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International Journal of Surgery Case Reports
j o ur na l h o m e p a g e :w w w . c a s e r e p o r t s . c o m
Case report: The theory of post-ileocystoplasty spherical configuration in patients with low-capacity bladder
Dwiki Haryo Indrawan
a,∗, Yacobda Sigumonrong
baDepartmentofUrology,FacultyofMedicine,UniversitasIndonesia–HajiAdamMalikGeneralHospitalMedan,Jl.BungaLauNo.17,KemenanganTani, Kec.MedanTuntungan,KotaMedan,SumateraUtara,20136,Indonesia
bDivisionofUrology,DepartmentofSurgery,FacultyofMedicine,UniversitasSumateraUtara–HajiAdamMalikGeneralHospitalMedan,Jl.BungaLau No.17,KemenanganTani,Kec.MedanTuntungan,KotaMedan,SumateraUtara,20136,Indonesia
a rt i c l e i nf o
Articlehistory:
Received11February2021
Receivedinrevisedform1March2021 Accepted3March2021
Availableonline5March2021
Keywords:
Bladderaugmentation Ileocystoplasty Detubularization Casereport
a b s t ra c t
INTRODUCTION:Bladderaugmentationcanbeperformedbydetubularizationofthesmallorlargeintes- tine.Alargecapacitybladderisnecessarytoavoidfrequenturination;thus,theilealsacmustbeableto storethemaximumvolumeofurinewithrelativelylowpressureandtheshortestlengthoftheintestine.
Theacceptablepressurecapacityshouldalwaysbeunderuretericpressuretoavoidbackpressureand kidneydamage.Largecapacityatlowpressureisreferredtoasgoodcompliance.Desirablepreparations foraugmentation,whichistheuseoftheshortestlengthoftheintestine,reducethechanceofdiarrhea andvitamindeficiencyandretaintheintestineswhichmayberequiredforaugmentation.
AIM:Clinicalandurodynamicevaluationoftherecentpostoperativeconditionofthepatientwhounder- wentileocystoplasty,confirmedbythetheoryofdetubularization(spherical)configuration.
CASEPRESENTATION:Patientwithcomplaintsoffrequenturinationandsmallamountofurine.Ultrasound examinationshowedlowvolumebladdercapacityandbilateralhydronephrosisandhydroureter.From cystographyandVCUGexamination,lowcapacitybladder,grade1VURontherightside,grade4VURon theleftsideaccompaniedbybilateralhydronephrosisandhydroureter.Thepatienthasahistoryofright nephrectomyin2014forpyonephrosisduetokidneystones.Thepatientwasthensubjectedtobladder augmentationusingasegmentoftheileum(ileocystoplasty)in2015.Inthepostoperativeevaluation, clinicalsymptoms,radiologicalanduroflowmetricexaminationswereevaluated.
CONCLUSION:Thedetubularizationformoffersgreatervolumeandlowerpressureinthereservoirto augmentthebladder.
©2021TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
1. Introduction
Bladderaugmentationisaclassicandeffectivesurgicalproce- dureforthemanagementofpatientswithsmallcapacitybladder thathastheabilitytocollectsmallamountofurinewithorwith- outoveractivityofthedetrusormuscle[1].Themainindicationof thisprocedurearecasesofneurogenicornon-neurogenicbladder dysfunctionthatdidnotrespondtomedicaltherapy,congenital disordersofthebladder,andinfectionorinflammationoftheblad- der.Bladderaugmentationcanbeperformedusingananastomosed intestinalsegmentintothebladdersothatthesizeoftheblad- derwillincreaseand preventtherefluxofurineintotheupper urinarytract[2].In1899,Mikuliczreportedthebladderaugmen-
∗ Correspondingauthorat:DepartmentofUrology,FacultyofMedicine,Univer- sitasIndonesia-CiptoMangunkusumoHospital,Jl.BungaLauNo.17,Kemenangan Tani,Kec.MedanTuntungan,KotaMedan,SumateraUtara,20136,Indonesia.
E-mailaddresses:[email protected](D.H.Indrawan), [email protected](Y.Sigumonrong).
tationusingonepartofthesmallintestineforthefirsttime.This casereportdiscussedthebladderaugmentationperformedona 13-year-oldboywithsmallbladdercapacityatRSUPHajiAdam MalikMedan.ThiscasereportwasmadeaccordingtotheSCARE guideline[3].
2. Casereport
A13-year-oldboycametoRSUPHajiAdamMalikMedanon March20,2014complainingoffrequenturinationandonly40–60 ccofurinecameouteverytimeheurinates.Thiscomplainthas beenexperienced by thepatient sincethe patientwas 8 years old.Thepatientcomplainedofurinatingatintervalsofevery30 mineveryurination.Intermittentbackpainontherightsidewas experiencedbythepatientoneyearago.OnultrasoundandBNO- IVP(BlassNierOverzicht–IntravenousPyelography)examination, non-visualconclusion,rightkidneypyonephrosisandleftkidney hydronephrosiswerefound.Thepatientthenunderwentaright kidney nephrostomy on March 24, 2014 due to pyonephrosis.
FromtheCTscan oftheabdomenonMarch25,2015,multiple
https://doi.org/10.1016/j.ijscr.2021.105731
2210-2612/©2021TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.
org/licenses/by/4.0/).
Table1
ComparisonofSymptomsandFrequencybeforeandaftersurgery.
Voidingcomplaint Frequencysymptom
Beforesurgery 60–80timesaday
1monthaftersurgery 25–30timesaday
2monthsaftersurgery 20–25timesaday
3monthsaftersurgery 15–20timesaday
2yearsaftersurgery 6–8timesaday
3yearsaftersurgery 6–8timesaday
stonesoftherightkidneywerefound,accompaniedbybilateral hydronephrosisand hydroureter.Thenanephrectomywasper- formedonApril24,2015forpyonephrosisandnon-visualright kidney.OnApril7,2015thepatientunderwentcystographyand voiding cystourethrogram (VCUG) with the conclusion of low- capacitybladder,grade1vesicoureteralreflux(VUR)ontheright side,grade4VURontheleftsideaccompaniedbyhydronephrosis andbilateralhydroureter.Inaddition,thepatientwasdiagnosed withneurogenicbladderafterthat.Thepatientwasthensubjected tobladderaugmentationduetolow-capacitybladderinSeptember 2015. Thepatient in supineposition, undergeneralanesthesia, underwentalowermidlineabdominalincision.Afterthebladder wasidentified,averticalincisionwasmadefromtheanteriorblad- dertotheposteriorbladder.Theileumwasidentifiedand then 20 cmlongilealsegmentwastakenandanend-to-endanasto- mosis wasperformed.Theilealsegmentsarethenwashedwith normal salineand betadinesolutions.Afterwards,theileal seg- mentisincisedandisreconstructedtoformadome.Thepartofthe ileumthathadbeenreconstructedwasanastomosedtothebladder usingMonocryl3.0thenacystostomywasplaced.Thepatientthen underwent2weekspostoperativecarewithnormalurineproduc- tionandcystostomy.Inthefirstmonthofpostoperativefollow-up, thesymptomfrequencywasreducedto25–30timesperday.From thepre-andpost-micturitionultrasoundevaluation firstmonth afterbladderaugmentation,thepre-micturitionbladdervolume was221ccandthepost-micturitionbladdervolumewas70cc.In thesecond-andthird-monthvisits,thepatientconveyedreduced frequencysymptoms,urinatefor15–25timesperday,andfromthe ultrasoundevaluation,thepre-micturitionbladdervolumewas350 ccandthepost-micturitionbladdervolumewas50cc.Thepatient thendidnotcomebackbutcamebackforvisitinthethirdyear.
Fromtheinterview,itwasfoundthatthefrequencysymptomsin thefirst,secondandthirdyearwas6–8timesmicturitionperday, andattheendofthemicturitionthepatienthadtochangeposi- tionsandpressthesupra-symphysisareauntilitfeltlight.Inthe thirdyear,thepatientcameforvisitandwasfollowed-upforclin- icalsymptom,ultrasound,cystoscopy,VCUGandurodynamics,all ofwhichshowedgoodresults.FromVCUGexaminationonJune28, 2019,bladderfullnesssensationwasfoundon250ccbladderfill- ing,noreflux,openbladderneck,andgoodsphincter.Thepatient hadtochangesittingandstandingpositionswhilepressingonthe supra-symphysisarea,withaurineresidueof40cc.Cystoscopy performedonthesamedateshowedgoodbladdermucosa,good ilealaugmentationanastomosistothebladder,andureteralestuary canbeidentifiedwithabladdercapacityof350cc(Table1).
ThepatientwasthensubjectedtouroflowmetrytwiceonJune 30,2018,withtheresultsof20surinationtime,18.8sflowtime, totalurineof544.8cc,averageflowrateof29.1mL/second,41.3s maximalflow,and7.5stimetomaximumflow.
3. Discussion
Pathological infections, such as genitourinary tuberculosis, schistosomiasis,andpost-radiotherapycystitisareoftenthecause oflow-capacitybladdercaseswithorwithoutureteralinvolvement [2,4].Patientswithlow-capacitybladderwhohavepoorcompli-
ancewithureteralinvolvementhavepoorrenalfunction.Bladder complianceisaconceptwherethebladdershouldretainlowintrav- esicalpressurewhilethevolumeincreasingtoacertainpoint.It isameasurethateveryurodynamiccareprovidershouldcalcu- late.Lowcompliancebladderwillcausenumeroussymptomsuch whichwillleadtoinsufficientbladderemptying.Onthelongrun, thisissuecouldendasChronicKidneyDiseaseandincreasepatient mortality.Therefore,thesepatientsneedpropermanagement[5].
Mostpatientswithbladderdysfunctionproblemscanbeman- aged medically without surgery. Treatment before surgery can includetheuseofantispasmodicsandintermittentcatheterization [5–7].Bladderaugmentationisamanagementoptionforneuro- genicandnon-neurogenicbladderdysfunctionwhenconservative management, medical pharmacological therapy and minimally invasivemanagementhavenotyieldedsatisfactoryresults.Ifthese therapiesareunsuccessful,patientswhofailwiththesetherapeu- ticmodalitiescanberecommendedforbladderaugmentation[7,8]
Theaimofdoingbladderaugmentationistocreateareservoirwith adequatefunctionalcapacityandlowbladderfillingpressureso thatlowintravesicalpressurewillnotinterferewiththeflowof urinefromthebladdertotheurethra.Italsopreventshighpres- sureofupperurinarytractthatcanleadtovesicoureteralreflux (VUR).Inthispatient,theindicationforbladderaugmentationis low-capacitybladderwhichdoesnotimprovewithmedicalther- apy.
Varioustypesofgastrointestinalsegmentshavebeenusedfor bladderaugmentation,buttheileumisthemostfrequentlyper- formed segment [9,10]. Von Mikulicz describes ileocystoplasty augmentationin1889[11].HinmannandKoffalsodescribethe benefitsofopeningthebowelattheantimesentericborder,detubu- larization,andreconfiguration[12].McGuiredemonstratesriskof increasedintravesicalpressureonrenalfunction[13].Thespherical shapeisthemostdesirableconfigurationbecauseithasamaximal volumefortheintendedsurfacearea,leadingtodullnessofbowel contractionsandanoverallincreaseandcomplianceaccordingto Laplace’slaw[14](Fig.1).
Thesizeandconfigurationoftheaugmentationsegmentmay be more important than the type of intestine used. Hinman (1988)andKoff(1988)haveclearlydemonstratedtheadvantage ofopeningtheintestinalsegmentatantimesentericborder,thus enabling detubularization and reconfiguration of this segment.
Detubularization and reconfiguration maximizes the additional surface area to the bladder and thus benefits from a specific segment.Furthermore,intrinsicinnervationisimpairedandperi- stalsisissignificantlyreduced.Reconfigurationtoasphericalshape providesmanyadvantagesthatincreasecapacityandoverallcom- pliance.Sphericalconfigurationwithgeometry,maximizesvolume achievedforagivenbladderwallarea.Inaddition,thespherical configurationmaximizestheradiusofcurvature,therebyincreas- ingthesurfacetensionforexertedbladderpressure,whichtendsto leadtofurtherbladderexpansion.ThisisarelationshipofLaplace’s law(T=kRP),whereTisthewallstress,kisaconstantdepending ontheelasticityandcharacteristicsofthewall,Ristheradiusof curvature,andPistheluminalpressure[15].
Thegeometriceffectcanbeseeninthefollowingexample:20 cmlongtubewithadiameterof3.4cm(equivalentwithphysi- ologicaldiameteroftheileum)hadacalculatedcapacityof175 mL(Fig.2A).Ifopenedlongitudinallyandfoldedbackasabag,the capacitycalculatedbytheequationwillbecloseto350mL,twice thatofthetube(Fig.2B)[12](Fig.3).
Inthispatient,bladderaugmentationwasperformedbytaking a segment of the ileum (ileocystoplasty) on indicationof low- capacitybladder.Someurologistsusethesmall bowelsegment inbladderaugmentation astheprocedureofchoicewhencon- servative management fails. In 1982, Good win described this procedure,whichwaslaterpopularizedbyMundyandStephen-
Fig.1.(a)thebladderthathasbeensplit(b)anastomosisofileumandbladder.
Fig.2. Comparisonofthetubecapacitycalculationwithalengthof20cmand adiameterof3.4cm(175cm2)andonthesametubethatisopenedandfolded lengthwisewithalengthof10cmandadiameterof6.8cm(316cm2)[15].
Fig.3.Anastomosedileumandbladder.
Fig.4.Thepatient’sultrasoundbeforebladderaugmentation.
Fig.5. Thepatient’sVCUG(VoidingCystouretrography)beforebladderaugmenta- tion.
son.[16]Mundyetal.reporteda90%successrateincystoplasty augmentationperformed in40 patientswithneuropathic blad- derdysfunctionwithameanfollow-upofoneyear.Severalother reportshaveconfirmedthehighsuccessrateofobtainingahigh capacityandlow-pressurereservoir.
Krishnaetal.studied39childrenwithspinabifidaandreported a91.7%reductioninupperurinarytractdilatation.[17]Riedmiller etal.,inacasereportusedtheilealsegmentforabladderaug- mentationprocedure.Post-treatmentfollow-upshowedincreased bladdercompliancewithmoderatemucusproduction.Thecompli- cationratewiththistechniqueisreportedlylow[18].
Intheliteratureitisstatedthattheilealsegmentrequiredfor thisprocedureisatleast20cmandislocatednexttotheproximal ileocecalvalve[19,20].Thisisconsistentwiththetechniqueusedin thiscasereport.InacasereportbyAhmadEl-Feeletal.,in2008on 23patientswithanagerangeof12–56yearsandanaverageageof 27years,itwasstatedthattheuseof10–15cmilealsegmentscould increasethebladdercapacityfromanaverageof111ml–788mlat 1yearpostoperativelyandalsodecreasedthedetrusorpressure fromameanof92cmH2Oto15cmH2O[21].
InthestatisticalanalysisofSchmidbaueretal.,pressurevolume curvesshowedsignificantlybettercompliancewithdetubulariza- tionthanilealsegmenttubularization.Theareaunderthecurve (AUC)p <0.02 after12 weeks was21.2vs85.3(cmH2O). [22]
Goldwasseretal.statedthatthemeanbladdervolumeatmaximal contractionwashigherinpatientswithdetubularizationthanwith tubularpost-ileocystoplasty.Themaximalcontractionthatoccurs atalowerbladdervolumeandahigheramplitudewasmorelikely occurinpatientswithtubularileocystoplasty[23].
Fig.6.Thepatient’spost-bladderaugmentationultrasound(A.1monthaftersurgery,B.2monthsaftersurgery.
Fig.7. Pre-micturitionandpost-micturitionultrasoundofpost-bladderaugmentationpatient(3yearsaftersurgery).
Shadpouretal.reportedaserialcaseof6patientswithlow- capacity bladderwithmyelomeningocelewhich had undergone laparoscopic augmentation ileocystoplasty in combination with Malone procedure (usingappendix segment as a conduit). The resultwasthatthemeanbladdercapacitybeforetheprocedure was48mL,andameanof260mLin13–16monthsaftertreat- ment.Detrusorpressurewasdecreased,fromameanof35cmH2O to12cmH2O.Khastgiretal.,in2003reported32patients,con- sistedof25malepatientsand7femalepatientswithanagerange of11years-52yearswithameanageof32.6years,whowereaug- mentedwiththeileocystoplastytechnique.Theresultsshowedthat themeancapacityofthepre-micturitionbladderfromanaverage
of143cctoameanof589ccinone-yearpost-treatmentevalua- tionanddecreaseddetrusorpressurefromameanof108cmH2O to19cmH2Oinpost-treatmentevaluationwhichconductedafter ayear.[24]Queketal.in2003reportedaserialcaseof26cases ofenterocystoplatyinpediatricpatientswithneurogenicbladder whofailedconservativetherapywithameanageof8years.The meanbladdercapacitywas201ccto618ccatthefourth-yearpost- procedureevaluationandareduction indetrusorpressurefrom anaverageof81cmH2Oto12cmH2O[25].Inthecasereportof laparoscopicroboticileocystoplastyaugmentationbyKang,2010, ilealresectionwascarriedoutalonga15cmlongsegmentofthe ileumandformedaU-shapedilealbag.Thebladderfunctioncapac-
Fig.8.Thepatient’sVCUGinthethird-yearpostbladderaugmentation.
ityincreasedto280ccandtheresidualvolumeofurinewas5ccor less[26].
Inthisstudy,theresultsofpostaugmentationbladdervolume inthefirstmonthwere221ccandpostmicturitionbladdervol-
umewas70cc.After3monthsofmonitoring,itwasfoundthat thevolumeofpre-micturitionwas350ccandthepost-micturition was50cc.Threeyearsafterthebladderaugmentation,ourpatient’s bladdercapacityincreasedto545cc.ThisisinaccordancewithLa Place’stheorythatHinnmanandKoffdidin1988wheretheblad- dercapacityisexpectedtoincreasemaximallywiththeuseofa shorterintestinallumen.However,thereisanothertheorywhere thebladdercapacityinchildrencontinuestoincreaseduetothe growthanddevelopmentofthebladdervolumeaccordingtotheir age(Figs.4–9).
4. Conclusion
In this case, the bladder augmentation was performed on theindicationof alow capacitybladderbyusingtheileocysto- plastytechnique, which is a technique that uses reconstructed ileal segmentwhich anastomosedtothe bladder.Bladder aug- mentationin thiscase requires good care becauseit cancause severalcomplications suchasinfection,stone formation,malig- nancy,metabolic disorders, perforation,dysuria, hematuria and lowbackpain[11–13].Inthefirstmonth,secondmonth,tothird yearevaluationaftersurgery,therewasimprovementofurinary symptoms,USG,VCUG anduroflowmetry.Thisisin accordance withthetheoryofileal detubularizationwhich offersa greater volumeandlowerpressureinthereservoirduringbladderaug- mentation.
Fig.9. Thepatient’surodynamicinthethird-yearpostbladderaugmentation.
DeclarationofCompetingInterest
Theauthor(s)havenoconflictofinteresttodeclare.
Funding
Thiscasereportsourceoffundingisself-funding.
Ethicalapproval
Thiscasereporthasbeenexemptedfromethicalapprovalby UniversitasSumateraUtaraEthicalCommittee.
Thepatientdanhisparentshavegiventheirconsentinorder forustopublishthiscase.Wehaveinformedthepatientandhis familycomprehensivelyandtheygaveustheirconsentandfully supportedthepublicationofthisstudy.
Authorcontribution
DHIcarriedoutthedatacollection,analyzingthedataandand draftedthemanuscript.YSparticipatedinthedesignofthestudy and helpedto draftthe manuscript.All authorshave read and approvedthemanuscript.
Registrationofresearchstudies NotApplicable.
Guarantor
DwikiHaryoIndrawanM.D.
Provenanceandpeerreview
Notcommissioned,externallypeer-reviewed.
Acknowledgement
Theauthorswouldliketothankeveryonewhosupportedthis study.SpecialthanksaregiventoAdamMalikGeneralHospital andUniversitasIndonesiawhichfullysupportedtheauthorsduring writingperiod.
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