Laparoscopic Augmentation Cystoplasty

Augmentation cystoplasty remains the most widely accepted reconstructive technique for creating a compliant, large-capacity bladder that protects the upper urinary tract and provides urinary continence for people with bladder dysfunction secondary to noncompliance or reduced functional capacity. This form of bladder reconstruction may even be combined with developing a continent catheteriz-able stoma for use as an accessible port for bladder emptying. Since 1888, the standard enterocystoplasty has classically evolved as a procedure performed through an open laparotomy incision using various segments of well-vascularized segments of the gastrointestinal system that are reconfigured before anastomosis with the urinary bladder. One hundred years have passed since the original open approach for this procedure has become an established reconstructive technique that can be performed laparoscopically. No matter which approach is chosen, the use of any bowel segment for augmentation is associated with advantages and disadvantages, but the versatility of choosing a particular bowel segment, both open and laparoscopic, provides a variety of clinical options based on an individualized set of objectives for the person requiring this form of bladder reconstruction.

Enterocystoplasty is effective in providing a durable increase in bladder capacity and compliance; however, the morbidity and postoperative discomfort associated with the open laparotomy incision are major deterrents. For patients with preexisting debilitating neurologic and other comorbid conditions,the open procedure may significantly prolong the hospital stay, increase the metabolic needs for wound healing, and delay postoperative recovery. Laparoscopy has distinct advantages when compared with open surgical procedures in regard to postoperative pain and morbidity, improved cosmesis, and a shorter hospital stay and decreased convalescence period. Recent studies have indicated that postoperative intraabdominal adhesions are significantly reduced after laparoscopic surgery when compared with open surgery.

Despite the established role of laparoscopy in diagnostic and ablative urologic surgery, the use of laparoscopic techniques in reconstruction has been limited because of the technical complexity of the procedures involved. The technical steps in performing a laparoscopic bladder augmentation are designed to emulate the open surgical counterpart in every aspect, thereby producing similar functional results with an improved recovery.

For laparoscopic or open approaches, the surgical technique of enterocystoplasty is based on the following fundamentals: a) selection of an optimal segment of bowel based on a broad, well-vascularized mesenteric pedicle, b) isolation of the bowel segment, c) reestablishment of bowel continuity and closure of the mesenteric defect, d) detubu-larization and reconfiguration of the bowel segment without peritoneal soiling of bowel contents, e) bladder mobilization with formation of an adequate-sized cysto-tomy, f) creation of a tension-free, water-tight, full-thickness, circumferential anastomosis of the bowel to the bladder, and g) confirmation of adequate postoperative urinary drainage (Figure 7-3.2). As is true in open entero-

Figure 7-3.2. Laparoscopic augmentation enterocystoplasty. (Reprinted with the permission of The Cleveland Clinic Foundation.)

cystoplasty, various segments of the gastrointestinal system may be used for the procedure depending on the clinical requirements of the patient. A length of 20 cm of bowel is usually desirable to attain an adequate augmented bladder capacity. An appropriate segment of bowel is identified based on the following criteria: 1) the bowel segment will reach the area of the bladder neck without tension, and 2) a well-defined arterial arcade should be present in the bowel mesentery.

We have reported on the largest series of laparoscopic enterocystoplasty in 17 patients with functionally reduced bladder capacities attributed to neurogenic causes. Procedures included ileocystoplasty (5), sigmoidocystoplasty (3), colocystoplasty (1), and cecocolocystoplasty with a continent catheterizable ileal stoma (8). Total surgical time (including cystoscopy, stent placement, extracorporeal bowel anastomosis and refashioning of the isolated loop, and laparoscopic dissection and suturing) ranged from 5.3 to 8 hours (average, 7.0 hours). The time for laparoscopic suturing ranged from 1.7 to 3.1 hours (average, 2.4 hours). Blood loss was minimal, and did not exceed 250 mL during any of the cases (average, 175 mL). Oral feeding was resumed by 24 hours in 11 of 12 patients. Although most of the study group had moderate to severe forms of neurologic dysfunction because of multiple sclerosis, the average hospital stay until the patient was discharged home was 5.7 days and ranged from 3 to 7 days. Most notable was the absence of long-term or extended-care needs for the patients with multiple sclerosis because of the demands of wound healing or functional neurologic loss that typically occur with an open procedure in this subset of patients.

All patients consented to participate in a long-term outcome study using preoperative and postoperative validated questionnaires concerning bladder control (BLCS) and bowel control (BWCS). In regard to the quality-of-life

(QOL) measure using the BLCS, there was significant clinical improvement. In regard to the potential risk of causing bowel dysfunction by harvesting various bowel segments for augmentation cystoplasty, there was no clinically significant difference in the bowel control score before or after the procedure.

Laparoscopic augmentation enterocystoplasty is technically feasible and successfully emulates the established principles of open enterocystoplasty whereas minimizing operative morbidity and maximizing clinical effectiveness. As is true in open surgery, various bowel segments can be fashioned and anastomosed to the bladder laparoscopi-cally. The increased costs associated with laparoscopy and with minimally invasive surgery in general have been a significant disadvantage; however, a previous report on the costs of laparoscopic procedures concluded that increased surgical experience reduces the surgical time and length of the hospital stay, thereby decreasing costs. Furthermore, the increased use of reusable instruments results in considerable economic benefits. Implementation of appropriate cost-saving strategies will ultimately result in decreased expenses associated with laparoscopy. Although laparo-scopic enterocystoplasty is currently a lengthy procedure lasting twice as long as open surgery, further technical modifications and increasing experience will continue to reduce the surgical time involved.

For patients with complex comorbid illnesses desiring an improved quality of life associated with traditional augmentation cystoplasty, the reduced morbidity observed in our series of patients undergoing a laparoscopic procedure makes this approach an attractive option to consider. A clinically significant positive impact on their postoperative QOL related to their bladder control compared with their preoperative status will be achieved using a laparoscopic approach. Furthermore, this benefit in their QOL from improvement of their bladder control can be achieved without a negative impact on their bowel control. Our experience suggests that laparoscopic enterocystoplasty has become a viable alternative to open enterocystoplasty and is a surgical option to consider in people with refractory OAB conditions who have failed other management options.

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