Bladder augmentation: Current and future techniques

The surgical management of the child with a neuropathic bladder can be a formidable task, but major advances in surgical technique have been made in recent decades. The ability to augment the capacity of the bladder with a piece of reconfigured bowel in conjunction with clean intermittent catheterization (CIC) has dramatically altered our ability to form a compliant urinary reservoir that protects the integrity of the upper urinary tract and promotes urinary continence. Conventional enterocystoplasty uses detubularized segments of small or large bowel. Despite the functional success of intestinocystoplasty, clinical experience has demonstrated that numerous complications can result from the incorporation of small and large bowel and their associated heterotopic epithelium into the urinary tract. To avoid some of these deleterious side effects of the use of bowel for bladder augmentation, several procedures have now been developed to augment the bladder without the use of bowel, including gastrocystoplasty, autoaugmentation, seromuscular enterocystoplasty, and ureterocystoplasty. In addition, recent advances in tissue engineering techniques have increased the possibility of regenerating new bladder tissue that is clinically useful for augmentation purposes. This chapter reviews the relevant surgical anatomy and physiology, advantages and disadvantages, surgical technique, and clinical results of conventional enterocystoplasty and each of the alternative procedures that avoid the use of bowel. These are summarized in Table 56.1. Since the care of the child with a neuropathic bladder can be complex and requires individualization that is dependent on the desires of the patient and family, familiarity with each of these procedures is extremely important for the pediatric urologist when considering augmentation cystoplasty.