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Enterocystoplasty: The Star Modification
0022-5347/96/1555-1723$03.00/0 Vol. 165, 1723-1725, May la96 Printed in U S A .
JOURNAL OF UROUX'Y
Copyright 0 1996 by AMERICAN U R O ~ I CAAsLs o c i ~ " h~c~ ~ ,
ENTEROCYSTOPLASTY: THE STAR MODIFICATION MICHAEL A. KEATING,* JOHN K. LUDLOW AND MARK A. RICH From the J . W. Riley Hospital for Children and Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, and Department of Pediatric Urology, Arnold Palmer Children's Hospital, Orlando Regional Medical Center, Orlando, Florida
ABSTRACT
Purpose: A modification of sagittal cystoplasty is described that maximally reconfigures the native neuropathic bladder, as required in enterocystoplasty. Materials and Methods: The star modification incorporates lateral cystotomies with anteroposterior cystotomy, as in t h e widely used sagittal clamshell technique. Results: Enterocystoplasty was performed in 27 patients with various bowel segments using this technique and none has had complications attributable to cystoplasty after a mean followup of 2.5 years. Conclusions: Star reconfiguration defunctionalizes any potential noncompliant or hyperreflexic tendencies inherent to the neuropathic bladder before augmentation. In addition, t h e modification provides a technical advantage by increasing t h e linear length of t h e edge available for the anastomosis of bowel to bladder. KEYWORDS: bladder. neurogenic; surgery, operative Functions of the bladder include storing adequate volumes of urine at low pressure, maintaining continence and volitionally emptying to completion. Various disorders can alter the urodynamic characteristics of the detrusor. Typical examples in children include spina bifida, spinal cord injury, severe bladder dysfunction, posterior urethral valves and exstrophy. When bladder compliance and capacity are significantly affected, incontinence and upper tract deterioration become the inevitable sequelae of altered bladder dynamics. When medical management fails to improve bladder dynamics, augmentation cystoplasty provides an effective surgical solution. A number of bowel segments and configurations have been used to augment the bladder since the procedure was first described in 1899 by Mikulicz.1 In contrast, preparation of the native bladder has received less attention in the literature despite its important role as the neuropathic recipient template of the transposed flap of bowe1.2.3 We report a modification of the widely used clamshell cystoplasty technique that further alters the native detrusor by splitting its bivalved halves with additional coronal cystotomies. The star reconfiguration that results offers technical benefits in the construction of enterocystoplasty and may also provide a urodynamic advantage over current techniques. MATERIALS AND METHODS
During a recent 5-year period augmentation cystoplasty using the star modification was performed in 17 boys and 10 girls 5.2 to 18.4 years old (average age 11.6).The etiology of bladder dysfunction included spinal cord dysraphism in 16 patients, the exstrophy/epispadias complex in 3, posterior urethral valves in 3 and imperforate anus, transverse myelitis, systemic hypotonia, juvenile diabetes and a cervical spine injury in 1 each. Indications for enterocystoplasty were recalcitrant incontinence in 18 patients and progressive upper tract deterioration in the remainder. In each case medical measures, including intermittent catheterization and anticholinergic medication, had failed to improve the condition. Preoperative urodynamic studies demonstrated small blad-
der capacity and/or poor bladder compliance in all patients. The bowel segment used to augment the native bladder comprised ileum in 17 cases, sigmoid colon in 6, stomach in 2 and an ileocecal segment in 2. Concomitant procedures included appendicovesicostomy (111, Young-Dees bladder neck reconstruction4 (5),fascial sling suspension of the bladder neck (9, transureteroureterostomy (5)and cross-trigonal ureteral reimplantation (3). Enterocystoplasty was begun with a midline incision carried to the level of the umbilicus, which gave excellent exposure. After opening the anterior abdominal fascia, and separating the rectus muscles and transversalis fascia, the urachus was identified and ligated. The peritoneum was opened, and the bowel was packed away superiorly with moist towels to expose the pelvis and bladder completely. Chromic 3-ZerO stay sutures were placed in each quadrant of the dome of the bladder to facilitate subsequent handling (fig. 1,A). These sutures also defined the segments created by the coronal and sagittal incisions, which would ultimately yield the star configuration. Cautery was used to open the bladder with a generous midline cystotomy that extended anteriorly to 2 cm. above the bladder neck and posteriorly to 2 cm. above the trigone or ureteral reimplants (fig. 1, B ) . This initial sagittal cystotomy created the standard bivalved or clamshell cystoplasty. At this point planned bladder neck procedures were begun. Young-Dees revisions were created in continuity with the distal extent of the anterior cystotomy while urethral mobilization, required in sling suspension, was more easily completed with the urethra viewed from within. When ureteroneocystotomy was necessary, the cross-trigonal technique was used. Feeding tubes (5F) were placed to help to identify the ureters during completion of the star reconfiguration. With the bladder halves on traction lateral extensions of the initial cystotomy were made in the coronal plane to divide further each hemibladder into 2 parts (fig. 1, C).These incisions were extended to approximately 2 cm. above the trigone to avoid disruption of the ureterovesical junction. Bladder neck revision or sling suspension was completed before anastomosing the enterocystoplasty to the native bladder. When appendicovesicostomywas planned, the right p s terior segment of the detrusor was lee slightly wider to create the recipient bed for the continent stoma. The appen-
Acce ted for publication October 13, 1995. ReaJat annual meeting of American Urological Association, Las Vegas, Nevada, April 23-28, 1995. * Re uests for reprints: J. W. Riley Hospital for Children, Pediatric d o g y Room 1739, Indianapolis, Indiana 46202. 1723
1724
STAFt MODIFICATION OF ENTEROCYSTOPLASW
F,
R G . 1. A, tacking sutures are placed in each quadrant of bladder dome to facilitate handling and define proposed cystotomies. cautery is used to o n bladder in sagittal and coronal plans. C,star configuration is completed by extending incisions to Just above tngone and bladder necfp
tant procedures to provide outlet resistance (2 fascial sling suspensions in boys and 2 Young-Dees procedures) in addition to star enterocystoplasty. Subsequently urodynamic studies showed adequate bladder capacity and compliance but inadequate urethral resistance. This finding was not believed to be attributable to the star modification since it does not affect the technical aspects of bladder neck procedures. However, the failure of sling suspension in male patients has been recently noted in a larger group of children who did not undergo concomitant enterocystoplasty (unpublished data). Two children required bladder neck closure and 2 underwent artificial urinary sphincter placement. Periurethral collagen was injected in 1 child, while 1 underwent RESULTS fascial sling bladder neck suspension. Each child is now Average followup was 2.5 years (range 0.4 to 4.4). There continent. After augmentation urodynamics demonstrated were no complications attributable to modified cystoplasty. significant increases in bladder volume and compliance in 13 In 1 patient small bowel obstruction 3 years after surgery cases. required adhesiolysis. Bladder calculi developed in 1patient 13 months postoperatively. Persistent urinary incontinence was a problem in 6 children 1of whom 4 underwent concomiDISCUSSION
dix was then fixed to the umbilicus or right lower quadrant using the previously described technique.5 Bowel segments were harvested, and anastomosed to the bladder using %zero polyglycolic acid suture as a single layer running closure. Ileum or sigmoid colon was reconfigured with the double fold or U technique: or as a n S shape, respectively (fig. 2). The star reconfiguration of the native bladder proved to be an ideal template to combine with these segments as well as stomach. Suprapubic tube diversion was continued for 3 weeks after surgery until a cystogram confirmed an intact repair, &r which intermittent catheterization was started.
FIG. 2. A, lateral extensions of star configuration roughly double length of bladder template for bowel segment anastomosis, decreasing need for bowel-to-bowel anastomosis elsewhere. Segments of S-shaped ileum are uniformly and sequentially aligned ( 1 to 8). E , enterocystoplasty is complete.
The evolution of contemporary enterocystoplasty is marked by 2 significant technical modifications other than the use of various bowel segments. Intestinal detubularization disrupts and dampens unit and mass contractions inherent to the segments of large and small bowel that are used for augmentation. Generous anteroposterior cystotomy (sagittal clamshell cystoplasty) is meant to dissipate pressures within the recipient neuropathic bladder.2 The clamshell procedure also facilitates bladder emptying by eliminating the hourglass appearance typical of augmentation done earlier in the evolution of the operation. This appearance resulted from anastomosing bowel segments to the bladder dome using less generous cystotomies. Despite this advance concern remains that the retained hemibladders continue to initiate uninhibited contractions and undesirable pressures in reservoirs that otherwise appear to be adequately augmented. Studies of post-augmentation instability suggest that much of it is attributable to intestinal rather than detrusor a ~ t i v i t y .However, ~ any residual detrusor contractions or noncompliant tendencies are dampened by the increased volume and compliance provided by the adjacent augmentation. Consequently any possible detrimental contributions by the native bladder after enterocystoplasty have been difficult to Prove UrodWamicallY. Nevertheless, star cystoplasty with its multiple CYstotomies should completely dissipate any Potential pressures within the augmentation. Such an approach
STAR MODIFICATION OF ENTEROCYSTOPLASTY
may be especially beneficial to the small, thickened neuropathic bladder in which the typically fibrotic and less flexible hemispheres tend to coapt in the midline, potentially decreasing compliance of the reconstructed reservoir. The technique is also applicable to the elongated neurogenic bladder and adds little time to the operation. Vascular compromise is not a problem given the radially based, superiorly projecting distribution of the bladder blood supply. The star reconfiguration, a logical extension of the commonly used clamshell cystoplasty, eliminates undesirable urodynamic characteristics from enterocystoplasty. In addition to the clamshell procedure, other options in cystoplasty have included coronal clamshell cystotomy3 and subtotal cystectomy, in which only t h e trigone remains.8 It has been reported that coronal cystotomy results in a higher incidence of postoperative reflwY although a long-term followup by Mundy and Stephenson did not confirm this finding.3 In addition, we have not observed reflux to be a problem after star cystotomy, which combines a similar coronal incision with that of t h e sagittal clamshell technique. It appears that this complication can be avoided by ending the lateral cystotomies above the trigone to avoid weakening the antireflw mechanism of the ureterovesical junction. Although the urodynamic benefits of the star modification are difficult to prove and may be largely theoretical, its technical benefits are real. We suspect that the bowel-tobowel anastomosis necessary to reconfigure the bowel segment in enterocystoplasty represents the weakest part of the reconstruction. Creating lateral extensions of the standard sagittal cystotomy nearly doubles the length of the edge of bladder template for the anastomosis of detrusor and bowel, and eliminates a similar amount of bowel-to-bowel anastomosis elsewhere in the reconstruction. For these reasons reconfiguring the detrusor using the star modification seems preferable to clamshell cystoplasty or subtotal cystectomy, in which the bladder template is almost entirely eliminated.
1725 REFERENCES
1. Mikulicz, J.: Zur Operation der Angerborener blasenspaite. Zentralbl. Chir.. 26 641,1899. 2. Bramble, F. J.:The treatment of adult enuresis and urge incontinence by enterocystoplasty. Brit. J. Urol., 54: 693,1982. 3. Mundy, A. R. and Stephenson, T. P.: 'Clam" ileocystoplasty for the treatment of refractory urge incontinence. Brit. J. Urol., 57: 641,1985. 4. Young, H. H.: An operation for the cure of incontinence of urine. Surg., Gynec. & Obst., 28: 84, 1919. 5. Keating, M. A,, Rink, R. C. and Adams. M. A,: Appendicovesicostomy: a useful adjunct to continent reconstruction of the bladder. J. Urol., 149 1091,1993. 6. Decter, R. M., Bauer, S. B., Mandell, J., Colodny, A. H. and Retik, A. B.: Small bowel augmentation in children with neurogenic bladder: an initial report of urodynamic findings. J. Urol., 138: 1014,1987. 7. Scott, J. E.: Instability in the augmented bladder. World J. Urol., 1 0 71, 1992. 8. Turner-Warwick, R. T. and Ashken, M. H.: The functional results of partial, subtotal and total cystoplasty with special reference to ureterocaeco-cystoplasty. Brit. J. Urol., 39 3,
1967. 9. George, V. K,Russell, G. L., Shutt, A,, Gaches, C. G. C. and Ashken, M. H.: Clam ileocystoplasty. Brit. J. Urol., 68: 487, 1991. EDITORIAL COMMENT
I used the star modification in a few augmentation cystoplasties earlier in my career because I thought that it gave a more spherical appearance to the bladder and, thus, was somehow conceptually more pleasing. However, with time I found that I could not see any difference between this modification and more conventional clamshell enterocystoplasty a s far as outcome was concerned, and so I stopped doing it because it took a little longer than the clamshell procedure without any clear evidence of superior outcome. In addition, the shape of a native bladder in these patients is often elongated, almost banana shaped, and a simple clamshell opening of the bladder leaves 2 long flaps, 1 on each side. Further incision of these CONCLUSIONS flaps, which is necessary in the star modification, might have an The evolution of augmentation cystoplasty continues. TO unfavorable impact on blood supply. I think that bladders with this ensure success with t h e procedure the undesirable charac- shape should not be candidates for this procedure. teristics of t h e neuropathic native bladder should be elimiTerry D. Allen Department of Ur0log.y nated as completely as possible. Star cystoplasty, a safe and Uniuersity of Texas Southwestern Medical Center simple modification of standard techniques, aims to accomDallas, Texas plish this end.
JOURNAL OF UROUX'Y
Copyright 0 1996 by AMERICAN U R O ~ I CAAsLs o c i ~ " h~c~ ~ ,
ENTEROCYSTOPLASTY: THE STAR MODIFICATION MICHAEL A. KEATING,* JOHN K. LUDLOW AND MARK A. RICH From the J . W. Riley Hospital for Children and Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, and Department of Pediatric Urology, Arnold Palmer Children's Hospital, Orlando Regional Medical Center, Orlando, Florida
ABSTRACT
Purpose: A modification of sagittal cystoplasty is described that maximally reconfigures the native neuropathic bladder, as required in enterocystoplasty. Materials and Methods: The star modification incorporates lateral cystotomies with anteroposterior cystotomy, as in t h e widely used sagittal clamshell technique. Results: Enterocystoplasty was performed in 27 patients with various bowel segments using this technique and none has had complications attributable to cystoplasty after a mean followup of 2.5 years. Conclusions: Star reconfiguration defunctionalizes any potential noncompliant or hyperreflexic tendencies inherent to the neuropathic bladder before augmentation. In addition, t h e modification provides a technical advantage by increasing t h e linear length of t h e edge available for the anastomosis of bowel to bladder. KEYWORDS: bladder. neurogenic; surgery, operative Functions of the bladder include storing adequate volumes of urine at low pressure, maintaining continence and volitionally emptying to completion. Various disorders can alter the urodynamic characteristics of the detrusor. Typical examples in children include spina bifida, spinal cord injury, severe bladder dysfunction, posterior urethral valves and exstrophy. When bladder compliance and capacity are significantly affected, incontinence and upper tract deterioration become the inevitable sequelae of altered bladder dynamics. When medical management fails to improve bladder dynamics, augmentation cystoplasty provides an effective surgical solution. A number of bowel segments and configurations have been used to augment the bladder since the procedure was first described in 1899 by Mikulicz.1 In contrast, preparation of the native bladder has received less attention in the literature despite its important role as the neuropathic recipient template of the transposed flap of bowe1.2.3 We report a modification of the widely used clamshell cystoplasty technique that further alters the native detrusor by splitting its bivalved halves with additional coronal cystotomies. The star reconfiguration that results offers technical benefits in the construction of enterocystoplasty and may also provide a urodynamic advantage over current techniques. MATERIALS AND METHODS
During a recent 5-year period augmentation cystoplasty using the star modification was performed in 17 boys and 10 girls 5.2 to 18.4 years old (average age 11.6).The etiology of bladder dysfunction included spinal cord dysraphism in 16 patients, the exstrophy/epispadias complex in 3, posterior urethral valves in 3 and imperforate anus, transverse myelitis, systemic hypotonia, juvenile diabetes and a cervical spine injury in 1 each. Indications for enterocystoplasty were recalcitrant incontinence in 18 patients and progressive upper tract deterioration in the remainder. In each case medical measures, including intermittent catheterization and anticholinergic medication, had failed to improve the condition. Preoperative urodynamic studies demonstrated small blad-
der capacity and/or poor bladder compliance in all patients. The bowel segment used to augment the native bladder comprised ileum in 17 cases, sigmoid colon in 6, stomach in 2 and an ileocecal segment in 2. Concomitant procedures included appendicovesicostomy (111, Young-Dees bladder neck reconstruction4 (5),fascial sling suspension of the bladder neck (9, transureteroureterostomy (5)and cross-trigonal ureteral reimplantation (3). Enterocystoplasty was begun with a midline incision carried to the level of the umbilicus, which gave excellent exposure. After opening the anterior abdominal fascia, and separating the rectus muscles and transversalis fascia, the urachus was identified and ligated. The peritoneum was opened, and the bowel was packed away superiorly with moist towels to expose the pelvis and bladder completely. Chromic 3-ZerO stay sutures were placed in each quadrant of the dome of the bladder to facilitate subsequent handling (fig. 1,A). These sutures also defined the segments created by the coronal and sagittal incisions, which would ultimately yield the star configuration. Cautery was used to open the bladder with a generous midline cystotomy that extended anteriorly to 2 cm. above the bladder neck and posteriorly to 2 cm. above the trigone or ureteral reimplants (fig. 1, B ) . This initial sagittal cystotomy created the standard bivalved or clamshell cystoplasty. At this point planned bladder neck procedures were begun. Young-Dees revisions were created in continuity with the distal extent of the anterior cystotomy while urethral mobilization, required in sling suspension, was more easily completed with the urethra viewed from within. When ureteroneocystotomy was necessary, the cross-trigonal technique was used. Feeding tubes (5F) were placed to help to identify the ureters during completion of the star reconfiguration. With the bladder halves on traction lateral extensions of the initial cystotomy were made in the coronal plane to divide further each hemibladder into 2 parts (fig. 1, C).These incisions were extended to approximately 2 cm. above the trigone to avoid disruption of the ureterovesical junction. Bladder neck revision or sling suspension was completed before anastomosing the enterocystoplasty to the native bladder. When appendicovesicostomywas planned, the right p s terior segment of the detrusor was lee slightly wider to create the recipient bed for the continent stoma. The appen-
Acce ted for publication October 13, 1995. ReaJat annual meeting of American Urological Association, Las Vegas, Nevada, April 23-28, 1995. * Re uests for reprints: J. W. Riley Hospital for Children, Pediatric d o g y Room 1739, Indianapolis, Indiana 46202. 1723
1724
STAFt MODIFICATION OF ENTEROCYSTOPLASW
F,
R G . 1. A, tacking sutures are placed in each quadrant of bladder dome to facilitate handling and define proposed cystotomies. cautery is used to o n bladder in sagittal and coronal plans. C,star configuration is completed by extending incisions to Just above tngone and bladder necfp
tant procedures to provide outlet resistance (2 fascial sling suspensions in boys and 2 Young-Dees procedures) in addition to star enterocystoplasty. Subsequently urodynamic studies showed adequate bladder capacity and compliance but inadequate urethral resistance. This finding was not believed to be attributable to the star modification since it does not affect the technical aspects of bladder neck procedures. However, the failure of sling suspension in male patients has been recently noted in a larger group of children who did not undergo concomitant enterocystoplasty (unpublished data). Two children required bladder neck closure and 2 underwent artificial urinary sphincter placement. Periurethral collagen was injected in 1 child, while 1 underwent RESULTS fascial sling bladder neck suspension. Each child is now Average followup was 2.5 years (range 0.4 to 4.4). There continent. After augmentation urodynamics demonstrated were no complications attributable to modified cystoplasty. significant increases in bladder volume and compliance in 13 In 1 patient small bowel obstruction 3 years after surgery cases. required adhesiolysis. Bladder calculi developed in 1patient 13 months postoperatively. Persistent urinary incontinence was a problem in 6 children 1of whom 4 underwent concomiDISCUSSION
dix was then fixed to the umbilicus or right lower quadrant using the previously described technique.5 Bowel segments were harvested, and anastomosed to the bladder using %zero polyglycolic acid suture as a single layer running closure. Ileum or sigmoid colon was reconfigured with the double fold or U technique: or as a n S shape, respectively (fig. 2). The star reconfiguration of the native bladder proved to be an ideal template to combine with these segments as well as stomach. Suprapubic tube diversion was continued for 3 weeks after surgery until a cystogram confirmed an intact repair, &r which intermittent catheterization was started.
FIG. 2. A, lateral extensions of star configuration roughly double length of bladder template for bowel segment anastomosis, decreasing need for bowel-to-bowel anastomosis elsewhere. Segments of S-shaped ileum are uniformly and sequentially aligned ( 1 to 8). E , enterocystoplasty is complete.
The evolution of contemporary enterocystoplasty is marked by 2 significant technical modifications other than the use of various bowel segments. Intestinal detubularization disrupts and dampens unit and mass contractions inherent to the segments of large and small bowel that are used for augmentation. Generous anteroposterior cystotomy (sagittal clamshell cystoplasty) is meant to dissipate pressures within the recipient neuropathic bladder.2 The clamshell procedure also facilitates bladder emptying by eliminating the hourglass appearance typical of augmentation done earlier in the evolution of the operation. This appearance resulted from anastomosing bowel segments to the bladder dome using less generous cystotomies. Despite this advance concern remains that the retained hemibladders continue to initiate uninhibited contractions and undesirable pressures in reservoirs that otherwise appear to be adequately augmented. Studies of post-augmentation instability suggest that much of it is attributable to intestinal rather than detrusor a ~ t i v i t y .However, ~ any residual detrusor contractions or noncompliant tendencies are dampened by the increased volume and compliance provided by the adjacent augmentation. Consequently any possible detrimental contributions by the native bladder after enterocystoplasty have been difficult to Prove UrodWamicallY. Nevertheless, star cystoplasty with its multiple CYstotomies should completely dissipate any Potential pressures within the augmentation. Such an approach
STAR MODIFICATION OF ENTEROCYSTOPLASTY
may be especially beneficial to the small, thickened neuropathic bladder in which the typically fibrotic and less flexible hemispheres tend to coapt in the midline, potentially decreasing compliance of the reconstructed reservoir. The technique is also applicable to the elongated neurogenic bladder and adds little time to the operation. Vascular compromise is not a problem given the radially based, superiorly projecting distribution of the bladder blood supply. The star reconfiguration, a logical extension of the commonly used clamshell cystoplasty, eliminates undesirable urodynamic characteristics from enterocystoplasty. In addition to the clamshell procedure, other options in cystoplasty have included coronal clamshell cystotomy3 and subtotal cystectomy, in which only t h e trigone remains.8 It has been reported that coronal cystotomy results in a higher incidence of postoperative reflwY although a long-term followup by Mundy and Stephenson did not confirm this finding.3 In addition, we have not observed reflux to be a problem after star cystotomy, which combines a similar coronal incision with that of t h e sagittal clamshell technique. It appears that this complication can be avoided by ending the lateral cystotomies above the trigone to avoid weakening the antireflw mechanism of the ureterovesical junction. Although the urodynamic benefits of the star modification are difficult to prove and may be largely theoretical, its technical benefits are real. We suspect that the bowel-tobowel anastomosis necessary to reconfigure the bowel segment in enterocystoplasty represents the weakest part of the reconstruction. Creating lateral extensions of the standard sagittal cystotomy nearly doubles the length of the edge of bladder template for the anastomosis of detrusor and bowel, and eliminates a similar amount of bowel-to-bowel anastomosis elsewhere in the reconstruction. For these reasons reconfiguring the detrusor using the star modification seems preferable to clamshell cystoplasty or subtotal cystectomy, in which the bladder template is almost entirely eliminated.
1725 REFERENCES
1. Mikulicz, J.: Zur Operation der Angerborener blasenspaite. Zentralbl. Chir.. 26 641,1899. 2. Bramble, F. J.:The treatment of adult enuresis and urge incontinence by enterocystoplasty. Brit. J. Urol., 54: 693,1982. 3. Mundy, A. R. and Stephenson, T. P.: 'Clam" ileocystoplasty for the treatment of refractory urge incontinence. Brit. J. Urol., 57: 641,1985. 4. Young, H. H.: An operation for the cure of incontinence of urine. Surg., Gynec. & Obst., 28: 84, 1919. 5. Keating, M. A,, Rink, R. C. and Adams. M. A,: Appendicovesicostomy: a useful adjunct to continent reconstruction of the bladder. J. Urol., 149 1091,1993. 6. Decter, R. M., Bauer, S. B., Mandell, J., Colodny, A. H. and Retik, A. B.: Small bowel augmentation in children with neurogenic bladder: an initial report of urodynamic findings. J. Urol., 138: 1014,1987. 7. Scott, J. E.: Instability in the augmented bladder. World J. Urol., 1 0 71, 1992. 8. Turner-Warwick, R. T. and Ashken, M. H.: The functional results of partial, subtotal and total cystoplasty with special reference to ureterocaeco-cystoplasty. Brit. J. Urol., 39 3,
1967. 9. George, V. K,Russell, G. L., Shutt, A,, Gaches, C. G. C. and Ashken, M. H.: Clam ileocystoplasty. Brit. J. Urol., 68: 487, 1991. EDITORIAL COMMENT
I used the star modification in a few augmentation cystoplasties earlier in my career because I thought that it gave a more spherical appearance to the bladder and, thus, was somehow conceptually more pleasing. However, with time I found that I could not see any difference between this modification and more conventional clamshell enterocystoplasty a s far as outcome was concerned, and so I stopped doing it because it took a little longer than the clamshell procedure without any clear evidence of superior outcome. In addition, the shape of a native bladder in these patients is often elongated, almost banana shaped, and a simple clamshell opening of the bladder leaves 2 long flaps, 1 on each side. Further incision of these CONCLUSIONS flaps, which is necessary in the star modification, might have an The evolution of augmentation cystoplasty continues. TO unfavorable impact on blood supply. I think that bladders with this ensure success with t h e procedure the undesirable charac- shape should not be candidates for this procedure. teristics of t h e neuropathic native bladder should be elimiTerry D. Allen Department of Ur0log.y nated as completely as possible. Star cystoplasty, a safe and Uniuersity of Texas Southwestern Medical Center simple modification of standard techniques, aims to accomDallas, Texas plish this end.