacity (greater than 150 cc) occurred in only 40% of their patients, while 35%had minimal change (0 to 60 cc) and 25%actually had a decrease (from 160 to 125 cc). Therefore, the procedure may be of benefit due to factors beyond an increase in bladder capacity, specifically the dissection of the bladder may have some beneficial denervating effect on the detrusor function. Ehrlich and Gershman first reported transperitoneal laparoscopic bladder auto-augmentation in an 8-year-old boy with a nonneurogenic neurogenic bladder, urodynamically FIG. 3. Cystogram 6 months after laparoscopic bladder auto-aug- characterized by limited capacity and high intravesical pressures associated with incontinence? The boy was continent 3 mentation shows normal-appearing bladder.
126
LAPAROSCOPIC RETROPUBIC AUTO-AUGMENTATION OF BLADDER
months postoperatively but postoperative urodynamics or cystography was not obtainable. In our first clinical experience with laparoscopic auto-augmentation of the bladder we elected to perform the autoaugmentation through an entirely retropubic approach to facilitate any later need for enterocystoplasty. We believe that by avoiding the peritoneal cavity, the risk of postoperative bowel adhesions should be minimized. Also, this could preclude subsequent intraperitoneal extravasation should the patient have difficulty with intermittent catheterization and perforate the thin back wall of the bladder. The extraperitoneal approach precludes the need for postoperative drains, even with a small mucosal tear, since Foley catheter drainage of the bladder is acceptable management of this clinical situation until bladder healing is confirmed by cystography. The report by Cartwright and Snow included excision of the detrusor muscle from the bladder mucosa, suturing of the detrusor to the side walls of the pelvis and a psoas hitch. In our laparoscopic procedure we elected to do only 1 of these 3 maneuvers (tacking the detrusor to the pelvic side wall). Furthermore, to decrease any restrictive fibrosis around the region of the detrusor excision in our patient we elected to maintain bladder distention by leaving the 5F,80 cc balloon inflated within the bladder for 2 weeks postoperatively. However, preliminary animal studies would suggest that this is not necessary if the detrusor flap is securely sutured to the pelvic side wall. Clinical experience with the open surgical approach to bladder auto-augmentation has not involved use of postoperative bladder distention and, therefore, this step in the laparoscopic technique may not be necessary. The urodynamic results in our patient at 9 weeks and 6 months postoperatively are consistent with the findings occurring after open bladder auto-a~gmentation.~ The improvement in bladder capacity (+150 cc) and decrease in intravesical pressures in our patient postoperatively were dramatic. The end result has been most satisfactory, since she is continent and catheter-free for the first time in a
decade. However, continued close followup is important to assess the durability of this minimally invasive approach. CONCLUSION
Extraperitoneal laparoscopic auto-augmentation of the bladder is a technically feasible operation. Our solitary patient had a brief hospital stay, minimal postoperative discomfort, and good improvement in bladder capacity, intravesical storage pressures and continence. The extraperitoneal approach should not complicate or preclude subsequent enterocystoplasty if necessary. Clinical followup is needed t o determine the durability of this procedure in the management of the small contracted bladder. REFERENCES
1. Cartwright, P. C. and Snow, B. W.: Bladder autoaugmentation: early clinical experience. J. Urol., part 2, 142:505, 1989. 2. Ehrlich, R. M. and Gershman, A,: Laparoscopic seromyotomy
(auto-augmentation)for non-neurogenic neurogenic bladder in a child: initial case report. Urology, 42: 175, 1993. 3. Goldstein, M. B. and Dearden, L. C.: Histology of omentoplasty of the urinary bladder in the rabbit. Invest. Urol., 3: 460,1966. 4. Telly, 0.: Segmental cystectomy with peritoneoplasty. Urol. Int., 2 6 236, 1970. 5. Novick, A. C., Straf€on, R. A., Banowsky, L. H., Nose, Y., Levin, H. and Stewart, B. H.: Experimental bladder substitution using biodegradable graft of natural tissue. Urology, 1 0 118, 1977. 6. Kelami, A,: Lyophilized human dura as a bladder wall substitute: experimental and clinical results. J. Urol., 105 518, 1971. 7. Fishman, I. J., Flores, F. N., Scott, F. B., Spjut, H. J. and
Morrow, B.: Use of fresh placental membranes for bladder reconstruction.J. Urol., 138 1291, 1987. 8. Cartwright, P. C. and Snow, B. W.: Bladder autoaugmentation: partial detrusor excision to augment the bladder without use of bowel. J. Urol., 142: 1050, 1989. 9. Snow, B. W. and Cartwright, P. C.: Autoaugmentation of the bladder. Contemp. Urol., 4:41, 1992.
THEJOURNAL OF UROLOGY Copyright 0 1995 by AMERICAN UROLOGICAL ASSOCIATION, INC
Vol. 153, 123-126, January 1995 Printed in U.S.A.
Urologists At Work LAPAROSCOPIC RETROPUBIC AUTO-AUGMENTATION OF THE BLADDER ELSPETH M. McDOUGALL, RALPH V. CLAMMAN, ROBERT S. FIGENSHAU AND MARGARET S. PEARLE From the Division of Urologic Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
ABSTRACT
The small capacity or contracted bladder is a difficult management problem. The goal of bladder augmentation is to create a storage structure with an adequate capacity and low pressure. Bladder auto-augmentation creates a large bladder diverticulum by partially excising the detrusor muscle. We report our initial experience with an extraperitoneal approach to laparoscopic auto-augmentation in a patient with a small contracted bladder. This is a technically feasible operation but longer clinical followup is necessary to determine its durability in the management of the small contracted bladder. KEY WORDS:bladder diseases, urinary diversion, peritoneoscopy The small capacity or contracted bladder can be a difficult management dilemma for the urologist. This clinical entity can be seen with neurological deficits, such as meningomyeloceles, traumatic spinal cord lesions and demyelinating diseases. However, nonneurogenic pathological conditions can also result in a contracted bladder, including interstitial cystitis, post-radiation therapy to the pelvis and occasionally idiopathic causes. Bladder augmentation attempts to create a bladder with adequate storage capacity and low storage pressure. Various surgical gastrointestinal segments have been used for this purpose. However, in 1989 Cartwright and Snow described the concept of creating a large bladder diverticulum by partially excising the detrusor muscle and thereby performing a bladder auto-augmentation.' More recently, Ehrlich and Gershman reported a transabdominal, laparoscopic seromyotomy (auto-augmentation) in a young boy with a nonneurogenic neurogenic bladder with good clinical results.2 We report our initial clinical experience with an extraperitoneal approach to laparoscopic auto-augmentation in a patient with a small contracted bladder.
monas aeruginosa, which was successfully treated with a course of parenteral gentamicin. Urodynamic assessment with a cystometrogram and pressure flow study revealed a poorly compliant bladder with a steady increase in intravesical pressure immediately upon filling. The initial bladder pressure was 6 to 8 cm.water, which increased rapidly to 40 cm. water at 85 cc of filling. Urine leakage occurred at 85 cc. The leak point pressure of the bladder was less than 60 cm. water. With the bladder neck occluded during filling, the bladder pressure increased to 70 to 80 cm. water with no uninhibited contractions (fig. 1). Urine leaked with coughing and Valsalva's maneuver. The post-void residual volume was 30 cc. Serum creatinine level was 0.7mg./dl. and serum electrolytes were all within normal limits. Excretory urography revealed normal upper tracts. Cystoscopy showed chronic bladder inflammation consistent with the indwelling catheter but no evidence of trabeculation, cellule formation or diverticula. The bladder neck and internal sphincter appeared intact. Management options were discussed extensively with the patient, who elected to undergo laparoscopic auto-augmenta-
CASE HISTORY
A 26-year-old white woman was involved in a motor vehicle accident 10 years ago in which she sustained a lower lumbar spinal injury requiring Hanington rod stabilization and L1 to L2 fusion. The rods were removed in 1984. Following the accident she experienced lower limb paralysis that lasted approximately 5 months before it gradually resolved. At presentation she was fully ambulatory but had residual neurological deficit in the sacral nerve distribution as evidenced by decreased perineal sensation and had been treated with an indwelling Foley catheter. During the months before presentation she had experienced increasing urine leakage around the Foley catheter and recurrent urinary tract infections. The remainder of the medical history was unremarkable. Physical examination was unremarkable except for decreased perineal sensation, decreased anal tone and an indwelling 18F Foley catheter. Urine culture revealed PseudoAccepted for publication July 22, 1994.
100
200
900
volurw, cc.
FIG.1. Preoperative urodynamics show that on initial bladder filling intravesical pressure was 6 to 8 cm. water, which increased rapidly to 70 to 80 em. water pressure at volume of 85 to 100 ~ e . 123
124
LAPAROSCOPIC RETROPUBIC AUTO-AUGMENTATION OF BLADDER
tion of the bladder. She understood that this would be our initial attempt at this procedure and that if difficulties were encountered a n enterocystoplasty would be performed. TECHNIQUE
Immediately before the planned laparoscopic procedure the patient underwent cystoscopy with bilateral double pigtail ureteral stent insertion. She was then placed in the supine position with the legs abducted on spreader bars. The abdomen and perineum were prepared in the sterile field. A 5F angiographic catheter was passed through the lumen of an 18F Council1 catheter. The small finger of a size 8, sterile, latex surgical glove was secured on the end of the 5F catheter with 2, 1-zero silk ligatures. The Foley catheter with the glove-covered tip of the 5F catheter protruding from the end was inserted into the bladder and placed to dependent drainage. The bladder was approached in a n entirely extraperitoneal manner. A skin incision was made in the midline midway between the umbilicus and symphysis pubis, and the subcutaneous tissue was bluntly dissected to expose the anterior abdominal fascia. Stay sutures of 1-zero polyglactin were placed on the superior and inferior aspects of the exposed anterior abdominal fascia, and a n incision was made in the fascia between the 2 stay sutures. Blunt finger dissection under the anterior fascia, between the bodies of the abdominis rectus muscles, allowed the retropubic space to be dissected bluntly along the posterior symphysis pubis to create a space within these fatty tissues. This space was further developed by balloon distention. A homemade dilating balloon catheter was constructed by tying the middle finger of a size 8 sterile, latex surgical glove onto the end of a 16F red rubber catheter with 2, 1-zero silk ligatures. This balloon catheter was back loaded into a 30F Amplatz sheath and the unit was inserted through the incision into the retropubic space. The Amplatz sheath, which assists in accurately directing the balloon, was withdrawn, leaving the balloon tip of the catheter in the retropubic space. The balloon was then inflated with 1 1. normal saline and emptied using suction, and the balloon catheter was removed. A blunt tip, disposable Hasson-type port was inserted into the retropubic space and secured to the incision by wrapping the 1-zero polyglactin stay sutures around the side arms of the port. Carbon dioxide insumation was then performed to 15 mm. Hg pressure. A 30-degree, 10 mm. laparoscope was inserted through this port and the retropubic space was examined. Our experience with laparoscopy has proved the 30-degree laparoscope to be a more versatile instrument, particularly for pelvic procedures. The posterior symphysis pubis with a small amount of adherent fatty tissue was easily identified. Gentle tugging on the Foley catheter at the urethral meatus allowed for identification of the urethra and catheter balloon at the bladder neck. Additional ports were then inserted under direct laparoscopic visualization: a 12 mm. port on the same horizontal level as the primary port at the lateral border of the left abdominis rectus muscle, a 5 mm. port at the same horizontal level as the primary port a t the lateral border of the right abdominis rectus muscle and a 5 mm. port approximately 2 cm. above the symphysis pubis at the lateral border of the left abdominis rectus muscle. The 12 mm. port is necessary for introduction of the laparoscopic clip applier. All ports were secured to the skin with a No. 2 polypropylene suture. Grasping forceps and electrocautery scissors were then used to dissect the anterior bladder from surrounding fatty tissues. This dissection was extended around both later-a1 walls of the bladder and over the dome to expose the back wall of the bladder. At the extreme lateral aspects of the dissection, electrocautew was used to achieve hemostasis at the point where the superior vesical vessels entered the bladder.
After the bladder was completely freed on the anterior, lateral and posterior aspects, the balloon on the end of the 5F angiographic catheter was inflated with 60 cc normal saline. Electrocautery was then used to score along the midline of the bladder from the bladder neck, over the dome and continuing along the back wall. A 3F right angle Greenwald electrode was used to incise the detrusor muscle down to but not through the mucosa (fig. 2, A). This dissection was continued laterally on both sides to free the detrusor muscle completely from the underlying bladder mucosa. The balloon inflated within the bladder facilitated this dissection, and allowed the plane between the mucosa and detrusor muscle to be easily identified. Detrusor flaps were developed bilaterally such that they could be loosely reflected back to the respective side wall of the pelvis in the region of Cooper’s ligament (fig. 2, B ) . A 6-inch length of 1-zero polyglactin on an SH needle was secured with a laparoscopic suture clip on the end of the suture. The needle and suture were passed through Cooper’s ligament on the right side of the pelvis. The suture was then passed through the edge of the right flap of the detrusor muscle and tightened down, drawing the edge of the detrusor flap against the pelvic side wall. A laparoscopic suture clip was placed on the suture as it exited the detrusor. This technique was repeated on the left side, tacking the left detrusor muscle flap onto the left pelvic side wall. This maneuver provided excellent exposure of the mucosa anteriorly and at the dome of the bladder. The retropubic space pressure was then decreased to 5 mm. Hg and the surgical sites were examined for hemostasis. The ports were removed un-
A
B
FIG. 2. A, detrusor muscle was incised down to but not through mucosa in midline. B . detrusor flaos were dissected from bladder mucosa and sutured back to respeciive side wall of pelvis.
LAPAROSCOPIC RETROPUBIC AUTO-AUGMENTATION OF BLADDER der laparoscopic visualization and the fascia of the 12 mm. ports was closed with a figure-of-8, 1-zero polyglactin suture. The blunt tip port was removed last under direct visualization and the fascia was approximated using the 2, 1-zero polyglactin stay sutures. The skin edges of the 12 mm. ports were approximated with a 4-2121-0absorbable subcuticular suture. The 5F angiographic catheter with the 80 cc inflated balloon was maintained postoperatively and the Foley catheter was placed to dependent drainage. Operating time was 6.5 hours. Estimated blood loss during the procedure was 75 cc. The patient resumed oral intake 12 hours postoperatively and was discharged home with both catheters and both ureteral stents in place on postoperative day 2, with a maintenance dose of ciprofloxacin. She received a total of 350 mg. meperidine hydrochloride and 8 tablets of oxycodone hydrochloride with acetaminophen in the hospital for control of postoperative discomfort. RESULTS
The patient returned for followup 2 weeks postoperatively. At that time the 5F catheter and balloon, and Foley catheter were removed. Flexible cystoscopy was performed t o remove the indwelling ureteral stents. The bladder appeared intact but exhibited some mild inflammation secondary to the catheters. We chose to wait 1month postoperatively before intermittent self-catheterization was begun. Therefore, a Foley bladder catheter was replaced for another 2 weeks. At 4 weeks postoperatively a cystogram revealed an intact bladder with no extravasation. The Foley catheter was removed and the patient began intermittent self-catheterization. She was also placed on 5 mg. oxybutynin 3 times a day. At 9 weeks Pseudomonas aeruginosa urinary tract infection recurred, which was treated with appropriate parenteral antibiotics. She was performing intermittent self-catheterization every 3 hours during the day and remained dry between catheterizations. She was experiencing some occasional nighttime leakage, which was resolved by limiting evening fluid intake. At 6 months the patient had a normal cystogram (fig. 3). Urodynamics revealed a compliant bladder with a bladder pressure of 4 cm. water at 200 cc that increased to 18 cm. water at 300 cc pressure (fig. 4). The patient had a strong sensation to void at 375 cc. Leakage occurred at 285 to 300 cc. The leak point pressure was tested and there was no leakage up to a bladder pressure of 80 cm. water. There were no involuntary detrusor contractions. Total bladder capacity was 350 cc and she voided by Valsalva’s maneu-
loo
125
200
vokme cc.
FIG. 4. Urodynamics 9 weeks following laparoscopic bladder autoaugmentation demonstrates intravesical pressure of only 4 cm. water on filling to 200 cc. Continued bladder filling to 300 cc increased intravesical pressure to 18 cm. water without any evidence of uninhibited detrusor contractions.
ver with a residual of 30 cc. The patient has discontinued intermittent self-catheterization and voids by Valsalva’s maneuver every 3 hours. She remains dry day and night. DISCUSSION
The small contracted bladder can present clinically in the pediatric or adult urological patient with associated debilitating urinary incontinence. In the most severe cases anticholinergic therapy provides minimal relief of symptoms for these patients. The goal of bladder augmentation is to create a storage structure with an adequate capacity and low pressure. Historically, enterocystoplasty has used various gastrointestinal segments, including the stomach, jejunum, ileum, cecum and colon. However, these operations have been complicated by significant electrolyte abnormalities, as well as urinary extravasation, abscess formation, abundant mucous production, enteric fistula and peritoneal adhesions. In an effort to preclude bowel interposition, laboratory and clinical studies have been completed with a variety of materials to augment the bladder (omentum, peritoneum, human dura and placental m e r n b r a n e ~ )These . ~ ~ materials have usually been placed on the incised or partially excised bladder wall. Unfortunately, none of these materials has been entirely successful and, therefore, clinical application has generally not occurred. Cartwright and Snow originally described the technique of partially excising the detrusor muscle in the dog to create a diverticular bulge of the bladder mucosa, thereby increasing urine storage volumes at low pressure.’ Their subsequent report of the clinical application of this same technique in 7 children showed significant urodynamic improvement in 5 (71%),with increased capacity and/or decreased storage pressures.l A recent report by Snow and Cartwright indicated that 3 months to 4 years following auto-augmentation of the bladder 80% of the patients in their expanded series were continent and another 10% had significant improvement in c~ntinence.~ Interestingly, a significant increase in bladder capacity (greater than 150 cc) occurred in only 40% of their patients, while 35%had minimal change (0 to 60 cc) and 25%actually had a decrease (from 160 to 125 cc). Therefore, the procedure may be of benefit due to factors beyond an increase in bladder capacity, specifically the dissection of the bladder may have some beneficial denervating effect on the detrusor function. Ehrlich and Gershman first reported transperitoneal laparoscopic bladder auto-augmentation in an 8-year-old boy with a nonneurogenic neurogenic bladder, urodynamically FIG. 3. Cystogram 6 months after laparoscopic bladder auto-aug- characterized by limited capacity and high intravesical pressures associated with incontinence? The boy was continent 3 mentation shows normal-appearing bladder.
126
LAPAROSCOPIC RETROPUBIC AUTO-AUGMENTATION OF BLADDER
months postoperatively but postoperative urodynamics or cystography was not obtainable. In our first clinical experience with laparoscopic auto-augmentation of the bladder we elected to perform the autoaugmentation through an entirely retropubic approach to facilitate any later need for enterocystoplasty. We believe that by avoiding the peritoneal cavity, the risk of postoperative bowel adhesions should be minimized. Also, this could preclude subsequent intraperitoneal extravasation should the patient have difficulty with intermittent catheterization and perforate the thin back wall of the bladder. The extraperitoneal approach precludes the need for postoperative drains, even with a small mucosal tear, since Foley catheter drainage of the bladder is acceptable management of this clinical situation until bladder healing is confirmed by cystography. The report by Cartwright and Snow included excision of the detrusor muscle from the bladder mucosa, suturing of the detrusor to the side walls of the pelvis and a psoas hitch. In our laparoscopic procedure we elected to do only 1 of these 3 maneuvers (tacking the detrusor to the pelvic side wall). Furthermore, to decrease any restrictive fibrosis around the region of the detrusor excision in our patient we elected to maintain bladder distention by leaving the 5F,80 cc balloon inflated within the bladder for 2 weeks postoperatively. However, preliminary animal studies would suggest that this is not necessary if the detrusor flap is securely sutured to the pelvic side wall. Clinical experience with the open surgical approach to bladder auto-augmentation has not involved use of postoperative bladder distention and, therefore, this step in the laparoscopic technique may not be necessary. The urodynamic results in our patient at 9 weeks and 6 months postoperatively are consistent with the findings occurring after open bladder auto-a~gmentation.~ The improvement in bladder capacity (+150 cc) and decrease in intravesical pressures in our patient postoperatively were dramatic. The end result has been most satisfactory, since she is continent and catheter-free for the first time in a
decade. However, continued close followup is important to assess the durability of this minimally invasive approach. CONCLUSION
Extraperitoneal laparoscopic auto-augmentation of the bladder is a technically feasible operation. Our solitary patient had a brief hospital stay, minimal postoperative discomfort, and good improvement in bladder capacity, intravesical storage pressures and continence. The extraperitoneal approach should not complicate or preclude subsequent enterocystoplasty if necessary. Clinical followup is needed t o determine the durability of this procedure in the management of the small contracted bladder. REFERENCES
1. Cartwright, P. C. and Snow, B. W.: Bladder autoaugmentation: early clinical experience. J. Urol., part 2, 142:505, 1989. 2. Ehrlich, R. M. and Gershman, A,: Laparoscopic seromyotomy
(auto-augmentation)for non-neurogenic neurogenic bladder in a child: initial case report. Urology, 42: 175, 1993. 3. Goldstein, M. B. and Dearden, L. C.: Histology of omentoplasty of the urinary bladder in the rabbit. Invest. Urol., 3: 460,1966. 4. Telly, 0.: Segmental cystectomy with peritoneoplasty. Urol. Int., 2 6 236, 1970. 5. Novick, A. C., Straf€on, R. A., Banowsky, L. H., Nose, Y., Levin, H. and Stewart, B. H.: Experimental bladder substitution using biodegradable graft of natural tissue. Urology, 1 0 118, 1977. 6. Kelami, A,: Lyophilized human dura as a bladder wall substitute: experimental and clinical results. J. Urol., 105 518, 1971. 7. Fishman, I. J., Flores, F. N., Scott, F. B., Spjut, H. J. and
Morrow, B.: Use of fresh placental membranes for bladder reconstruction.J. Urol., 138 1291, 1987. 8. Cartwright, P. C. and Snow, B. W.: Bladder autoaugmentation: partial detrusor excision to augment the bladder without use of bowel. J. Urol., 142: 1050, 1989. 9. Snow, B. W. and Cartwright, P. C.: Autoaugmentation of the bladder. Contemp. Urol., 4:41, 1992.