Reconstructive Urology - Bladder

Introduction

The bladder is a hollow organ found in our lower abdomen, and its main function is to store and expel urine. To do this, it has muscular walls that expand and contract to store and empty urine through the urethra.

Why would we need to undergo bladder reconstruction?

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1. Bladder Augmentation (Cystoplasty)

Bladder augmentation is a type of surgery done for patients who do not have an adequate bladder capacity (i.e. bladder is unable to store as much urine as before), or in those whose bladder muscles do not stretch well due to disease conditions like previous radiation therapy. Bladder augmentation helps increase its size and capacity, and improves its ability to stretch.

Bladder augmentation is a complex reconstructive procedure that often involves using the body’s own tissue. This often comes from a section of the small intestine (ileocystoplasty) or the large intestine (sigmoid cystoplasty). Creating a larger bladder results in:

The storage of urine at low pressures, as well as the maintenance of normal urinary outflow to prevent deterioration and damage to the urinary tract.
Decreased pressure and increased capacity of the bladder, which, in turn, increases the amount of time needed before you will feel the urge to urinate.

Who is bladder augmentation recommended for?

A patient who has a severe reduction in bladder compliance and/or bladder capacity may be a suitable candidate for bladder augmentation surgery. This surgery is usually only indicated in patients with severe symptoms or complications of bladder dysfunction and when all other less invasive treatments have failed. Conditions that may cause such bladder dysfunction include:

Neurological conditions such as spinal cord injury, multiple sclerosis, myelodysplasia, tethered spinal cord
Overactive bladder resulting in urinary incontinence
Bladder inflammation (cystitis)
- Chronic cystitis, as seen in diseases like tuberculosis
- Radiation cystitis
- Interstitial cystitis

In children, conditions which cause neurogenic bladder are also why some children get bladder augmentation. Such conditions include:

Spina bifida — a birth defect where the spine and spinal cord form incorrectly.
Posterior urethral valves (PUV) — an occurrence where obstructive membranes develop in the urethra, obstructing the flow of urine.
Bladder exstrophy — a rare birth defect where the bladder develops outside the foetus.

These conditions will lead to sequelae such as urine leaks, bladder stiffness, loss of bladder capacity, and loss of bladder muscle function.

What to expect for a bladder augmentation procedure

Before the surgery, the urologist will take a medical history from you as well as perform a physical examination and series of investigations. These investigations include blood tests to check your kidney function and overall health, as well as an array of other radiological investigations to look at your bladder and assess its function. Other tests include a urodynamic flow study to check for any abnormalities in urine flow (which can arise due to bladder dysfunction) as well as a cystoscopy, which involves the insertion of a long, thin, hollow tube at the end of it through the urethra and into the bladder, enabling the surgeon to visualise the inside of the bladder.

You will also have an appointment with the anaesthetist, a doctor in charge of administering anaesthesia to you during the surgery. The anaesthetist will take a further look at your medical history and background to assess your fitness and suitability for the operation. They may also advise you on what medications you can take and which you should stop (e.g. blood thinners like aspirin must be stopped a week before the surgery), as well as other lifestyle habits that will help minimise your risk of postoperative complications (e.g. to not smoke for at least 8 weeks before the surgery).

Bladder augmentation surgery s done under general anaesthesia, and the urologist can perform it either via the traditional, open surgery method (which involves a long cut down the centre of the abdomen) or through minimally invasive surgery, which involves either the use of robot-assisted surgery or laparoscopic surgery.

After the surgery, a catheter will be placed in your bladder to drain the bladder as it heals, as well as to allow for the washing of mucous and blood out of the bladder. Because a piece of the bowel is in contact with the bladder, you will need to irrigate the mucous regularly. You will be taught how to do this by nurses in the hospital before you are discharged. If irrigation is not done regularly, you may run the risk of bladder stones and a UTI.

Are there alternatives to bladder augmentation?

Generally, bladder augmentation is only indicated when more conservative methods have failed. These could include medications such as oxybutynin, or minimally invasive methods such as the injection of medication or intermittent catheterisation.

Is bladder augmentation surgery painful?

You will not feel any pain during the surgery as you will under general anaesthesia. Post-operation, you may experience cramping in your lower belly and may be given medicine for one to two weeks.

What is the maximum amount of urine the bladder can hold?

Generally, the bladder can store up to 500ml for women and 700ml for men. However, we feel the need to urinate when the bladder is between 200-350ml full.

2. Ileal Conduit

In some cases, the bladder needs to be completely removed (radical cystectomy). The creation of an ileal conduit involves surgically fashioning a tube from a piece of the small intestine (most often the ileum) to attach to the ureters & kidneys to allow urine to drain out of the body. The urine will then exit the body through a small opening in the skin, known as a stoma. After the surgery, the person will live with a urostomy bag that collects urine.

Who is an ileal conduit procedure recommended for?

An ileal conduit is the most common form of urinary diversion performed by urologists after a patient undergoes a surgical procedure to remove the bladder. The ileum serves as an alternative pathway for the drainage of urine from the kidneys out of the body. Surgeries to remove the bladder are most often indicated in cases of cancer.

Some forms of these surgeries include:

Radical cystectomy — done for advanced bladder cancers that have invaded the muscles of the bladder.
Pelvic exenteration — done for pelvic or bladder cancers and in cancer of the gynaecological organs in females
The correction of anatomical abnormalities in the urinary tract.

What to expect for an ileal conduit procedure?

The surgery can either be done via the traditional, open surgery method (which involves a long cut down the centre of the abdomen) or through a minimally invasive surgery which involves either the use of robotic surgery or laparoscopic surgery.

Similar to the aforementioned condition, a urology referral and check-up, as well as an appointment with the anaesthetist, will be conducted before the surgery.

The urologist will take a closer look at your medical history, and if you have cancer, they will also discuss at length with you the treatment options that are available. Because ileal conduits are often part of a major surgery, other surgeons, like a colorectal surgeon, may also be involved in the operation. You will be given advice on what medications to take and stop, what lifestyle measures to institute before the operation, as well as be given more information regarding the ileal conduit surgery.

Maintaining the ileal conduit will be a routine part of your everyday life. You will be briefed on how to look after your stoma properly. It is also important to help maintain your overall health after the surgery.

Why would someone get an ileal conduit?

An ileal conduit acts as a diversion, making it possible for a person to drain urine out of their body after their bladder has been removed or damaged.

How often do you empty a urostomy bag?

You will need to empty the bag every 2 or 3 hours, depending on how much you drink. A drainable ostomy bag allows you to empty the contents of your pouch and then reuse it.

How often do you replace a urostomy bag?

Generally, urostomy bags should be replaced 1 to 2 times a week.

3. Neobladder

As the name suggests, neobladder reconstruction refers to the surgical construction of a “new bladder”. This is another option for urinary diversion, where the bladder is removed, and your urologist surgically recreates a new pouch to contain the urine. Usually, a piece of the small intestine is fashioned into the new bladder.

Patients with neobladder can generally urinate normally, often having to use abdominal muscles to empty the neobladder. Sometimes, a catheter may be used to empty the bladder.

Who is neobladder surgery recommended for?

Neobladder surgery is usually recommended for a person healthy enough for complex surgery. For example, one needs to have normal kidney and liver functions, and cannot have cancers in the urethra.

What makes robot-assisted surgery different from conventional surgery?

Contrary to popular belief, robotic surgery is not performed by a robot independently, but is performed by an experienced surgeon who guides the robot for the entire procedure via a console. These technological advancements allow for better visualisation, manual dexterity and control than what is possible with conventional techniques — a combination of the surgeon’s skill and critical thinking with the precision of a machine.

Furthermore, robotic surgery allows access to hard-to-reach areas using small incisions. This leads to a lower risk of complications and shorter recovery times.

Summary

Hopefully this has helped you better understand certain aspects of reconstructive bladder surgery and what it entails. Depending on your condition, your urologist will discuss the best method of urinary diversion for you.

Reconstructive Urology - Bladder