SURGICAL ALTERNATIVES EXCLUDING DENERVATION PROCEDURES TO TREAT

In document Neurologic Urinary and Faecal Incontinence (Page 57-59)

STIMULATION OF THE ANTERIOR SACRAL ROOTS

5. SURGICAL ALTERNATIVES EXCLUDING DENERVATION PROCEDURES TO TREAT

REFLEX INCONTINENCE DUE TO NEURO- GENIC DETRUSOR OVERACTIVITY

• Keywords

neurogenic bladder; spinal cord injury; spina bifida; myéloméningocèle; multiple sclerosis; bladder augmentation; enterocystoplasty; gastrocystoplasty; sigmoidocystoplasty; colocystoplasty; uretero- cystoplasty ; autoaugmentation; detrusorectomy a) Bladder augmentation using intestinal segments

The aim of bladder augmentation is to provide long- term protection to the upper urinary tract by reducing the risk of impairment due to high bladder pressure, as well as to improve micturition comfort [1].

First performed in man in 1889 by Von Mickulicz [2] who used a segment of small intestine, the technique has regained popularity since the 1970s after the introduction of intermittent catheterization [3]. Unlike complete bladder replacement, enterocysto- plasty preserves the integrity of the trigone of the bladder with the urethra and ureters and reimplantation is not necessary. A segment of the gastrointestinal tract is then removed and sutured onto the bladder.

Various augmentation techniques using different segments of the gastrointestinal tract (caecum, colon, and ileum) have been described.

1. INDICATIONS

Bladder augmentation is indicated wherever bladder capacity and compliance is reduced, or in the event of detrusor overactivity, when all conservative treatments (medical treatments, detrusor injections of botulinum toxin and/or neuromodulation of the posterior sacral roots) have failed [1, 4].

Before performing bladder augmentation, it is essential to ensure that:

• There is no malignant disease or lithiasis in the bladder.

• Renal function is normal and the upper urinary tract is unimpaired (screen particularly for lithiasis). • There is no gastrointestinal tract disease (Crohn’s disease, hemorrhagic rectocolitis, short gut syndrome, etc.).

• The patient is capable of, and willing to, perform self-catheterization. This can be combined with continent cystostomy, a topic to be dealt with in a separate chapter.

2. TECHNICAL PRINCIPLES

There are two stages to the surgical procedure: first bladder preparation and then augmentation. Usually open surgery is performed, but recently laparoscopy has been reported [5, 6](LOE3). At present, except for technical articles on laparoscopy, there are no publications comparing this technique with open surgery.

The bladder can be prepared either by clam cystoplasty or by supratrigonal cystectomy. The preferred preparation depends on the quality of the detrusor, and more particularly on whether the bladder has retained its visco-elastic properties. Where the detrusor is very fibrous and thick, supratrigonal cystectomy should be envisaged, since exclusion of the ileal patch may occur. Nowadays, supratrigonal cystectomy is often performed because compliance disorders in a bladder that has retained its visco- elastic properties can be treated effectively by detrusor injections of botulinium toxin [7].

a. Bladder preparation • CLAM CYSTOPLASTY

Clam cystoplasty involves freeing the anterior/posterior surfaces and dome of the bladder and then sectioning from front to back in the sagittal plane. The bladder can be opened either in the transverse plane or sagittal plane, the incision starting and ending about 2 cm above the bladder neck. The lateral surfaces are not freed. The umbilical arteries are preserved to maintain vascularization of the bladder dome.

or is able to perform intermittent cathe- terization ( B). In this indication, it seems better to use an aponevrotic tape (C). • AUS can be proposed to patients with a

neurological bladder dysfunction after careful assessment of their general handicap and a detailed discussion regarding the sphincter cuff implantation site (A). Even if one third of the patients would be able to urinate, it is preferable to be sure that the patient accepts or is able to perform intermittent catheterization (B).

• Bulking agents can be used in patients with a neurological bladder dysfunction demanding a minimally invasive treatment (D). It is probably better to verify that the patient accepts or is able to perform intermittent catheterization (D).

• When a continent cystostomy has been performed, and if no other treatment is possible, bladder neck closure can be proposed to patients with a neurological bladder dysfunction (D).

• Bladder neck surgery should be proposed, in patients with a neurological bladder dysfunction only if no other treatment option is available (D).

• SUPRATRIGONAL CYSTECTOMY

Supratrigonal cystectomy involves resection of the bladder tegument and sparing the trigone. The bladder is freed under the peritoneum and the right and left umbilical arteries ligated and sectioned. The bladder tegument is completely freed and the bladder pedicles ligated and sectioned laterally up to the trigone, which is preserved. During the bladder dissection, care must be taken to spare the ureteral vascularization. Supratrigonal cystectomy is performed by making a circular incision with an electric scalpel into the tegument 1 to 2 cm above the trigone.

• URETERAL REIMPLANTATION

Ureteral reimplantation must be carefully discussed in the event of vesicorenal reflux. Several authors have reported that improved bladder compliance precludes the need for vesicoureteral reimplantation (LOE 3) [8-11]. They have reported a resolution rate of about 85% for vesicorenal reflux, classified below grade IV. For grade V reflux, improvement was observed in 2/3 of patients. It is important to point out that, except for the work of Simforoosh [8], these consistent results were obtained in small heterogeneous series of children (neurogenic bladders and congenital anomalies). The results were published after relatively short mean follow-up times (1 to 5 years).

Recently, Hayashi et al. [12] reported on 22 patients treated by ureteral reimplantation during bladder augmentation (LOE 3). Their work was original in that it gave detailed account of renal function after long- term follow-up (mean: 12 years). In the hands of this experienced team, ureteral reimplantation during bladder augmentation did not result in greater morbidity and 97% of patients recovered. Renal function was preserved and satisfactory.

It is therefore too early to rule out the need for ureteral reimplantation during bladder augmentation, especially for cases of grade V reflux. However, it is clear that improved compliance will reduce some vesicorenal reflux.

b. Intestinal segments • STANDARD TECHNIQUE

The choice of intestinal segment depends on patient’s history and the local conditions. All segments of the gastrointestinal tract may be used, except the jejunum because of the risk of water-electrolyte disorders. The most frequently used segment in adults is the ileum because it is easy to remove, is close to the bladder and may be shaped easily into a reservoir. Colon segments are used more often in children.

The removed intestinal segment must always be detubularized to reduce peristalsis to a minimum and to obtain a reservoir with low pressure. The segment

is then placed and sutured onto the bladder in the form of a patch. For supratrigonal cystectomy, the intestinal segment needs to be longer and fashioned into a neo bladder [4].

• TECHNICAL VARIATIONS

The main objective is to reduce mucus secretion and prevent the reabsorption of urine by the intestinal mucosa that leads to metabolic acidosis. Two variant techniques have been proposed but not developed extensively, probably because they involve relatively major surgery for the benefits they bring.

The first is seromuscular colocystoplasty lined with urothelium. This involves removing the detrusor, leaving the bladder mucosa intact, and then covering it with a demucosalized sigmoid patch [13].

The second technique is seromuscular entero- cystoplasty. After preparing the bladder, a segment of the ileum or the sigmoid is removed and detubularized. The mucosal membrane of the intestinal segment is surgically removed, or destroyed by argon beam [14] and the segment is then placed on the prepared bladder [15].

c. Results of enterocystoplasty

The main published series for patients undergoing surgery for neurogenic bladder are summarized in Table 10.

• EARLY MORBIDITY AND MORTALITY

Peri-operative mortality is estimated between 0 and 3.2% (LOE 2-3). The most frequently reported early morbidity (LOE 2-3) is prolonged post-operative ileus. It occurs in up to 11.7% of cases [16-18]. However, it should be noted that systematic and prolonged use of a nasogastric catheter is no more justified in neurological patients than in the general population (LOE3)[19]. Other common complications include episodes of febrile urinary infection (4.8 to 9%), urinary fistula (0.4 to 4%) that usually resolve and thrombo- embolic complications (1 to 3%). When the pelvis has been irradiated, the patient must be warned of the increased risk of entero- or colovesicular fistula. • LATE MORBIDITY

Chronic bacteriuria always occurs with intermittent catheterization and should not be considered a complication [20](LOE4).

The risk of calculus in the enlarged reservoir ranges from 10 to 50% [21-24] (LOE 2-3). It would appear that there is a higher risk of developing upper urinary tract lithiasis than in the general population [25-27] (LOE3). After bladder augmentation, intestinal transit disorders are frequent and probably underestimated (0 to 30% of cases [17, 28-30]). Several explanations have been proposed (ileocecal valve not preserved, biliary salt malabsorption, etc.). Somani et al. recently conducted

T

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