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Cystometric Properties of Ileum and Right Colon After Bladder Augmentation, Substitution or Replacement
0022-524 7/87/1381-1007$02.00/0
'lol. Prin!ed
THE ,JOURNAL OF UROLOGY
Copyright© 1987 by The Williams
VVilkins Co.
October US.A.
CYSTOIVIETRIC PROPERTIES OF ILEUl\A AND RIGHT COLON AFTER BLADDER AUGMENTATION, SUBSTITUTION OR REPLACEMENT BENAD GOLDWASSER,* DAVID M. BARRETT, GEORGE D. WEBSTER STEPHEN A. KRAMERt
AND
From the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and Division of Urology, Duke University Medical Center, Durham, North Carolina
ABSTRACT
Cystometric studies were performed on 38 patients who had undergone augmentation, substitution or replacement enterocystoplasty. These studies were done to determine the choice of bowel segment to augment or replace the detrusor and the shape in which the bowel segment should be reconstructed. Eleven patients underwent tubular and 10 detubularized right colon cystoplasty, while 10 underwent tubular (Camey bladder) and 7 detubularized ileocystoplasty. Compliance curves were normal in nearly all patients except those who underwent tubular ileocystoplasty. Cystoplasty contractions were more common with tubular cystoplasty. These contractions appeared at a lower bladder capacity and were higher in amplitude in tubular cystoplasty patients. Detubularizing the bowel for bladder reconstruction appears to create a better low pressure capacitor with better compliance and fewer high pressure cystoplasty contractions. (J. Urol., part 2, 138: 1007-1008, 1987) Dissatisfaction with the long-term results of cutaneous urinary diversion and urete:rosigmoidostomy, and a demand for a more socially acceptable solution have prompted the development of bladder reconstruction. Treatment options for patients who are candidates for enterocystoplasty are augmentation, substitution and replacement. Continence depends on factors related to the bladder and outlet. The bladder must possess large capacity, good compliance and no or at most low amplitude contractions. It is important to determine the choice of bowel segment to augment or to replace the detrusor and the configuration in which the bowel segment should be constructed to best achieve these characteristics. Attempts at circumventing the problem of high intravesical pressures by implantation of an artificial urinary sphincter to augment outlet resistance may result in deterioration of the upper tracts from a type of bladder and artificial sphincter dyssynergia.
chance of an anastomotic stricture and hourglass deformity of the enterocystoplasty. Water cystometry was performed at a filling rate of 35 to 100 ml. per minute in adults and 20 to 35 ml. per minute in children. A 14F Foley catheter was used for the cystometric studies. The vesical neck was not occluded intentionally at the time of bladder filling. Total bladder and subtracted bladder pressures were recorded simultaneously in each patient. Age, postoperative interval and capacity as measured during cystometry were recorded in each patient. "Bladder" compliance up to a capacity of 400 ml. was assessed by noting the subtracted pressures at 100, 200, 300 and 400 ml. The appearance of cystoplasty contractions (greater than 15 cm. water in amplitude) was recorded with the various intestinal segments. The amplitude and volume at which the first and maximal contractions occurred were recorded.
MATERIALS AND METHODS
RESULTS
Cystometric studies were performed on 38 patients 4 to 75 years old from 4 to 24 months after bladder reconstruction. Of the patients 21 had an augmentation or substitution cystoplasty in which the entire right colon including the hepatic flexure was used: in 11 the right colon was kept in a tubular configuration and in 10 the bowel segment was detubularized. 1 An ileal segment was used for the bladder reconstruction in 17 patients: 40 cm. of ileum in a tubular shape was used to construct the bladder replacement (Camey bladders) 2 in 10 and in 7 the bladder was augmented by cup-patch ileocystoplasty3 in which approximately 40 cm. of ileum were used in a detubularized fashion. In the majority of the patients the entire bladder was preserved and only infrequently was supratrigonal excision of a grossly abnormal bladder necessary. It is important to incise the bladder in the midline anteroposterior plane from 2 cm. above the bladder neck anteriorly to 1 to 2 cm. above the inner ureteral ridge posteriorly. This technique provides for a wide anastomosis between the bowel segment and bladder with less
All types of cystoplasty studied, except tubular ileocystoplasty (Camey bladder), demonstrated on the average normal or nearly normal compliance (table 1). Of 11 patients with tubular right colon cystoplasties 2 had somewhat reduced compliance. In these 11 patients mean bladder capacity was 630 ml., with a range of 300 to 1,100 ml. Bladder capacities were similar in patients undergoing detubularized right colon cystoplasty. Reduced compliance was observed in only 1 of these patients. In patients undergoing tubular ileocystoplasty bladder volumes were adequate but discernibly less than those in patients undergoing colocystoplasty. Decreased compliance was noted in 6 of 10 patients in this group. Patients undergoing detubularized ileocystoplasty had bladder capacities that were lower than those in patients with colocystoplasty but not unlike those in patients with a Camey bladder. None of the 7 patients with detubularized ileocystoplasty had reduced compliance. Cystoplasty contractions greater than 15 cm. water in amplitude occurred in 9 of 11 patients with tubular and 6 of 10 with detubularized right colon cystoplasty, as well as 8 of 10 with tubular and 3 of 7 with detubularized ileocystoplasty. The average bladder volume at which the first cystoplasty contraction occurred was discernibly higher in patients with detubularized than in those with tubular cystoplasty, and the ampli-
* Current address: Department of Urology, Chaim Sheba Medical Center, Tel-Hashomer, Israel. t Requests for reprints: Mayo Clinic, 200 First St., S. W., Rochester, Minnesota 55905.
1007
1008
GOLDWASSER AND ASSOCIATES TABLE
Cystoplasty
Mean Age (yrs.)
Mean Mos. Postop.
Tubular rt. colon Detubularized rt. colon Tubular ileum (Camey) Detubularized ileum
17.5 28.5 66.8 20.0
9.7 5.1 7.0 5.7
TABLE
1. Compliance of intestinal cystoplasties Mean Ml. Bladder Capacity (range) 630 641 311 403
(300-1,100) (160-1,050) (130-4 75) (150-1,000)
Mean Cm. Water Pressure (range) at lOOMI. 3.2 (0-10) 4.2 (4-8) 14.8 (0-40) 3.6 (0-10)
300Ml.
200 Ml. 9.1 4.8 28 8
(0-20) (0-10) (12-70) (5-12)
18.6 9.4 36 14.4
(0-60) (5-20) (14-80) (5-25)
400Ml. 13 (0-25) 13.9 (5-40) 15.7 (5-30)
2. Cystoplasty contractions with various intestinal cystoplasties
Cystoplasty
Mean Age (yrs.)
Mean Mos. Postop.
Tubular rt. colon Detubularized rt. colon Tubular ileum Detubularized ileum
17.5 28.5 66.8 20.0
9.7 5.1 7.0 5.7
No. Pts. First Contraction Mean Ml. With Bladder Capacity Mean Ml. Vol. Mean Cm. Water Contractions/ (range) (range) Pressure (range) Total 630 641 311 403
(300-1,100) (160-1,050) (130-4 75) (150-1,000)
9/11 6/10 8/10 3/7
139 329 110 197
(50-300) (50-800) (50-200) (130-300)
37 24 60 22
(15-90) (20-25) (15-100) (20-25)
Maximal Contraction Mean Ml. Vol. (range) 467 596 218 265
(75-800) (150-950) (50-400) (175-320)
Mean Cm. Water Pressure (range) 63 42 81 28
(50-90) (25-55) (50-100) (20-38)
tude of these contractions also was lower in those with detubularized cystoplasty (table 2). The average bladder volume at which maximal contraction occurred was higher in patients with detubularized than with tubular right colon cystoplasty, and the amplitude of these contractions was higher in the latter patients (table 2). Maximal cystoplasty contractions occurred at a lower bladder volume and were higher in amplitude in patients with tubular than with detubularized ileocystoplasty (table 2). Cystoplasty contractions were defined arbitrarily as clinically significant when they occurred at a bladder capacity of less than 200 ml. and an amplitude of greater than 40 cm. water. Of 10 patients with a tubular ileocystoplasty (Camey bladder) 7 (70 per cent) had significant contractions compared to 36 per cent of those with a tubular right colon cystoplasty. The detubularized bowel segments were less likely to have significant cystoplasty contractions, which occurred in only 10 per cent of the patients with detubularized right colon and in none of those with detubularized ileum.
those with detubularized right colon cystoplasty the differ~nce did not become apparent until bladder volumes of greater than 300 ml. Conversely, the average bladder capacity of a colon cystoplasty was approximately twice that of ileocystoplasty. Similar findings demonstrating the cystometric superiority of detubularizing the ileum and right colon were reported by others who studied the effect of detubularizing the sigmoid colon. 8 We were unable to find a direct relationship between the cystometric properties of enterocystoplasty and the postoperative interval. However, we have not studied these changes with time in the same patient. Our experience is that the cystometric properties of enterocystoplasty change within the first 3 months or so postoperatively and they tend to stabilize thereafter. Others also reported changes in the cystometric properties of enterocystoplasty patients studied at 1 and 6 months postoperatively. 8
DISCUSSION
All cystoplasties studied demonstrated normal or nearly normal compliance except tubular ileocystoplasty-the Camey bladder. Tubular cystoplasty had a higher incidence of cystoplasty contractions at a smaller capacity and with higher amplitudes than did the detubularized segments. Detubularized ileum appears to be superior to detubularized right colon as a low pressure capacitor but only at large volumes.
Continence and preservation of the upper urinary tracts depend on reconstruction of a bladder that acts as a low pressure capacitor. Reduced compliance or high pressure cystoplasty contractions in patients with a competent or dyssynergic bladder outlet may produce deterioration of the upper tracts. 4 The same bladder characteristics in patients with low outlet resistance may produce incontinence. Augmenting outlet resistance with either bladder neck reconstruction or placement of artificial genitourinary sphincters in such patients may make them dry at the expense of endangering the upper tracts. Although pharmacological treatment has been shown to reduce cystoplasty contractions it is effective in only about a third of the patients. Detubularization disrupts the strong circular muscle layer of the bowel. Since pressure is inversely proportional to the square of the radius (Laplace's law), patching together adjacent loops of bowel5 • 6 or folding over the bowel segment onto itself1 • 7 increases the radius of the cystoplasty and may contribute to a decrease in bladder pressure. Therefore, any technique that incorporates these principles may create a low pressure enterocystoplasty. Our findings have shown that tubular small bowel possesses lower compliance and exhibits higher pressure contractions than does tubular right colon. It also is clear that tubular ileum or right colon has a higher incidence of high pressure cystoplasty contractions than does the same bowel segment in the detubularized form. Whether detubularized ileum should be considered superior to right colon on a urodynamic basis is questionable. Although detubularized ileocystoplasty patients had a lower incidence of high pressure contractions than did
CONCLUSION
REFERENCES
1. Goldwasser, B. and Webster, G.D.: Augmentation and substitution enterocystoplasty. J. Ural., 135: 215, 1986. 2. Lilien, 0. M. and Camey, M.: 25-Year experience with replacement of the human bladder (Camey procedure). J. Ural., 132: 886, 1984. 3. Goodwin, W. E., Winter, C. C. and Barker, W. F.: "Cup-patch" technique of ileocystoplasty for bladder enlargement or partial substitution. Surg., Gynec. & Obst., 108: 240, 1959. 4. McGuire, E. J., Woodside, J. R., Borden, T. A. and Weiss, R. M.: Prognostic value of urodynamic testing in myelodysplastic patients. J. Ural., 126: 205, 1981. 5. Thuroff, J. W., Alken, P., Riedmiller, H., Engelmann, U., Jacobi, G. H. and Hohenfellner, R.: The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion. J. Ural., 136: 17, 1986. 6. Light, J. K. and Engelmann, U. H.: Le bag: total replacement of the bladder using an ileocolonic pouch. J. Ural., 136: 27, 1986. 7. Goldwasser, B., Barrett, D. M. and Benson, R. C., Jr.: Bladder replacement with use of a detubularized right colonic segment: preliminary report of a new technique. Mayo Clin. Proc., 61: 615, 1986. 8. Sidi, A. A., Reinberg, Y. and Gonzalez, R.: Influence of intestinal segment and configuration on the outcome of augmentation enterocystoplasty. J. Ural., 136: 1201, 1986.
'lol. Prin!ed
THE ,JOURNAL OF UROLOGY
Copyright© 1987 by The Williams
VVilkins Co.
October US.A.
CYSTOIVIETRIC PROPERTIES OF ILEUl\A AND RIGHT COLON AFTER BLADDER AUGMENTATION, SUBSTITUTION OR REPLACEMENT BENAD GOLDWASSER,* DAVID M. BARRETT, GEORGE D. WEBSTER STEPHEN A. KRAMERt
AND
From the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and Division of Urology, Duke University Medical Center, Durham, North Carolina
ABSTRACT
Cystometric studies were performed on 38 patients who had undergone augmentation, substitution or replacement enterocystoplasty. These studies were done to determine the choice of bowel segment to augment or replace the detrusor and the shape in which the bowel segment should be reconstructed. Eleven patients underwent tubular and 10 detubularized right colon cystoplasty, while 10 underwent tubular (Camey bladder) and 7 detubularized ileocystoplasty. Compliance curves were normal in nearly all patients except those who underwent tubular ileocystoplasty. Cystoplasty contractions were more common with tubular cystoplasty. These contractions appeared at a lower bladder capacity and were higher in amplitude in tubular cystoplasty patients. Detubularizing the bowel for bladder reconstruction appears to create a better low pressure capacitor with better compliance and fewer high pressure cystoplasty contractions. (J. Urol., part 2, 138: 1007-1008, 1987) Dissatisfaction with the long-term results of cutaneous urinary diversion and urete:rosigmoidostomy, and a demand for a more socially acceptable solution have prompted the development of bladder reconstruction. Treatment options for patients who are candidates for enterocystoplasty are augmentation, substitution and replacement. Continence depends on factors related to the bladder and outlet. The bladder must possess large capacity, good compliance and no or at most low amplitude contractions. It is important to determine the choice of bowel segment to augment or to replace the detrusor and the configuration in which the bowel segment should be constructed to best achieve these characteristics. Attempts at circumventing the problem of high intravesical pressures by implantation of an artificial urinary sphincter to augment outlet resistance may result in deterioration of the upper tracts from a type of bladder and artificial sphincter dyssynergia.
chance of an anastomotic stricture and hourglass deformity of the enterocystoplasty. Water cystometry was performed at a filling rate of 35 to 100 ml. per minute in adults and 20 to 35 ml. per minute in children. A 14F Foley catheter was used for the cystometric studies. The vesical neck was not occluded intentionally at the time of bladder filling. Total bladder and subtracted bladder pressures were recorded simultaneously in each patient. Age, postoperative interval and capacity as measured during cystometry were recorded in each patient. "Bladder" compliance up to a capacity of 400 ml. was assessed by noting the subtracted pressures at 100, 200, 300 and 400 ml. The appearance of cystoplasty contractions (greater than 15 cm. water in amplitude) was recorded with the various intestinal segments. The amplitude and volume at which the first and maximal contractions occurred were recorded.
MATERIALS AND METHODS
RESULTS
Cystometric studies were performed on 38 patients 4 to 75 years old from 4 to 24 months after bladder reconstruction. Of the patients 21 had an augmentation or substitution cystoplasty in which the entire right colon including the hepatic flexure was used: in 11 the right colon was kept in a tubular configuration and in 10 the bowel segment was detubularized. 1 An ileal segment was used for the bladder reconstruction in 17 patients: 40 cm. of ileum in a tubular shape was used to construct the bladder replacement (Camey bladders) 2 in 10 and in 7 the bladder was augmented by cup-patch ileocystoplasty3 in which approximately 40 cm. of ileum were used in a detubularized fashion. In the majority of the patients the entire bladder was preserved and only infrequently was supratrigonal excision of a grossly abnormal bladder necessary. It is important to incise the bladder in the midline anteroposterior plane from 2 cm. above the bladder neck anteriorly to 1 to 2 cm. above the inner ureteral ridge posteriorly. This technique provides for a wide anastomosis between the bowel segment and bladder with less
All types of cystoplasty studied, except tubular ileocystoplasty (Camey bladder), demonstrated on the average normal or nearly normal compliance (table 1). Of 11 patients with tubular right colon cystoplasties 2 had somewhat reduced compliance. In these 11 patients mean bladder capacity was 630 ml., with a range of 300 to 1,100 ml. Bladder capacities were similar in patients undergoing detubularized right colon cystoplasty. Reduced compliance was observed in only 1 of these patients. In patients undergoing tubular ileocystoplasty bladder volumes were adequate but discernibly less than those in patients undergoing colocystoplasty. Decreased compliance was noted in 6 of 10 patients in this group. Patients undergoing detubularized ileocystoplasty had bladder capacities that were lower than those in patients with colocystoplasty but not unlike those in patients with a Camey bladder. None of the 7 patients with detubularized ileocystoplasty had reduced compliance. Cystoplasty contractions greater than 15 cm. water in amplitude occurred in 9 of 11 patients with tubular and 6 of 10 with detubularized right colon cystoplasty, as well as 8 of 10 with tubular and 3 of 7 with detubularized ileocystoplasty. The average bladder volume at which the first cystoplasty contraction occurred was discernibly higher in patients with detubularized than in those with tubular cystoplasty, and the ampli-
* Current address: Department of Urology, Chaim Sheba Medical Center, Tel-Hashomer, Israel. t Requests for reprints: Mayo Clinic, 200 First St., S. W., Rochester, Minnesota 55905.
1007
1008
GOLDWASSER AND ASSOCIATES TABLE
Cystoplasty
Mean Age (yrs.)
Mean Mos. Postop.
Tubular rt. colon Detubularized rt. colon Tubular ileum (Camey) Detubularized ileum
17.5 28.5 66.8 20.0
9.7 5.1 7.0 5.7
TABLE
1. Compliance of intestinal cystoplasties Mean Ml. Bladder Capacity (range) 630 641 311 403
(300-1,100) (160-1,050) (130-4 75) (150-1,000)
Mean Cm. Water Pressure (range) at lOOMI. 3.2 (0-10) 4.2 (4-8) 14.8 (0-40) 3.6 (0-10)
300Ml.
200 Ml. 9.1 4.8 28 8
(0-20) (0-10) (12-70) (5-12)
18.6 9.4 36 14.4
(0-60) (5-20) (14-80) (5-25)
400Ml. 13 (0-25) 13.9 (5-40) 15.7 (5-30)
2. Cystoplasty contractions with various intestinal cystoplasties
Cystoplasty
Mean Age (yrs.)
Mean Mos. Postop.
Tubular rt. colon Detubularized rt. colon Tubular ileum Detubularized ileum
17.5 28.5 66.8 20.0
9.7 5.1 7.0 5.7
No. Pts. First Contraction Mean Ml. With Bladder Capacity Mean Ml. Vol. Mean Cm. Water Contractions/ (range) (range) Pressure (range) Total 630 641 311 403
(300-1,100) (160-1,050) (130-4 75) (150-1,000)
9/11 6/10 8/10 3/7
139 329 110 197
(50-300) (50-800) (50-200) (130-300)
37 24 60 22
(15-90) (20-25) (15-100) (20-25)
Maximal Contraction Mean Ml. Vol. (range) 467 596 218 265
(75-800) (150-950) (50-400) (175-320)
Mean Cm. Water Pressure (range) 63 42 81 28
(50-90) (25-55) (50-100) (20-38)
tude of these contractions also was lower in those with detubularized cystoplasty (table 2). The average bladder volume at which maximal contraction occurred was higher in patients with detubularized than with tubular right colon cystoplasty, and the amplitude of these contractions was higher in the latter patients (table 2). Maximal cystoplasty contractions occurred at a lower bladder volume and were higher in amplitude in patients with tubular than with detubularized ileocystoplasty (table 2). Cystoplasty contractions were defined arbitrarily as clinically significant when they occurred at a bladder capacity of less than 200 ml. and an amplitude of greater than 40 cm. water. Of 10 patients with a tubular ileocystoplasty (Camey bladder) 7 (70 per cent) had significant contractions compared to 36 per cent of those with a tubular right colon cystoplasty. The detubularized bowel segments were less likely to have significant cystoplasty contractions, which occurred in only 10 per cent of the patients with detubularized right colon and in none of those with detubularized ileum.
those with detubularized right colon cystoplasty the differ~nce did not become apparent until bladder volumes of greater than 300 ml. Conversely, the average bladder capacity of a colon cystoplasty was approximately twice that of ileocystoplasty. Similar findings demonstrating the cystometric superiority of detubularizing the ileum and right colon were reported by others who studied the effect of detubularizing the sigmoid colon. 8 We were unable to find a direct relationship between the cystometric properties of enterocystoplasty and the postoperative interval. However, we have not studied these changes with time in the same patient. Our experience is that the cystometric properties of enterocystoplasty change within the first 3 months or so postoperatively and they tend to stabilize thereafter. Others also reported changes in the cystometric properties of enterocystoplasty patients studied at 1 and 6 months postoperatively. 8
DISCUSSION
All cystoplasties studied demonstrated normal or nearly normal compliance except tubular ileocystoplasty-the Camey bladder. Tubular cystoplasty had a higher incidence of cystoplasty contractions at a smaller capacity and with higher amplitudes than did the detubularized segments. Detubularized ileum appears to be superior to detubularized right colon as a low pressure capacitor but only at large volumes.
Continence and preservation of the upper urinary tracts depend on reconstruction of a bladder that acts as a low pressure capacitor. Reduced compliance or high pressure cystoplasty contractions in patients with a competent or dyssynergic bladder outlet may produce deterioration of the upper tracts. 4 The same bladder characteristics in patients with low outlet resistance may produce incontinence. Augmenting outlet resistance with either bladder neck reconstruction or placement of artificial genitourinary sphincters in such patients may make them dry at the expense of endangering the upper tracts. Although pharmacological treatment has been shown to reduce cystoplasty contractions it is effective in only about a third of the patients. Detubularization disrupts the strong circular muscle layer of the bowel. Since pressure is inversely proportional to the square of the radius (Laplace's law), patching together adjacent loops of bowel5 • 6 or folding over the bowel segment onto itself1 • 7 increases the radius of the cystoplasty and may contribute to a decrease in bladder pressure. Therefore, any technique that incorporates these principles may create a low pressure enterocystoplasty. Our findings have shown that tubular small bowel possesses lower compliance and exhibits higher pressure contractions than does tubular right colon. It also is clear that tubular ileum or right colon has a higher incidence of high pressure cystoplasty contractions than does the same bowel segment in the detubularized form. Whether detubularized ileum should be considered superior to right colon on a urodynamic basis is questionable. Although detubularized ileocystoplasty patients had a lower incidence of high pressure contractions than did
CONCLUSION
REFERENCES
1. Goldwasser, B. and Webster, G.D.: Augmentation and substitution enterocystoplasty. J. Ural., 135: 215, 1986. 2. Lilien, 0. M. and Camey, M.: 25-Year experience with replacement of the human bladder (Camey procedure). J. Ural., 132: 886, 1984. 3. Goodwin, W. E., Winter, C. C. and Barker, W. F.: "Cup-patch" technique of ileocystoplasty for bladder enlargement or partial substitution. Surg., Gynec. & Obst., 108: 240, 1959. 4. McGuire, E. J., Woodside, J. R., Borden, T. A. and Weiss, R. M.: Prognostic value of urodynamic testing in myelodysplastic patients. J. Ural., 126: 205, 1981. 5. Thuroff, J. W., Alken, P., Riedmiller, H., Engelmann, U., Jacobi, G. H. and Hohenfellner, R.: The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion. J. Ural., 136: 17, 1986. 6. Light, J. K. and Engelmann, U. H.: Le bag: total replacement of the bladder using an ileocolonic pouch. J. Ural., 136: 27, 1986. 7. Goldwasser, B., Barrett, D. M. and Benson, R. C., Jr.: Bladder replacement with use of a detubularized right colonic segment: preliminary report of a new technique. Mayo Clin. Proc., 61: 615, 1986. 8. Sidi, A. A., Reinberg, Y. and Gonzalez, R.: Influence of intestinal segment and configuration on the outcome of augmentation enterocystoplasty. J. Ural., 136: 1201, 1986.