John J Bauer, MD, FACS John J. Bauer, M.D.
www.flinturology.com

Urology Services, Inc.
G-1121 West Hill Rd.
Flint, Michigan 48507
Tel: 810.232.8888
Fax: 810.232.9190
Email: jbauer@flinturology.com
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Augmentation Cystoplasty
Surgery Details

Contents
General information
Pre-operative instructions
Risks and Complications
Detailed Surgery Description
Family waiting instructions
Post-operative instructions

Printing tip: If you want to print only one portion of this entire document, you should be able to do this depending on your software. To print a selection, highlight the section you want to print using your mouse, then click on print, and then in the print menu, choose "selection."

Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary�.



General Information

This procedure is most commonly performed for a contracted neurogenic bladder. A neurogenic bladder is the loss of normal bladder function caused by damage to part of the nervous system. A neurogenic bladder may result from a disease, an injury, or a birth defect affecting the brain, spinal cord, or nerves leading to the bladder, its outlet (the opening into the urethra from the bladder), or both. A neurogenic bladder can be underactive, in which it is unable to contract (non-contractile) and unable to empty well, or it can be overactive (spastic), emptying by uncontrolled reflexes.

Causes

An overactive bladder usually results from an interruption of normal control of the bladder by the spinal cord and brain. A common cause is an injury or a disorder, such as multiple sclerosis, affecting the spinal cord, which may also result in paralysis of the legs (paraplegia) or the arms and legs (quadriplegia). Often, such an injury first causes the bladder to become flaccid for days, weeks, or months (the shock phase). Later, it becomes overactive and empties without voluntary control. It can also be caused by other neurological diseases such as stroke, Parkinson�s disease, Multiple Sclerosis, etc. An additional cause can be from Interstitial Cystitis.

Symptoms

The symptoms vary, according to whether the bladder is underactive or overactive. An overactive bladder may fill and empty without control and with varying degrees of warning, because it contracts and empties by reflex (involuntarily). With an underactive or overactive bladder, the pressure and back-flow of urine from the bladder up through the ureters may damage the kidneys. Among people who have a spinal cord injury, the contraction of the bladder and relaxation of the bladder outlet may not be coordinated, so that the pressure in the bladder stays elevated and does not allow the kidneys to drain.

Diagnosis

Often, a doctor can detect a small contracted bladder by examining the lower abdomen. X-ray imaging studies using a radiopaque substance injected through a vein (intravenous urography) or through a catheter into the bladder (cystography) and urethra (urethrography) provide more information. The x-rays can show the size of the ureters and bladder, and possibly stones and kidney damage, and give the doctor an indication of how the kidneys are functioning. Ultrasound imaging provides similar information. Cystoscopy is a procedure in which a doctor can look inside the bladder through a flexible scope that's inserted through the urethra usually painlessly.

The amount of urine left in the bladder after urination can be measured by inserting a catheter through the urethra to drain the bladder. Pressure within the bladder and urethra can be measured by connecting the catheter to a meter (cystometrography).

Treatment

A catheter may be inserted through the urethra to drain the bladder continuously or intermittently. The catheter is inserted as soon as possible after the injury to prevent the bladder muscle from becoming damaged by being overstretched and to prevent a bladder infection.

Permanent placement of a catheter causes fewer physical problems in women than in men. In a man, the catheter may cause inflammation of the urethra and surrounding tissue. However, for both men and women, use of a catheter that can be inserted by the patient periodically--four to six times a day--and removed after the bladder is empty (intermittent self-catheterization) is preferred.

People who develop an overactive bladder may also need to have a catheter inserted for drainage if spasms of the bladder outlet prevent the bladder from emptying completely. For quadriplegic males who can't catheterize themselves, the sphincter (ring-like muscle that closes an opening) at the outlet may have to be cut to allow emptying, and an external collecting device can be worn. Electrical stimulation may be applied to the bladder, the nerves that control the bladder, or the spinal cord to induce the bladder to contract, but this type of treatment is still experimental.

Drug treatment may improve the bladder's storage of urine. Control of an overactive bladder can usually be improved with drugs that relax the bladder, such as anticholinergic drugs. However, these drugs commonly cause side effects, such as a dry mouth and constipation, and improving bladder emptying with drugs is difficult for people who have a neurogenic bladder.

Surgery to divert the urine to an external opening (ostomy) made in the abdominal wall or to increase the bladder size is sometimes recommended. Urine from the kidneys may be diverted to the body's surface by removing a short segment of the small intestine, connecting the ureters to it, and attaching it to the ostomy, allowing the urine to be collected in a bag. This procedure is called an ileal loop. The bladder can be enlarged with a segment of the intestine in a procedure called augmentation cystoplasty, and self-catheterization is performed. For infants, a connection is made between the bladder and an opening in the skin (vesicostomy) as a temporary measure until the child is old enough for definitive surgery.

Although complete recovery is uncommon with any type of neurogenic bladder, some people recover considerably with treatment.

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Pre-Operative Instructions

Your pre-operative appointments

Before your surgery, you will be seen by the physician and the anesthesiologist, and when applicable, there is a pre-admission appointment with the hospital. Click here to read more details about these appointments, referred to as the Pre-Operative Work-Up.

Change In Health Status

Notify your surgeon if you experience any significant change in your health status: develop a cold, influenza, a bladder infection, diarrhea, or other infection, before your surgery.

Pre-Operative Medication Instructions

Unless specifically instructed otherwise by your surgeon or anesthesiologist, please observe the following guidelines for taking your medicines before surgery:

  1. One Week Prior to Surgery:
    - STOP all aspirin and all aspirin-containing medicines (e.g., Anacin, Excedrin, Pepto-Bismol). Check any cold or pain medication bottles to make certain aspirin is not contained. See additional list at Blood Thinners.

  2. Two Days Prior to Surgery:
    - STOP all nonsteroidal anti-inflammatory medications (e.g., etodolac [Lodine], fenoprofen [Nalfon], ibuprofen [Advil, Motrin, Nuprin], ketorolac [Toradol], maproxen [Aleve], meclofenarnate [Meclomen], mefenamic acid [Ponstel], naproxen [Anaprox, Naprosyn].

  3. Day Before Your Surgery:
    Start the pre-operative Bowel Prep (cleansing procedure) appropriate for this surgery, as described below:

    Your procedure involves the bowel and therefore needs the most thorough cleaning protocol. It will be ordered by your physician and it may require hospital admission the day before.

  4. On the Morning of your Surgery:

Pre-Operative Diet Instructions

Unless specifically instructed otherwise by your surgeon or anesthesiologist, patients of all ages must observe the following diet restrictions before surgery:

  1. Eight hours before the Scheduled Start of your Surgery:
    DO NOT EAT any solid foods, including juices with pulp (e.g., orange juice, nectars), lozenges, candy, chewing gum, and mints. DO NOT DRINK full liquid, such as milk, cream, and jello. You may continue to drink up to eight ounces of clear liquids until SIX hours before the scheduled start of your surgery. Clear liquids include Water, clear juices (e.g., apple, grape), black tea and black coffee.
  2. Six hours before the Scheduled Start of your Surgery:
    DO NOT TAKE anything by mouth except for your usual medicines; follow the Preoperative medication instructions above.
  3. Exceptions:
    DO NOT TAKE anything by mouth for eight hours, except for your usual medicines, if you are pregnant, morbidly obese, or are diagnosed with diabetes, renal failure, or stomach acid reflux with heartburn.

Patients undergoing operative or diagnostic procedures involving sedation are required to refrain from eating, drinking or taking anything by mouth for a stated period prior to their surgery or procedure. The reason for this is to prevent complications caused by nausea or vomiting while you are unconscious. Should you vomit while in the unconscious state, the risk exists that the vomit may enter into your lungs causing serious complications such as pneumonia. These complications may result in an extension of your hospitalization following your surgical procedure. It is for this reason patients are often instructed to have nothing by mouth after midnight the night prior to your operation unless otherwise instructed by an anesthetist.

Pre-Operative Cleaning Instructions (bathing and showering instructions)

Pre-operative showers are to be taken the night before and the morning of surgery just prior to your arrival. All adults are required to take a shower using either a Betadine or Hibiclens Surgical Scrub antibacterial soap. The reason is to remove as much bacteria from your skin as possible prior to your surgery. If you are allergic to these products please notify your physician or nurse. Perform your shower as follows:

  1. Generously lather your body, scrub well, and rinse. Give particular attention to the area were the incision will be made for your procedure.
  2. Following the morning shower, do not apply creams, body oils, lotions, perfumes, deodorants, makeup, lipstick, nail polish or any other cosmetic product to the skin or nails.
  3. Do not use Hibiclens on your face. You may use any other antibacterial soap for the face.
  4. Children under 5 years of age are to be given a bath using an over the counter antibacterial soap.

On The Day Of Surgery

The anesthesiologist will discuss with you the anesthetic most appropriate for your medical condition and procedure prior to surgery.

After your surgery you must be escorted/driven home by a responsible adult. You may take a taxi car or shuttle if accompanied by a responsible adult who can stay with you after the driver departs.

Time To Arrive For Your Surgery

During your Pre-Admission Interview, our Registered Nurse will provide you with the correct time to arrive for check-in prior to your surgery.

ARRIVAL TIME:
WHERE TO ARRIVE:

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Risks and Complications

The risks and complications for this surgery are described in the "Counseling and Pre-Op Note" that you will need to sign before the surgery. The main content of that note is listed below.


Indications:

Patient is a male/female with severe bladder dysfunction. Patient has undergone thorough evaluation with urodynamic testing (UDT�s) demonstrating a small capacity bladder intractable hyperreflexia or detrussor instability with or without urge incontinence without response to typical medical therapy. Patient was given the options and has chosen an augmentation cystoplasty.

Alternatives:

Alternatives include: watchful waiting, timed voiding, continued medical therapy, Interstim therapy, behavioral/biofeedback/pelvic floor electrical stimulation therapy, and condom catheter.

Risks/Complications:

ThThe risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.

The specific risks of this procedure include, but are not limited to: failure to improve urinary urgency and incontinence, bowel/bladder/ureteral injury, persistent pelvic serous drainage, urinary stones, urinary tract infections/pyelonephritis, hernias, metabolic abnormalities that may need chronic medication, adhesions, ileus, fecal fistula, and atelectasis

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.


To view the actual printable form for this surgery, click here: Counseling Note for Augmentation Cystoplasty. To print the document, simply select print after you have opened the page. You can use that copy to sign before your surgery.

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Detailed Surgery Description

Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary�.


Indications: Patient with neurogenic bladder.

Sample Procedure Dictation:

Patient was given a continuous epidural anesthetic with supplemental general anesthesia. He was placed in the supine position and then was prepped and draped in the usual standard sterile fashion. A 16 French Foley catheter was placed per urethra with good return of urine; balloon was inflated to 30 cc with sterile saline. A midline incision was made from the above the umbilicus to the symphysis pubis coagulating all bleeders as the where encountered. The rectus fascia was divided the length of the incision and the space of Retsius was developed bluntly to expose the bladder and obturator fossa. The obturator lymph nodes were palpated. All nodes were normal in character. The bladder was then entered in a transverse manner from the lateral borders with bovie coagulation and using 0-chromic stay sutures for traction. The ureteral orifices were noted to be intact with good efflux. 2-0 vicryl sutures were placed at the lateral borders of the bladder incision to prevent tearing the lateral wall of the bladder. These sutures will be used later in the case to attach the bowel segment. Approximately 15 cm of Ileum proximal to the ileocecal valve was measured and tagged with 3-0 GI silk sutures. The mesentery was then delicately dissected from the ileum near the sutures to allow a GIA stapler to be placed. The mesentery was then incised in a sequential manner using Kelly clamps and 3-0 silk free ties. Large feeding vessels were avoided during this process to avoid vascular compromise. The bowel segment was then isolated using the GIA stapler. The wound was then draped off with sterile towels and both ends of the segment were opened to allow copious irrigation of the bowel lumen with saline until clear. The anti-messenteric border was then opened using the bovie. The stapled ends were then excised using heavy scissors. The two ends of the ileum were then re-anastomosed using the GIA/TIA stapler in a standard side-to-side manner. The staple line was then reinforced and everted with 3-0 silk sutures. The anastomosis was inspected with bowel contents milked through without leakage. The mesentery was closed with 3-0 vicryl sutures to prevent internal herniation. The augmented ileum and mesentery were in a position below the anastomosis and closed mesentery. The augmented ileum was the tacked at four corners to the bladder and sutured with 2-0 vicryl sutures in a running baseball stitch manner from each corner, with care not to dog-ear the bowel segment. Before final closure, a 24-French Mallecot SP Tube was placed through a separate stab wound in the bladder. It was secured with a purse-sting 0-chromic suture. Once the closure was accomplished, the new augmented bladder was filled through the Foley catheter to identify areas of leakage. These were closed with figure eight 2-0 vicryl sutures until no leakage was noted with 500 cc of saline instilled in the bladder. The bladder was drained. The bowel anastomosis was re-inspected without vascular compromise or leakage. The augmented ileal segment was also re-inspected and noted to be devoid of vascular comprise. A 10mm Jackson-Pratt drain was placed through a separate stab incision in the pelvis. The operative site was inspected for possible bleeders, which were clipped if found. The fascia was then closed in a running fashion with #2-vicryl suture. The subcutaneous tissue was irrigated with saline and the skin was closed with staples. Xerofoam gauze was placed over the incision and bandaged. The JP drain and Mallecot was secured with 3-0 nylon sutures to the abdominal wall. These and the Foley were securely tapped. The patient was then awaken from anesthesia without complications and transferred to the Recovery Room (RR) with the epidural used for pain control. The patient arrived to the RR in stable condition and without complications.

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Family Waiting Instructions

To the family and friends of patients undergoing surgery.

SCHEDULED STARTING TIME OF SURGERY:

ESTIMATED LENGTH OF SURGERY:

You should plan to check in at the waiting area information desk as soon as your family member or friend has left for the Operating Room. This is the only way we can talk to you afterwards, or on occasion; reach you to give you updates on the operation's progress. If the surgery is scheduled for many hours, you can leave to eat or do other things, but you should let the information desk know that you are going to leave the area, where you are going, and how long you might be gone so that we might reach you if need be. You should be in the area before the elected time of the end of the operation.

The information deck will overhead page you or the "family of" when they receive the recovery call to let you know that the surgery has been completed. The overhead page system works ONLY on the Surgical Waiting Area and not throughout the hospital or the cafeteria.

We will plan to see you in the surgical waiting area after we have safely completed the early phases of the post-anesthesia recovery in the "Recovery Room" or PAR (Post Anesthesia Recovery). This may take up to an hour after the initial call. Sometimes, especially if another case is ready to start, we will call and talk to you. If for some reason, we have not come or called within 30 minutes, please ask the information desk to page us.

Your family member will be in the Recovery Room for 1-2 hours. This is standard recovery time, although the times vary with each individual. For example, spinal anesthetics take longer to "wear off," local anesthetics are much shorter acting. Under no circumstances are family members or friends allowed in the recovery room. The information deck will inform you of the patient's return to the room as soon as they receive the information that the patient has left recovery. At that time, they will give you the room number and direct you to the correct wing and floor.

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Post-Operative Instructions

Activity

  1. No heavy lifting (more than 15 lbs.) for 4 weeks (1 week for an implant).
  2. No driving for 3 weeks (1 week for an implant). We also discourage riding in a car since the vibrations and movement may cause bleeding.
  3. Use the stairs infrequently. Take one step at a time, and have assistance available.
  4. No long trips for 3 weeks.
  5. No cutting the lawn, shoveling snow, raking leaves, etc., for 4 weeks.
  6. No sexual activity for 6 weeks after surgery.
  7. No manipulation of the prosthesis
  8. Showers after the bandages are removed (48 hrs) are okay. It is okay to wash the wound, do not rub the wound just pat dry it. Avoid tub baths or swimming in a pool for 1 week.
  9. Regular light activity is encouraged several times daily. We encourage walking. Do not be a couch potato.
  10. If discomfort returns then reduce activity, take it easy, and more gradually resume activities.

Diet

  1. Drink plenty of fluids. We recommend 24-32 oz over your usual daily fluid intake. Limit fluids after 6 PM. Avoid tea, coffee (including decaf) and pop.
  2. Resume a regular diet at home. Take high calorie supplements if appetite is poor.
  3. If you have a special diet secondary to Diabetes, Renal Disease, Liver Disease, etc. you may resume eating when tolerated.

Medication

  1. Please take the medications as prescribed by your doctor. Start them on day of discharge, and please complete the entire prescription. Take pain medication only as needed. Try Tylenol or Motrin for milder pain. You will typically be discharged with your old medications and new pain medication, antibiotics and stool softeners
  2. Resume all medications you normally took before surgery, unless instructed otherwise. Do not take blood thinners or aspirin products for 1-2 weeks or as directed.
  3. If there is a problem taking or getting the medication, call us.

Catheter and Wound Care

  1. Do not remove the dressing from the wound unless instructed. If you are home with a bandage, it is usually removed after 48 hrs.
  2. Your sutures will dissolve over time and do not need to be removed. Your steri-strips will fall off over a two-week period; please let them fall off on their own rather than removing them. You can trim the edges of the steri-strips that have rolled up onto themselves if they bother you.
  3. You may cover the wound with gauze if there is mild drainage.
  4. If the wound becomes red, inflamed, or has excessive drainage, please contact your doctor immediately.
  5. If you notice pus coming from any wound, please call your physician.
  6. Expect some spotting or bleeding from your incision for the next 1-week, if it progressively worsens then please call your physician.
  7. If you have a catheter in place, wash around it gently with soap and water. Keep the catheter taped to your thigh or abdomen to avoid inadvertent jerking or pulling. Do not disconnect the catheter from the drainage bag unless directed by your doctor. You may apply Bacitracin ointment at the point the catheter enters your body.

Bowel Movements

  1. Do not strain when having a bowel movement. Expect irregular bowel habits after surgery until fully recovered. Increase fiber in your diet.
  2. You may need to use a stool softener or laxative. Try Colace (Docusate Sodium), Metamucil or Milk of Magnesia at your local pharmacy.

When to Contact your Doctor

  1. Excessive bleeding or passage of large clots. Also if you feel your bladder is not draining or if you are unable to urinate.
  2. Fevers greater than 101º F, excessive chills.
  3. Nausea and vomiting or inability to keep down fluids.
  4. If you have any questions or concerns that are not covered by this handout.
  5. Significant tenderness or swelling in the legs, chest pain, shortness of breath.
  6. If it is a serious emergency, go the Emergency Room or call 911.
  7. Please call the office to arrange your follow-up appointment.

Contacting Your Physician

Dr. Bauer can be contacted by calling the number listed at the top of the page. You may also call the hospital to have them contact us. Please do not hesitate to call with any questions or concerns.

Frequently Asked Questions after surgery

This section is under construction.

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