What is Augmentation Surgery (Ileocystoplasty - Bladder Enlargement)?

One of the most important functions of the bladder is to store urine filtered by the kidneys until the individual urinates. Bladder augmentation surgery is a procedure aimed at increasing bladder capacity in cases where bladder capacity has decreased for various reasons.

How is bladder volume calculated in children?

The volume of the bladder (urinary bladder) also changes with age in children. For this reason, bladder volume is calculated using different formulas for different ages. In very young infants (under 2 years of age), bladder capacity (mL) = 38 + 2.5 × age (months). In older children (over 2 years of age), bladder capacity (mL) can be calculated using the formulas: bladder capacity (mL) = [age (years) + 2] × 30 or bladder capacity (mL) = 30 + [age (years) × 30].

Who is eligible for augmentation surgery in children?

The main reasons for performing augmentation (ileocystoplasty) in children are as follows.

• Neurological causes such as spina bifida/meningomyelocele
• Posterior urethral valve
• Bladder exstrophy
• Cloacal exstrophy
• Some patients who have undergone surgery due to anal atresia.
• Bladders that behave as if they have nerve damage but do not actually have nerve damage (non-neurogenic neurogenic bladder)
• Very rare and selected patients with overactive bladder who do not respond to other treatments.

Who is not eligible for augmentation?

Patients should be thoroughly evaluated before ileocystoplasty surgery. The details are explained to the family (mother, father) and the child several times at different times. If possible, patients and families who have used this method are consulted. As a result, this method should not be performed on some patients.

• Patients with hand problems. Because these patients cannot empty their bladder on their own, catheterization will be necessary. If the patient is unable to do this, other methods should be tried.
• Those with severe kidney damage: Kidney function must be normal for this type of surgery. If there is severe deterioration in kidney function, extra caution should be exercised with these patients.
• Patients with psychological issues who cannot undergo catheterization after surgery and patients with a family history of psychological issues up to adulthood.

Is Augmentation Cystoplasty Surgery Successful in Patients with Overactive Bladder?

There are various treatment options for overactive bladder surgery. These patients should first be treated with medication (anticholinergic drugs). If medication does not work, Botox injections into the bladder or neuromodulation therapy may be used. If these do not work, the last resort is autoaugmentation cystoplasty surgery. In cases where bladder volume is significantly reduced, medication is generally ineffective, and surgery is required.

What is Auto Augmentation Surgery, and How is it Performed?

It is performed on patients with overactive bladder who do not respond to drug treatment or on some patients with neurogenic bladder who have insufficient bladder capacity. The procedure can be performed laparoscopically. The detrusor muscle layer of the bladder is completely removed, leaving only the innermost layer, known as the mucosa, intact. As a result, the mucosa takes on a diverticulum shape and expands. However, the mucosa may collapse (shrink), leading to surgical failure or even a smaller bladder.

 

Is Augmentation Cystoplasty Surgery Successful in Children with Neurogenic Bladder?

In spastic neurogenic bladder disease, bladder capacity is significantly reduced and vesicoureteral reflux (VUR, urine flowing from the bladder to the kidneys) may occur. In such cases, ileocystoplasty surgery may be necessary to expand the bladder volume. The results of surgery in these patients are quite successful. After this surgery, bladder volume increases and VUR is corrected.

What are the goals of augmentation surgery?

These patients have two main problems: small bladder capacity and urinary incontinence. The main goal in these patients is to prevent urinary incontinence and preserve kidney function, and to keep the patient dry by preventing urinary incontinence (wetting the bed). Therefore, the following goals should be achieved after surgery.

• Improvement in urinary incontinence symptoms
• Increase in bladder capacity
• Reduction in intravesical pressure
• Preservation of kidney function

Which Organs Can Be Used for Augmentation Surgery in Children?

Due to metabolic and anatomical advantages, the terminal ileum (the last part of the small intestine) is most commonly used. Depending on the patient's condition, the stomach, colon (large intestine), and dilated ureters may also be used.

How Are Patients Who Undergo Augmentation Prepared for Surgery?

Ileocystoplasty is a major surgery, and there are things that the family and patient must do for the rest of their lives after the surgery. Therefore, as mentioned earlier, if the child is older, the family should be informed with detailed videos and pictures. In fact, time should be given for reflection, and the child should be informed 2-3 times at different intervals. The child and family should be introduced to other children and families who have undergone this procedure. However, the patient must first be thoroughly evaluated, and the necessary tests must be conducted.

What Are the Procedures That Need to Be Performed Before Surgery?

• Patients should undergo a general evaluation to determine whether this surgery is truly necessary.
• Cystoscopy should be performed to evaluate the position and shape of the bladder and ureter orifices.
• A urodynamic evaluation should be performed.
• Neurological examinations should be performed if necessary.
• Since the surgery will be performed under general anesthesia, routine preoperative blood tests are performed on patients and evaluated by an anesthesiologist, and the necessary information is provided.
• Prophylactic antibiotic treatment is started to prevent infection.
• Five to six hours before surgery, the intake of liquids and solid foods is stopped.

How is Augmentation Surgery Performed?

The surgery can be performed either open or laparoscopically (closed). To increase bladder capacity, a section of the small intestine (the ileum section of the small intestine) with elastic properties is used for bladders with significantly reduced capacity. The terminal ileum section, located 15 cm behind the cecum, is preserved. This is because important vitamins such as vitamin B12 are absorbed from this area. For this reason, this section of the small intestine is not removed. A 20-40 cm section is removed from the ileum, depending on the volume required, and the intestinal sections are reconnected. The removed ileum is opened from the section where the blood vessels do not reach (antimesenteric) and becomes a flat layer.

This opened intestinal layer is brought to the dome of the bladder (urinary bladder) in a U-shape or sometimes an S-shape, and the edges of the bladder and the edges of this patch are sutured together without leaving any gaps. This surgical procedure is called Bladder Augmentation. In medical terminology, this procedure is called Ileocystoplasty.

 

Are there other methods to increase the volume of the bladder (urinary bladder)?

Yes, there are. These methods can be successfully applied in selected patients. The main ones are:

1. Use of medications to relax the bladder: Medications such as oxybutynin, which relax the bladder muscles, can increase bladder volume with long-term use. These medications should always be tried before surgical procedures in cases of non-anatomical pathologies.
2. Autoaugmentation: It may be possible to increase the volume of the bladder by cutting the bladder muscle along a line and allowing the inner tissue to herniate. For this surgery to be successful, the bladder volume must be more than half of the expected volume for the patient's age, and no additional surgery should be required.
3. Botox Injection: Botox injection into the bladder paralyzes the bladder muscles, allowing them to relax. The effect is short-lived and must be repeated at regular intervals (approximately every 6 months). It is not effective in severely damaged bladders, known as fibrotic bladders.

Can kidney transplants be performed on patients who have undergone augmentation?

Whether kidney transplantation can be performed on patients who have previously undergone augmentation cystoplasty surgery due to bladder problems is a matter of debate. In such cases, patients and their families should consult with their doctors for a detailed assessment, and a decision should be made after carefully weighing the benefits and risks.

If patients experience severe kidney dysfunction after this surgery and kidney transplantation is the last resort, the transplant surgery should be performed at an experienced center. Since immunosuppressive therapy (immunosuppressive drugs) is used after kidney transplantation, infection is a serious problem in these patients. Catheter use should be carefully monitored in these patients. Appropriate antibiotic prophylaxis should be administered. In this way, it is possible to prevent serious complications.

How long does the surgery take, and how long is the hospital stay?

The duration of bladder augmentation surgery varies depending on the procedure to be performed. If only augmentation is to be performed on the patient, it takes approximately 4 hours. However, if antireflux, bladder neck repair, and Mitrofanoff procedures are also to be performed, the duration may extend to 6-8 hours.

Patients typically stay in the hospital for about 2 weeks. The urinary catheter remains in place for 2-3 weeks. Patients can return to their normal activities after 4-6 weeks. However, full recovery may take up to 3 months.

Should VUR Surgery Be Performed at the Same Time as Augmentation Surgery?

Some patients with small bladder capacity may also have vesicoureteral reflux (VUR) at the same time. This is because high intravesical pressure causes urine to flow backward from the bladder to the ureters and kidneys. In our scientific study, we demonstrated that VUR surgery is not necessary during cystoplasty surgery. We found that even in cases of high-grade VUR, surgery is not necessary and that VUR resolves spontaneously over time. However, it would be more appropriate to make a decision based on the patient's condition, taking into account kidney function.

Should Bladder Neck Surgery Be Performed at the Same Time as Augmentation Surgery?

This is often necessary in pediatric patients. This is because these patients also suffer from urinary incontinence. This is because most patients have bladder neck abnormalities due to congenital or neurological pathologies. In some patients, it is even necessary to completely close the bladder neck.

Can children who have undergone augmentation voluntarily urinate?

Most patients are unable to urinate spontaneously.

How do patients who have undergone augmentation surgery empty their bladder if they are unable to do so themselves?

A procedure called Mitrofanoff is performed to drain urine. The patient drains urine by catheterization at regular intervals.

Can patients who have undergone augmentation retain their urine? In other words, will they remain dry?

If the augmentation and Mitrofanoff procedure is successful and the patient is able to empty their bladder regularly, they will remain dry.

How Long Is the Recovery Process After Surgery?

Since this is a major surgery, the recovery process is somewhat lengthy. The patient begins to eat by mouth on the 3rd or 4th day. Catheters are removed sequentially between the 5th and 21st days, and the Mitrofanoff procedure is initiated. Patients typically return to their normal lives after 4-6 weeks. Full recovery takes approximately 12 weeks. During this period, patients should avoid lifting heavy objects and engaging in strenuous exercise.

What is the success rate of bladder augmentation surgery?

This surgery has been performed for many years and has a high success rate. When performed by experienced teams, the success rate is between 90 and 95 percent.

What Should Be Considered After Augmentation Surgery?

• After surgery, patients may remain under close observation in the intensive care unit for one night, depending on their condition.
• An intravenous line is inserted and painkillers and antibiotics are administered.
• Patients are encouraged to get up and walk as soon as possible. However, care must be taken to ensure that the catheters do not come out.
• Patients are not fed orally for 3-4 days after surgery and are fed intravenously during this period. Later, depending on bowel movements, liquid food is started and gradually transitioned to normal food.
• Intravenous feeding is performed to meet the child's daily fluid and calorie needs.
• The catheters placed during surgery are monitored, and the patient's intake and output are recorded.
• Regular irrigation is performed through the urinary catheter to prevent obstruction by mucus secreted from the intestines.
• The patient's bowel sounds are monitored.

How Often Should You Visit Your Doctor After Surgery?

Patients should always stay in contact with the doctor who performed the surgery. Patients should visit their doctor every two weeks at first, then three times a month, twice every three months, twice every six months, and then once a year. In addition, patients should visit their doctor immediately if any of the following conditions develop.

• If there is a high fever, chills, or shaking
• If there is fluid leaking from the surgical site or drain
• If there is a blockage in the urinary catheter
• If patients who have had the catheter removed are unable to urinate or if there is swelling in the abdomen

Does Cancer Develop After Augmentation Systoplasty Surgery?

One of the most frequently asked questions after this surgery is whether bladder cancer will develop in the future. A review of the literature shows that cancer can develop in the bladder long after ileocystoplasty in rare cases. Therefore, patients must not neglect their routine follow-ups.

Are there any complications associated with augmentation?

Yes, early and late complications may occur. For this reason, patients should be monitored by a physician throughout their lives.

Early complications:

1. Urinary leakage into the abdomen: Urine may leak from the sutures between the bladder and intestine. This condition is detected early on through drains. It can be treated by waiting for the bladder to drain or through open surgery.
2. Urinary tract infection: This condition can be treated with antibiotics.
3. Wound site infection: This condition can be treated with antibiotics. Surgical drainage may sometimes be necessary.
4. Complete necrosis of the newly created bladder
5. Leakage of intestinal contents into the abdomen: This occurs when there is a leak at the site where the intestines are sutured together. It requires repair through open surgery. It can lead to sepsis, a condition that causes serious infections and even multiple organ failure.

Late-stage complications:

1. Bladder rupture: Bladder rupture is a significant complication that occurs in 6% of cases. It is caused by the patient not emptying their new bladder regularly or by a severe blow to the abdomen while the bladder is full. It can manifest as abdominal pain, nausea, vomiting, fever, and severe infection. Abdominal swelling may occur. Severe infection can result in organ failure, which can lead to the death of the patient.
2. Bladder stone formation: This condition often develops due to infection caused by microorganisms that break down urea and mucus secreted by the intestine. It can be seen in 18-50% of patients. Small stones can be treated endoscopically, while large stones require open surgery for removal. The best way to prevent stone formation is to ensure that the bladder empties properly. Daily washing to clean the mucus is recommended. Washing can be done with tap water, saline solution, or certain mucus-dissolving solutions.
3. Metabolic disorders: These conditions vary depending on the type of intestinal segment used. When the ileum, the last part of the small intestine, is used, acidosis may occur. If the stomach is used, alkalosis may be observed. This condition may be associated with cardiac arrhythmias and seizures. If the large intestine is used, acidosis may again occur. If the valve structure between the small and large intestines, called the cecum, is damaged or used, prolonged diarrhea may occur. In children, long-term vitamin B12 deficiency may occur. As a result, they may experience dizziness, fatigue, sleepiness, and memory problems. When these conditions are observed, vitamin levels should be checked and supplemented with injections if deficient.
4. Intestinal obstruction: This condition may occur in approximately 3% of patients at any time during their lifetime after surgery. It occurs as a result of the intestines adhering to each other or to the abdominal wall. It presents with abdominal swelling, bilious vomiting, inability to pass stool, or mild diarrhea. If left untreated, it can lead to life-threatening complications. In some cases, it may resolve spontaneously with intravenous fluids and antibiotics. In other cases, surgery is required to separate the adhesions.
5. Bacteriuria
6. Urinary incontinence
7. Perforation (rupture of the bladder)
8. Inability to urinate and need for a catheter
9. Malabsorption
10. Other: In very rare cases, cancer may develop in the areas where the intestines and bladder meet over a long period of time. This condition, which is generally observed around the 20th year, should be monitored with intermittent endoscopy and biopsy, if necessary, starting from the fifth year after the procedure.
11. In cases where the stomach and bladder have been enlarged, a condition called hematuria-dysuria syndrome, characterized by burning during urination and bloody urine, may occur. This condition is particularly common in children with kidney failure and low urine output. It can be treated with medication.

What tissue is used to perform a Mitrofnoff procedure to drain an augmentation, and how is it performed?

It is made from the appendix or ileum. The surgery can be performed either open or closed. One end of the prepared tube is sutured to the bladder (urinary bladder), while the other end is sutured to the navel or the lower right quadrant of the abdomen for aesthetic and ease of use reasons.

How to Use Mitrofanoff?

Mitrofanof is initially catheterized 12 times a day, then every 3 hours, and later every 4-6 hours. A prepared catheter and lubricant are used for this procedure.

Are there any complications associated with Mitrofanof?

Yes, there are rare cases of urine leakage from the skin, skin constriction, and perforation, all of which may require a second surgery.

Can Mitrofanof be performed laparoscopically?

Yes, it is possible.

Is there a method similar to Mitrofanoff for preventing fecal incontinence in children?

Yes, there is. Using a method called MACE, which is formed by combining the first letters of the words Malone Antegrade Continence Enema, the patient's fecal incontinence is prevented using a method similar to Mitrofanoff.

Which Patients Are Eligible for the MACE Method?

It is generally used in children with neurological disorders (spina bifida patients), patients with anal atresia, and some patients with cloacal anomalies who are unable to control their bowel movements.

How is the MACE Method Performed?

It is usually made from the appendix. In patients where the appendix is not suitable, a portion of the ileum may also be used. The procedure can be performed either open or closed (laparoscopically). One end of the prepared tube is connected to the cecum, which is the beginning of the large intestine, and the other end is connected to the navel or the lower right quadrant of the abdomen.

Is the Mace Method Performed Laparoscopically?

Yes, it is possible.

How Does the Patient Use the Mace Method?

The patient performs an anterior enema once a day using a catheter inserted here. Serum or normal tap water is administered here according to age, and the patient goes to the toilet. A slightly longer than normal toilet time (20-30 minutes) is waited for. During this time, the entire colon (large intestine) empties. It takes 24 hours for it to refill with stool from the small intestine. Thus, the patient has not missed any stool and remains clean for 24 hours.

Are there any complications associated with the Mace method?

The most common complication is narrowing at the site where the tube is inserted into the skin, which may require a second surgery.

Does the patient experience fecal incontinence after the Mace procedure?

Generally, it does not leak, but it may leak minimally when consuming foods that cause diarrhea or excessively spicy foods. It may also leak when the patient has diarrhea due to an intestinal infection or other causes.

*** The information provided here is intended to inform visitors to the website. None of the information should be considered as advice by visitors and should not be the basis for any decision or action. Families should have their child examined by a pediatric surgeon, consult with them, and make decisions based on their individual advice.