1. Enterocystoplasty and Urinary Diversion
Hann-Chorng Kuo
Department of Urology
Buddhist Tzu ChiGeneral Hospital Hualien

2. Enterocystoplasty
Bladder augmentation – increase bladder capacity without (autoaugmentation) or with tissues such as stomach,intestine, or ureter
Bladder substitution—total in situ replacement of bladder with anastomosis to bladder neck or urethra

3. Indication for augmentation cystoplasty
Intractable detrusor hyperreflexia – and incontinence refractory totreatment
Poor bladder compliance and hydronephrosis – compliance is more important than end-filling pressure
Contracted bladder and incontinence
Chronic interstitial cystitis causes bladder pain

4. Causes of contracted bladder for enterocystoplasty
Irradiation cystitis
Chronic non-bacterial cystitis
Tuberculosis granulomatous cystitis
Status post partial cystectomy
Unknown origin resulting contracted bladder – surgical trauma, frequent cystitis
Contracted bladder with vesicoureteral reflux

5. Surgical techniques A 40-cm segment of terminal ileum
Detubularization and fashioned into a W-shaped or double-folded cup
Antireflux mechanism by a nipple valve or direct reimplantation with a submucosal segment of ureter
Bladder was opened as clam-shape
Double layer meticulous anastomosis

6. Surgical technique of Enterocystoplasty (1)

7. Surgical technique of Enterocystoplasty (2)

8. Surgical technique of Enterocystoplasty (3)

9. Surgical technique of Enterocystoplasty (4)

10. Surgical technique of Enterocystoplasty (5)

11. Surgical technique of Enterocystoplasty (6)

12. Surgical technique of Enterocystoplasty (7)

13. Surgical technique of Enterocystoplasty (8)

14. Results of Augmentation cystoplasty

15. Complications of enterocystoplasty
Ureteral reimplantation stenosis 9-16%
Continence %
Need for clean intermittent catheterization 8- 44%
Stone formation
Impairment of bone formation & mineralization

16. Stone formation after enterocystoplasty
More in intestinal reservoir than gastrocystoplasty
Staples, suture materials, metabolic abnormality, PH value
Mucus plays an important role
PH conducive to crystallization of uric acid
Calcium-phosphate ration is elevated in forming stone in intestinal reservoir

17. Late complications of Enterocystoplasty
Mucus production and obstruction
Bacteriuria
Stone formation
Metabolic alteration
Bowel dysfunction
Secondary malignancy

18. Changes of intestinal mucosa

19. Mucosal alteration in ileal bladder
Started at 1 year and completed at 4 years
Reduction in microvilli and inflammatory infiltration of lamina propria
Flattening of mucosa with pseudourothelial morphology
Muscular degeneration and hypertrophy
Collagen deposition and fibrosis

20. Ileal mucosa in enterocystoplasty

21. Muscular degeneration at 1 month after Enterocystoplasty

22. Active peristalsis at initial stage of enterocystoplasty

23. Muscular degeneration at 6-month after Enterocystoplasty

24. Decrease in peristaltic pressure in enterocystoplasty

25. Muscular degeneration at 1-year after Enterocystoplasty

26. Silence of peristaltic waves after enterocystoplasty

27. Contracture of anastomosis of enterocystoplasty in TB patient

28. Changes in bladder compliance in enterocystoplasty

29. Persistent DESD and poor compliance in enterocystoplasty

30. Significance in low compliance after enterocystoplasty
Persistent hydronephrosis after augmentation cystoplasty
Urinary incontinence at full bladder
Night time urinary incontinence due to high peristaltic pressure
Prone to urinary tract infection due to mucosal defects
Dysuria due to small bladder capacity

31. Large capacity and compliance in enterocystoplasty for 5 years

32. Changes in peristaltic pressure and com-pliance before and after enterocystoplasty

33. Gastrocystoplasty
Advantages of gastrocystoplasty– absence of mucus production, hydrogen ion absorption, bacteriuria, acidexcretion
Preferable in patients with chronic renal failure
Disadvantages – excessive acid depletion, metabolic alkalosis, hematuria, peptic ulceration, perforation, dumping syndrome

34. Technique of gastrocystoplasty

35. Ureterocystoplasty Avoid performing gastroenteral surgery
Prevent mucus secretion, secondary malignancy, frequent infection
Indicated only in patients with megaloureter and contracted bladder
Tissue expansion may be another way in achieving a dilated ureter for harvest

36. Bladder autoaugmentation
Increase of bladder capacity is limited
Successful result in detrusor instability comparable with enterocystoplasty
May be indicated in chronic interstitial cystitis with bladder pain
The preoperative bladder capacity determines the final outcome
Minimal surgical morbidity

37. Surgical technique for bladder autoaugmentation
Extraperitoneal exploration of bladder
Inserting Foley catheter and tenting the draining tube to a pressure to keep the intravesical pressure and bladder volume
Dissection of detrusor muscle to mucosa
Dissect the detrusor muscles off mucosa (detrusor myomectomy) with perforation
Dissecting half of bladder wall
Covering with omentum or mucosectomized intestinal wall

38. Bladder autoaygmentation

39. Continent urinary reservoir (Kock pouch)
Indicated in quadriplegics with less good hand function
Women who cannot perform CISC
Severe urethral incompetence and inconti- nence after repeat surgical procedures
Patient with a severely damaged or scarred urethra

40. Contracted bladder with a non-functioning urethra

41. Technique of formation of a Kock pouch

42. Intraluminal pressure and anti-incontinence mechanism

43. Cystoscopic finding of Anti-reflux nipple valve

44. Sonography of anti-incontinence efferent loop

45. Urodynamic results after augmentation cystoplasty
Cystometric capacity cmH2O
End filling pressure cmH2O
Bladder compliance ml/cmH2O
MUCP cmH2O
Preoperative
165±97
50±23
10.8±2.7
62±28
Postoperative
760±289
13±4.7
75±43 －
Statistics
p<0.005
MUCP= Maximal urethral closure pressure.

46. Changes in pressure and capacity after enterocystoplasty

47. Continent cystostomy
Indicated for patients with a fair bladder compliance but a damaged urethra and incontinence
Closed the bladder outlet and augmented with anti-incontinence ileum or cecum with appendix
Avoid excessive intestinal surgery and prevent the need of ureteral reimplantation

48. Seromuscular enterocystoplasty
To avoid mucus secretion and complication from enterocystoplasty
To prevent secondary contracture of the bladder after autoaugmentation
Combined detrusor myomectomy and enterocystoplasty with a segment of mucosecomized ileum
Adequate myomectomy is necessary

49. Technique of Seromuscular enterocystoplasty

50. Orthopedic neobladder in woman
Urinary incontinence is not a problem after neobladder formation without preserving bladder neck
Pelvic floor muscle exercises improve stress urinary incontinence
Pubovaginal sling procedure may help in achieving continence
Complete daytime and night time continence rates are 88% and 79-82%

51. Orthotopin Neobladder in woman after radical cystectomy

52. Contraindication for enterocystoplasty in NVD
Azotemia with elevated creatinine (>2.5mg%) and BUN, CCr <10ml/min
Severely damaged or incompetent urethra
Low abdominal straining ability and poor hand function for catheterization
Severe intestinal dysfunction and diarrhea
Low social status and far to reach medical resources