Ileocecal Bladder Augmentation in Myelodysplasia

0022-5347/88/1394-0786$02.00/0 Vol. 139, April

THE JOURNAL OF UROLOGY

Copyright © 1988 by The Williams & Wilkins Co.

Printed in U.S.A.

ILEOCECAL BLADDER AUGMENTATION IN MYELODYSPLASIA MICHAEL E. MAYO

AND

WARREN H. CHAPMAN

From the Department of Urology, University of Washington, Seattle, Washington

ABSTRACT

We discuss 14 children and adolescents with myelodysplasia who underwent bladder augmentation with the ileocecal segment. The bowel was not detubularized nor was the ileocecal valve intussuscepted. Urodynamic evaluation was performed before and after the procedure in 13 patients with a followup of 1 to 8 years. Postoperative capacity and compliance were normal but cecal contractions occurred in 8 patients despite adequate doses of anticholinergics. Reflux was demonstrated at capacity with a cecal contraction in 4 patients but upper tract dilatation and infection were not clinical problems. Three patients required reoperation for complications owing to ureteroileal stenosis and/or urinary tract calculi. Although the clinical results were satisfactory, detubularized segments of bowel with intussuscepted afferent loop valves to prevent reflux may resolve these problems in the future. (J. Ural., 139: 786-789, 1988) Bladder neuropathy secondary to myelodysplasia is associated occasionally with such poor bladder compliance that upper tract damage cannot be reversed or controlled by an adequate intermittent catheterization program and anticholinergic agents. 1 Also, there are many myelodysplastic adolescents with ileal conduits who underwent construction more than 10 years ago, before the widespread adoption of the intermittent catheterization program. 2 In both of these groups bladder augmentation may be indicated. Various segments of bowel have been used for bladder augmentation in a diverse population of children with various types of bladder dysfunction, including neuropathy, or as part of an undiversion procedure. 3 Because of the many variables, it often is difficult to draw conclusions from such reports. We present our results, and the preoperative and postoperative urodynamic assessment of the ileocecal segment used in a well defined group of children and adolescents with myelodysplasia. MATERIALS AND METHODS

We treated 14 patients between 14 months and 18 years old with myelodysplasia. The procedure was indicated for progressive and massive reflux with poor bladder compliance in 4 children and it was part of an undiversion procedure in 10. All patients underwent preoperative urodynamic assessment and all but 1 had postoperative evaluation, giving a total of 13 cases available for analysis. Of the patients 4 used wheelchairs, and 9 were ambulatory with or without crutches and orthoses. All candidates for undiversion performed bladder cycling, using intermittent urethral catheterization and bladder irrigation 2 to 3 times a day for 6 to 8 weeks before the initial assessment. Urodynamic evaluation was done with the patient in the upright position if possible or with the x-ray table tilted as far as possible into the upright position. Fluoroscopy was performed with spot films and combined with a measurement of detrusor pressure. In the early cases sphincter electromyography and/or urethral profilometry also was done but fluoroscopic appearance alone was used in the latter cases to assess sphincter function. Cystourethroscopy was performed in all patients. The procedure consisted of separating the terminal 10 cm. of the ileum and half of the ascending colon (that segment based on the ileocecal artery), reconstituting bowel continuity, and using the ileocecal segment so that the ascending colon was anastomosed to the bladder. The end of the terminal ileum was Accepted for publication July 20, 1987. Supported in part by the March of Dimes Birth Defects Foundation Grant.

closed and the ureters were anastomosed end to side (fig. 1). The bowel segment was not detubularized nor was the ileocecal valve intussuscepted but the terminal ileum was sutured to the cecal wall to maintain its normal relationships. The bladder was opened widely but supratrigonal cystectomy was only performed if it was grossly thickened. All patients initially performed intermittent catheterization after the procedure and 11 were taking anticholinergic medications. Postoperative assessment was performed between 3 and 6 months, and then at 1 or 2 yearly intervals. Followup ranged from 1 to 8 years. RESULTS

The postoperative data given are those obtained at the initial postoperative visit at 3 to 6 months. Figure 2 illustrates the capacity and compliance before and at 3 to 6 months after surgery. All except 1 bladder had a small capacity (less than 150 ml.) and low compliance (less than 10 ml.fem. water). The exception (capacity 200 ml. and compliance 40 ml.fem. water) was a candidate for undiversion and it was decided to augment the bladder anyway. Compliance and capacity improved to adequate levels postoperatively in all patients. The lower capacities of 115 and 165 ml. occurred in 2 children 14 months and 4 years old, respectively. Reflux through the ileocecal valve was seen in 4 patients and it always occurred at capacity with a pressure increase in the augmented bladder. However, no reflux was demonstrated in 4 other patients in whom bladder contractions were present, and the association of reflux and bladder contractions did not reach significance (see table). Despite reflux through the ileocecal valve, reflux into the upper collecting system was minimal, calicectasis was absent or improved postoperatively in all 4 patients, and there were no clinical episodes of pyelonephritis. Bladder contractions generated pressures of 30 to 50 cm. water and they appeared to be owing to contractions of the cecal segment as judged fluoroscopically, despite adequate doses of anticholinergics in 7 of 8 patients. Four patients had incontinence owing to contractions in the augmented bladder if they allowed the bladder volume to get too high. Some degree of hydronephrosis was present in 11 patients preoperatively and all except 1 improved (fig. 3). All complications occurred within the first year. The case that deteriorated had stones and obstruction at the ureteroileal anastomosis, which required surgery. Urinary tract calculi developed in 2 patients. Some degree of sphincter weakness was found in 9 patients at preoperative assessment but it was insignificant in 6 postoperatively. Of these 6 patients 1 had had

786

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ILEOCECAL AUGMENTATION IN MYELODYSPLASIA

Postoperative reflux through the ileocecal valve with augmented bladder contractions Bladder Reflux Present Absent

Contractile

N oncontractile

4 4

0 5

p >0.05

GRADE OF HYDRONEPHROS!S

III II

0 PRE-OP

POST-OP

FIG. 3. Grade of hydronephrosis preoperatively and postoperatively

impairment preoperatively, all of whom were assessed accurately as judged by postoperative history and urodynamic evaluation. During the followup period of 1 to 8 years 2 bladders increased in capacity as the children grew but no significant changes were seen in compliance, contractility, reflux or sphincter function in any of the patients.

FIG. 1. Technique of ileocecocystoplasty

DISCUSSION

RESULTS OF BLADDER AUGMENTATION

60

"- Before • After

50 0

N

I

8 40 'E w 30

u

z

<:(

ct

::;;

20

0

u 10

50

100

150

CAPACITY

200

250

300

(ml)

FIG. 2. Preoperative and postoperative compliance versus capacity

a successful bladder neck reconstruction at the time of augmentation because of an earlier Y-V plasty. The 3 patients with significant sphincter weakness incontinence have had an artificial urinary sphincter inserted. One of these children underwent a bladder neck resection because of difficulty with catheter insertion and he had been dry between catheterizations previously. After sphincter insertion all 3 patients could empty adequately by straining and they were able to discontinue intermittent catheterization. Four patients had no sphincter

Recently, Goldwasser and Webster reviewed enterocystoplasty in general,4 and the 3 most important aspects of bladder augmentation in myelodysplasia are patient selection, the choice of bowel segment and the prevention of ureteral reflux. The patients for undiversion, especially those with well functioning conduits without complications, must be motivated, have good family support, and be able and willing to perform lifetime intermittent catheterization. Renal function must be adequate to compensate for reabsorption of urine with possible worsening of azotemia and acidosis. The exact level of function is not clearly defined, with the upper level of serum creatinine being reported as 2.5 mg./dl. 5 or creatinine clearance as low as 10 ml. per minute. 6 We would be reluctant to perform undiversion in anyone with a serum creatinine of greater than 2.5 mg./ dl. unless there was some reversible renal pathological condition present or unless the procedure was done before renal transplantation as a planned staged procedure. 7 Ureteral function is rarely a limiting factor in this group of patients, although it may be in children diverted for severe primary ureteral reflux. To assess bladder function we prefer to have the patient undertake bladder cycling for 4 to 6 weeks before definitive urodynamic assessment is performed. Although cycling via a suprapubic catheter may be performed in 5 days,8 we prefer to use intermittent urethral catheterization so that the patient and physician can be assured that motivation is strong enough for the patient to continue with this indefinitely. Bladder cycling only produces a moderate increase in bladder capacity but it makes assessment of sphincter function easier. Urodynamic assessment can be done in a variety of ways but, since these patients rarely void spontaneously, filling studies are adequate to assess the compliance and contractility. There is less agreement on the best way to assess sphincter function. The fluoroscopic appearance of the urethra during bladder filling and at capacity, combined with measurement of bladder

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pressure, will show at what level of detrusor pressure passive leakage occurs through the sphincters. Also, if the patient can be placed in the upright position and asked to perform Valsalva's maneuver or cough, the active and reflex sphincter mechanisms can be tested. 9 Although electromyography and urethral profiles have been advocated, 10 many authors have found that these studies are misleading. 8 • 11 Whether sphincter weakness incontinence would occur postoperatively depends on patient activity, with those in wheelchairs being less likely to have significant incontinence compared to those ambulating energetically on orthoses or with crutches. None of our patients was incontinent on intermittent catheterization postoperatively who had been predicted to be continent on preoperative assessment. Of the 8 children in whom some degree of incontinence was predicted and who had no corrective surgery only 3 were significantly wet postoperatively (more than 3 pads a day during normal daily activity). The artificial sphincter has been used successfully in these 3 patients at a subsequent operation. We believe that it is better not to insert the sphincter at the time of the augmentation procedure unless severe incontinence seems certain. The decision to perform augmentation in all of these patients was affected by previous experience with bilateral ureteroureterostomy for undiversion in a 15-year-old girl. Although she had excellent capacity and compliance, and minimal contractility after preoperative cycling, within 6 months she had a hyperreflexic noncompliant bladder with upper tract dilatation and incontinence. Subsequently, the patient did well with bladder augmentation. Also, the early reports on undiversion in myelodysplasia were not encouraging with 8 of 25 deemed failures owing to incontinence, hydronephrosis and decreasing renal function. However, only 3 of these 25 bladders were augmented, and it is probable that many of the failures were caused by hyperreflexia and poor compliance. 12 The choice of bowel segment was based on the experience at the start of this series 8 years ago. The ileocecal segment had many attractions. It was the right size and shape, and it provided good mobility, a segment of ileum to which to attach the ureters and the ileocecal valve that may prevent reflux. 13 The main disadvantage is that it is contractile. Although Mitchell and associates found no difference in results among cecum, small bowel or sigmoid colon, 14 Goldwasser and associates have reported recently that detubularized ileum or detubularized right colon was the ideal segment for low pressure bladder augmentation. 15 Similar results also can be obtained with a detubularized ileocecal segment. 16• 17 Despite anticholinergics, 8 of our patients had contractions near capacity and in 4 some incontinence was present. In the past reflux prevention by intussuscepting the ileocecal valve has not been successful. Of 10 cases reported by W espes and associates 2 had obstruction and 1 had recurrent reflux. 18 Burbige and Hensle reported 8 of 12 intussusception failures. 19 In our series when the valve was not intussuscepted reflux only occurred at capacity in 4 and it was not a significant clinical problem. With stapling and other techniques now available, intussusception may be more successful. There also are other ways to prevent reflux, such as tunneling the ureter into the cecum, use of a split cuff nipple4 or construction of a valve in the small bowel.1 7 Although the clinical results in this series have been satisfactory, complications, mostly contractions of the cecal segment and reflux, have been sufficient to warrant assessment of other techniques. Presently, our choice of bowel segment for augmentation is the ileum sewn into the bladder in a clamshell technique 20 if the bladder is large enough and the wall thickness is not excessive. If the bladder wall is grossly abnormal a small bowel pouch as described by Kock and associates is used. 21 If undiversion is to be done or if the ureters cannot be reimplanted into the trigone in cases of ureteral reflux, an afferent valve is used for reflux prevention.

REFERENCES

1. Kass, E. J. and Koff, S. A.: Bladder augmentation in the pediatric neuropathic bladder. J. Urol., 129: 552, 1953. 2. Shapiro, S. R., Lebowitz, R. and Colodny, A. H.: Fate of 90 children with ileal conduit urinary diversion a decade later: analysis of complications, pyelography, renal function and bacteriology. J. Urol., 114: 289, 1975. ' 3. Brendler, C. B. and Stephenson, T. P.: Urinary diversion and undiversion in children. J. Urol., 125: 457, 1981. 4. Goldwasser, B. and Webster, G.D.: Augmentation and substitution enterocystoplasty. J. Urol., 135: 215, 1986. 5. Skinner, D. G.: Further experience with the ileocecal segment in urinary reconstruction. J. Urol., 128: 252, 1982. 6. Dounis, A. and Gow, J. G.: Bladder augmentation-a long-term review. Brit J. Urol., 51: 264, 1979. 7. Stephenson, T. P. and Mundy, A. R.: Treatment of the neuropathic bladder by enterocystoplasty and selective sphincterotomy or sphincter ablation and replacement. Brit. J. Urol., 57: 27, 1985. 8. Firlit, C. F., Sommer, J. T. and Kaplan, W. E.: Pediatric urinary undiversion. J. Urol., 123: 748, 1980. 9. Bates, C. P., Whiteside, C. G. and Turner-Warwick, R.: Synchronous cine/pressure/flow/cysto-urethrography with special reference to stress and urge incontinence. Brit. J. Urol., 42: 714, 1970. 10. Bauer, S. B., Colodny, A. H., Hallet, M., Khoshbin, S. and Retik, A. B.: Urinary undiversion in myelodysplasia: criteria for selection and predictive value of urodynamic evaluation. J. Urol., 124: 89, 1980. 11. Webster, G.D. and Older, R. A.: Video urodynamics. Urology, 16: 106, 1980. 12. Borden, T. A., McGuire, E. J., Woodside, J. R., Allen, T. D., Bauer, S. B., Firlit, C. F., Gonzales, E. T., Kaplan, W. E., King, L. R., Klauber, G. T., Perlmutter, A. D., Thornbury, J. R. and Weiss, R. M.: Urinary undiversion in patients with myelodysplasia and neuroge:qic bladder dysfunction. Report of a workshop. Urology, 18: 223, 1981. 13. Gil-Vernet, J.M., Escarpenter, J.M., Perez-Trujillo, G. and Vic, J. B.: A functioning artificial bladder: results of 41 consecutive cases. J. Urol., 87: 825, 1962. 14. Mitchell, M. E., Kulb, T. B. and Backes, D. J.: lntestinocystoplasty in combination with clean intermittent catheterization in the management ofvesical dysfunction. J. Urol., 136: 288, 1986. 15. Goldwasser, B., Barrett, D. M., Kramer, S. A. and Webster, G.D.: Cystometric properties of ileum and right colon in patients following bladder augmentation, substitution and replacement. In: Proceedings of the 3rd Joint Meeting of the International Continence Society and the Urodynamics Society, Boston, Massachusetts, abstract, p. 133, September, 1986. 16. Light, J. K. and Engelmann, U. H.: Le bag: total replacement of the bladder using an ileocolonic pouch. J. Urol., 136: 27, 1986. 17. Thiiroff, 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. Urol., 136: 17, 1986. 18. Wespes, E., Stone, A. R. and King, L. R.: Ileocaecocystoplasty in urinary tract reconstruction in children. Brit. J. Urol., 58: 266, 1986. 19. Burbige, K. A. and Hensle, T. W.: The complications of urinary tract reconstruction. J. Urol., 136: 292, 1986. 20. Mundy, A. R. and Stephenson, T. P.: "Clam" ileocystoplasty for the treatment of refractory urge incontinence. Brit. J. Urol., 57: 641, 1985. 21. Kock, N. G., Nilson, A. E., Nilsson, L. 0., Norlen, L. J. and Philipson, B. M.: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J. Urol., 128: 469, 1982. EDITORIAL COMMENT The authors present a small but well defined group of patients in whom the same surgical technique for bladder augmentation was performed. They have defined clearly 2 important conditions in patients undergoing bladder augmentation and undiversion procedures: adequate bladder capacity and good compliance. Their statement that "the fluoroscopic appearance of the urethra during bladder filling and at capacity, combined with measurement of bladder pressure, will show at what level of detrusor pressure passive leakage occurs through the sphincter" is most important. They also correctly recommend further