Bladder augmentation, also known as augmentation cystoplasty, is a surgical procedure designed to increase the capacity of the urinary bladder or reduce abnormally high pressures within it. This reconstructive surgery typically involves using a segment of the patient’s own intestinal tissue to enlarge the bladder, allowing it to store a greater volume of urine at a lower pressure. The goal is to improve bladder function, alleviate symptoms such as incontinence, and protect the kidneys from potential damage caused by elevated bladder pressures.
Conditions Requiring Bladder Augmentation
Bladder augmentation is generally considered when a person’s bladder is too small, stiff, or exhibits uncontrolled contractions, leading to issues like frequent urination, leakage, or urine reflux back towards the kidneys. One common condition necessitating this procedure is neurogenic bladder, where nerve damage, often from conditions like spina bifida or spinal cord injury, impairs the bladder’s ability to store and empty urine effectively.
Bladder exstrophy, a birth defect where the bladder is open and exposed on the outside of the body, also frequently requires augmentation after initial repairs, as the bladder may remain small and non-compliant. In some cases of interstitial cystitis, an inflammatory condition causing chronic bladder pain and urgency, augmentation may be considered when other treatments have failed to provide relief. Other congenital or acquired bladder dysfunctions that lead to a contracted or high-pressure bladder, potentially compromising kidney function, can also lead to the recommendation for this surgery.
The Surgical Process
Preparation for bladder augmentation involves pre-operative assessments to evaluate bladder and kidney function and structure, which may include blood tests, X-rays, and bladder pressure studies. Patients often undergo bowel preparation for a day or two before surgery to clean out the intestines and reduce infection risk.
During the surgery, performed under general anesthesia, a segment of the patient’s small intestine (ileum) or large intestine (colon), or sometimes even the stomach, is used to enlarge the bladder. The chosen segment, typically 15-20 cm long, is carefully detached from the rest of the bowel while preserving its blood supply. The remaining intestine is then reconnected to ensure normal digestive function.
The detached intestinal segment is then cut open along one side, or “detubularized,” to create a flat patch. This patch is sewn onto an opening made in the top of the bladder, increasing its overall volume and reducing internal pressure. After attachment, the surgeon ensures the connections are watertight. A suprapubic catheter is usually placed through the abdominal wall directly into the bladder to drain urine, along with a urethral catheter, and sometimes a surgical drain near the bladder to monitor for any leakage.
Recovering and Adapting
Following bladder augmentation surgery, patients typically remain in the hospital for about a week. Pain management is provided, often involving medications, to manage discomfort in the lower abdomen. A nasogastric tube may be in place for a few days until bowel function returns.
A suprapubic catheter, inserted through the lower abdomen, usually stays in place for approximately three weeks to ensure continuous urine drainage and allow the augmented bladder to heal. After catheters are removed, regular clean intermittent catheterization (CIC) becomes a lifelong practice for most patients, as the augmented bladder often loses its ability to empty completely. Patients or their caregivers receive detailed instruction on how to perform CIC, which involves inserting a thin tube through the urethra to drain urine at regular intervals.
Because intestinal tissue produces mucus, the augmented bladder will also produce mucus. To prevent blockages and reduce the risk of infections or bladder stones, daily bladder irrigations with saline are often necessary, especially in the first few months post-surgery, and then typically once daily for life. Patients are encouraged to maintain good hydration and a balanced diet. Most individuals can return to normal activities within 4 to 6 weeks, though full recovery may take up to three months, and strenuous activities should be avoided during this time. Regular follow-up appointments, often annually, are important to monitor bladder function and kidney health.
Potential Adverse Outcomes
While bladder augmentation significantly improves bladder function and quality of life for many, potential complications can arise. One of the most common issues is increased mucus production by the intestinal segment, which can lead to catheter blockages and requires routine irrigation. Urinary tract infections (UTIs) are also frequent, and careful adherence to catheterization and hygiene protocols helps minimize their occurrence.
Bladder stones can form in the augmented bladder, often linked to mucus retention and chronic bacterial colonization, with incidence rates varying but sometimes reported in up to 50% of patients. Metabolic imbalances, such as acidosis, can occur if stomach tissue is used for augmentation due to the reabsorption of stomach acid by the bladder lining. Less commonly, patients may experience bowel obstruction due to adhesions forming after surgery, though this is rare.
More severe, though infrequent, complications include bladder perforation, which can be life-threatening and may be linked to high bladder pressures, traumatic catheterization, or chronic infection. Fistulas, abnormal connections between the bladder and other organs, are also a rare but serious adverse outcome. Management of these complications typically involves medical interventions, such as antibiotics for UTIs or dietary adjustments for metabolic issues, and sometimes further surgical procedures for stones, perforations, or fistulas.