Interstitial Cystitis

Interstitial cystitis is a symptom complex comprised of chronic irritative voiding symptoms, sterile and cytologically negative urine, and bladder pain that is exacerbated by bladder filling but relieved, in many instances, by bladder emptying. This is predominantly a woman’s disease because they comprise more than 90% of all patients diagnosed with this disease. The low percentage of men reported in epidemiologic studies involving interstitial cystitis may in part reflect the difficulty in differentiating interstitial cystitis from chronic abacterial prostatitis because both conditions have similar overlapping symptoms. The exact etiology and pathogenesis of this debilitating disease are as yet unknown but may be related to an insufficient glycosaminoglycan layer, an abnormal inflammatory response to noxious urinary components, a primary sensory neuronal abnormality, and chronic infection with an as yet unidentified and/or fastidious organism, or a combination of these different etiologies.

DIAGNOSIS

The diagnosis of interstitial cystitis is based on the presence of irritative voiding symptoms, the absence of urinary organisms, and typical cystoscopic appearance. In 1988, an NIDDK-sponsored workshop was convened to propose inclusion and exclusion criteria to assist those investigating this disease.

Cystoscopic examination at the time of hydrodistention is mandatory in confirming the diagnosis of this disease as well as in ruling out other possible etiologies that could be responsible for bladder pain and irritative voiding symptoms. Hydrodistention is performed under regional or general anesthesia. The bladder is distended with either sterile water or normal saline irrigant at a pressure of 100 to 120 cm H2O and then emptied after 5 minutes. The presence of glomerulations or Hunner’s ulcers, which universally spare the trigone, are highly suggestive, though not pathognomonic, of interstitial cystitis. Some authors prefer to categorize those patients exhibiting Hunner’s ulcers separately from those patients exhibiting the much more common finding of glomerulation.

Pathologic features of interstitial cystitis include nonspecific chronic inflammatory infiltrate, edema, and vasodilation of the submucosa and detrusor layers. Bladder mastocytosis is often found on pathologic examination, but it is not pathognomonic, nor does its absence exclude the diagnosis of interstitial cystitis.

INDICATIONS FOR SURGERY

Other than hydrodistention and the intravesical instillation of certain agents, the primary treatment for interstitial cystitis is usually not surgical in nature. Most would agree that surgical treatment is appropriate only for a small and select group of patients with incapacitating and debilitating symptoms resistant to conventional medical and/or behavioral therapy.

ALTERNATIVE THERAPY

Alternatives to surgical treatment would include anticholinergics, anti-inflammatories, behavioral modification, and other methods of managing chronic pain, including TENS units and tricyclic antidepressants.

SURGICAL TECHNIQUE

Patient Selection

Once the diagnosis of interstitial cystitis is established, a reasonable attempt should be made to assess the impact of the disease on daily activities, work activities, leisure activities, and interpersonal relations. It is imperative that the patient be counseled extensively regarding the realistic goals and limitations of surgical therapy for this poorly defined disease. This is especially true in patients who are considering cystectomy with an incontinent or continent diversion. Instruction on the care involved in stoma care and use of a urinary appliance are certainly a vital part of patient teaching for those contemplating this type of surgical intervention. For those considered candidates for augmentation cystoplasty or continent diversion, assessment of manual dexterity and ability to perform self-catheterization is necessary before proceeding with surgery. A dedicated nurse or stomal therapist available to advise and instruct patients preoperatively is a crucial element in the preoperative preparation process.

Hydrodistention and Instillation of Vesical Agents

Hydrodilation of the bladder as a treatment for interstitial cystitis was first described nearly 65 years ago and remains the most common surgical treatment for the relief of bladder symptoms. Hydrodistention is an easy and relatively safe technique and is usually necessary as part of the diagnostic algorithm in patients with the symptom complex of irritative bladder symptoms in the face of sterile and cytologically negative urine. The therapeutic effect of hydrodistention appears to result from ischemia of the suburothelial nerve plexus with resultant sensory denervation secondary to bladder overdistention.

Before any endoscopic manipulation is done, the patient must have a sterile urine. Preoperative antibiotics are recommended. The patient then undergoes cystoscopy under general or regional anesthesia, which allows for adequate distention of the bladder. The bladder is distended with the irrigant bag (sterile water or saline) elevated to 100 to 120 cm above the bladder, which assures that distention up to at least 100 cm H2O occurs during filling. The bladder is inspected before and during filling. In the vast majority of patients, the bladder before distention is unremarkable. Bladder capacity is reached when the irrigant no longer flows in the drip chamber on the irrigant tubing. The bladder is distended for 3 to 5 minutes, drained, and the bladder volume measured. The presence of hematuria at the terminal portion of the drained fluid is very common in patients with interstitial cystitis. Reinspection of the bladder in patients with interstitial cystitis reveals diffuse glomerulations in most cases and, in some cases, Hunner’s ulcers. On rare occasions the lesions may be focal. Biopsies of the affected area(s) are necessary to rule out other possible pathologic conditions such as carcinoma in situ.

Additional intravesical agents such as dimethylsulfoxide (DMSO), silver nitrate, heparin sulfate, and chlorpactin WCS 9 can be instilled at the same time as the hydrodistention. Fifty milliliters of 50% aqueous solution of DMSO with or without steroids (i.e., 100 mg hydrocortisone or 50 mg methylprednisolone) are left indwelling for 20 to 30 minutes. Intravesical heparin in a dose of 10,000 IU can also be instilled and left indwelling much the same manner as DMSO. Silver nitrate in concentrations of 0.5% to 2% can also be instilled and left to dwell for 5 to 7 minutes. At the end of the dwell time, the silver nitrate solution is irrigated with copious amounts of saline solution. A white precipitate of silver chloride is formed, and saline irrigation should continue (usually 1 to 2 liters) until the irrigant is clear. It is best to avoid using silver nitrate at the same time as biopsy or in patients with vesicoureteral reflux. Chlorpactin at 0.4% is instilled in a similar manner as DMSO. However, the same precautions should be observed with chlorpactin instillation as with silver nitrate in that it should not be administered if vesicoureteral reflux is present or if bladder biopsies were performed.

Endoscopic Resection or Fulguration

Endoscopic resection or fulguration of lesions can also be performed in those select few patients who have Hunner’s ulcers or localized disease. Resection can be carried out with the loop resectoscope in which the continuous-flow resectoscope is very helpful because it allows a constant bladder volume during the resection, minimizing the risk of inadvertent bladder rupture. Fulguration of discrete areas of glomerulation can be performed with electrocautery, using either the Bugbee or rollerball electrode, or with the neodymium:YAG laser. With the laser set at 25 watts continuous and the tip set 1 to 2 mm from the bladder wall, the entire lesion is treated including a 2- to 3-mm margin of normal mucosa. Retreatment can be repeated at 4 to 6 weeks.

Cystolysis

Bladder denervation procedures have been reported in the treatment of patients with intractable bladder pain and urinary frequency and urgency. Division of the posterior sacral roots, posterior rhizotomy, or division of the inferior vesical neurovascular pedicle has resulted in temporary improvement in urinary frequency, urgency, and pain. However, the return of symptoms and the development of poorly compliant bladders over the long term have resulted in the abandonment of these procedures as a viable surgical treatment for interstitial cystitis.

Ingelmann-Sundberg has recently described a more selective denervation in which a transvaginal approach is used to resect the inferior hypogastric plexus, whereby both the sympathetic and parasympathetic fibers to the bladder are divided4. Candidates for transvaginal denervation are selected by first performing a subtrigonal injection with bupivacaine. Patients amenable to denervation should experience a period of complete or significant relief from their irritative symptoms.

To perform the denervation, place the patient in a lithotomy position and determine the bladder neck and trigone by palpation of the Foley catheter balloon. Ureteral stents should be placed before the vaginal dissection is done to avoid inadvertent injury to the ureters during the vaginal dissection. A posterior-based U incision is made in the anterior vagina, and the vaginal epithelium is sharply dissected off the underlying proximal urethra, bladder neck, and distal trigone. The vaginal epithelium is then reapproximated using a running suture of 2-0 or 3-0 chromic catgut. The ureteral stents are removed, and the Foley catheter is left indwelling for 24 hours.

Urinary Diversion

Urinary diversion without removal of the diseased bladder usually is not sufficient to relieve symptoms secondary to interstitial cystitis. Most patients will continue to be symptomatic, and therefore, urinary diversion alone is not an adequate or appropriate method of treatment.

Augmentation Cystoplasty

Simple augmentation of the bladder without excision of the diseased bladder has been described as a method of treating patients with intractable interstitial cystitis who are found to have small-capacity bladders (<400 cc under general anesthesia). Both small and large bowel segments can be used. Concern remains regarding the relative wisdom of leaving a significant portion of affected bladder behind in interstitial cystitis patients when performing simple augmentation. Intuitively, removal of as much diseased or affected bladder would be preferred in patients with interstitial cystitis, and therefore, partial or subtotal cystectomy with substitution cystoplasty would appear to be a better surgical choice.

Partial Cystectomy and Substitution Cystoplasty

Supratrigonal cystectomy with enterocystoplasty is the preferred surgical choice for patients with small-capacity bladders (<400 cc under general anesthesia) and urinary frequency and urgency related to this small bladder capacity. Patients who have a predominant pain component, especially if it is unrelated to bladder fullness, are not good candidates for partial cystectomy and substitution cystoplasty because they are unlikely to experience symptomatic relief. Patients undergoing partial cystectomy and cystoplasty should also be able to perform intermittent catheterization in order to achieve complete bladder emptying as well as to perform bladder irrigation of the mucus secreted by the bowel segment used.

The patient is given a bowel prep and adequate hydration before surgery and is placed in a supine position. A Foley catheter is placed sterilely in the bladder and connected to a three-way irrigation. The peritoneal cavity is entered through a vertical midline incision, and an appropriate segment of either large or small bowel with a mesentery long enough to reach down to the bladder is selected. The preferred bowel segments are the cecum, sigmoid colon, or ileum. The bladder is filled with irrigant via the three-way irrigation and is then divided in a clam-shell technique, exposing the trigone. Ureteral catheters are placed before resection of the bladder to avoid inadvertent injury to the ureters. Using electrocautery, supratrigonal cystectomy is performed, resecting all but a 1- to 2-cm cuff of bladder that includes the trigone and bladder neck. Hemostasis during the resection is controlled by placement of Allis clamps on the edges of the remaining bladder. The vesicoenteric anastomosis is completed using a two-layer running closure of 3-0 chromic on the mucosa and 2-0 chromic on the muscularis layer. In addition to the Foley, a 22-Fr Malecot suprapubic catheter is left indwelling via a separate “cystotomy” to provide adequate postoperative drainage.

Starting on postoperative day 2, gentle irrigation of the suprapubic tube and Foley catheter is done to prevent obstruction secondary to mucus production from the bowel segment. Patients are usually discharged on postoperative day 7 to 10 when normal bowel function returns. Before discharge, the Foley catheter is removed, and patients are taught how to irrigate via the suprapubic tube. At 3 to 4 weeks postoperatively, a cystogram is performed, and the suprapubic tube is removed if no leakage is noted. Patients are instructed to perform intermittent catheterization to ensure adequate bladder emptying as well as to ensure irrigation of mucus.

An alternative to the supratrigonal cystectomy is a total cystectomy and orthotopic urinary diversion, which has been described in both men and women after cystectomy for bladder cancer . This type of diversion may be a viable alternative to partial cystectomy because less of the affected bladder is left behind.

Total Cystectomy with Urinary Diversion

Total cystectomy with urinary diversion is the treatment option for patients who have failed to respond to all previous conservative treatments or who have failed partial cystectomy and enterocystoplasty. Patients with a significant component of urethral pain are probably better candidates for complete cystectomy and urinary diversion rather than partial cystectomy. The choice of performing a continent versus an incontinent diversion is based mainly on patient preference. As continent diversions have become more popular in recent years, the majority of my patients have preferred this type of urinary diversion. To be considered a candidate for a continent diversion, patients must show a proficiency in performing intermittent catheterization and be highly motivated. The technique of cystectomy and urinary diversion, including complications.

OUTCOMES

Complications

The most serious complication is bladder rupture, but fortunately, this is very uncommon, occurring in fewer than 0.1% of more than 1,500 hydrodistentions performed for the treatment of interstitial cystitis at our institution over the past 8 years. No return of irrigant fluid after distention, or the sudden return of irrigant fluid at the end of bladder filling, or severe suprapubic and/or abdominal pain should alert one to the possibility of a spontaneous bladder rupture. Immediate cystogram should be performed. Prolonged Foley catheter drainage is probably all that is necessary to allow the rupture to heal spontaneously. Any bladder rupture that occurs following instillation of agents such as chlorpactin or silver nitrate probably warrants open exploration with copious irrigation of the site of extravasation because of the severe caustic properties of these agents.

Bladder perforation is more likely to occur following fulguration or excision of interstitial cystitis lesions because the bladder wall is normally quite thin. In addition, bowel injury can occur following aggressive loop resection or injudicious use of laser energy.

Persistence of symptoms is probably the most common and disheartening for both patient and surgeon.

Results

Hydrodistention alone without the addition of intravesical agents relieves the symptoms in up to 30% of patients. The addition of DMSO with or without steroids has been shown to relieve symptoms in about 50% of patients. Similar clinical responses are also seen with chlorpactin and heparin. Interestingly, after intravesical therapy, symptoms may improve, but the cystoscopic appearance of the bladder, regardless of the agent used, typically remains unchanged. The choice of intravesical agent used, and in which order, is not critical to how a patient may respond clinically. It is common for patients to become resistant to one treatment and respond favorably to another treatment. The advantage to DMSO and heparin is that these agents can be administered in the office under topical anesthesia, whereas silver nitrate and chlorpactin almost universally require general or regional anesthesia.

Resection or fulguration in select patients results in clinical improvement in 33% to 80% of patients, with those with Hunner’s ulcers responding more favorably than those patients with focal glomerulations.

The more aggressive, open surgical approaches have shown good results in selected patients. Relief of symptoms in a highly select group of patients undergoing supratrigonal cystectomy and enterocystoplasty has been reported to range between 60% and 90%.6,8 The results of total cystectomy for the treatment of incapacitating interstitial cystitis are varied. Although a significant percentage of this highly select group of patients who undergo cystectomy will experience significant relief, there are reports of patients having persistent pelvic pain despite having undergone complete cystectomy and urethrectomy.

Interstitial cystitis is a difficult disease to treat in a surgical manner aside from hydrodistention and intravesical instillation therapy. Fortunately, the vast majority of patients with interstitial cystitis do not ever have symptoms so severe or incapacitating as to warrant any further invasive surgical intervention aside from hydrodistention. In those few patients who continue to have significant symptoms and who are interested in further surgical intervention, a thorough discussion of treatment options between physician and patient is critical to ensure a satisfactory outcome. Suffice it to say that our basic understanding of this poorly understood disease is still in its infancy, and therefore, proper therapy including surgery is as yet poorly delineated.

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VESICAL HEMORRHAGE

Significant bleeding from the bladder in the absence of trauma is usually associated with hemorrhagic cystitis. This can result from a variety of infectious and noninfectious etiologies. Sports hematuria or stress hematuria is a well-known cause of vesical hemorrhage seen mainly in marathon runners and other athletes. It is believed to be caused by the repeated impact of the posterior wall and base of the bladder, which results in mucosal contusions. An empty bladder at the time of running facilitates this process. Maintaining a partially full bladder in which the urine acts as a hydrostatic cushion will help prevent it.

Infections with various viruses such as the BK virus, adenovirus, and the influenza A virus can result in hemorrhagic cystitis. Bacterial infections, most often with E. coli, can also result in hemorrhagic cystitis. Fungal infections seen frequently after treatment with broad-spectrum antibiotics can also result in this condition. Parasitic infections with organisms such as Schistosoma hematobium are known to be associated with this form of cystitis. This indicates that hemorrhagic cystitis is a symptom of an underlying condition rather than a disease in itself. Infection-related hemorrhagic cystitis is usually treatable by addressing the underlying cause.

Radiation therapy to the prostate, bladder, or other pelvic organs can result in hemorrhagic cystitis. Initially there is mucosal edema with submucosal hemorrhage. Chronically, radiation causes obliterative endarteritis with subsequent urothelial ischemia. Various measures such as steroids, vitamin E, and trypsin have proved futile in treating radiation-induced cystitis, which can manifest many years after exposure. Coating the bladder mucosa with synthetic agents such as sodium pentosanpolysulfate has some beneficial effect. Hyperbaric oxygen therapy has also proved effective.

Amyloidosis of the bladder, which tends to occur in patients with rheumatoid arthritis and Crohn’s disease, can also result in hemorrhagic cystitis. The hemorrhage can be particularly severe after instrumentation or biopsy of the bladder. This hemorrhage may require aggressive treatment measures including angiographic vessel occlusion or cystectomy.

Urothelial malignancies can also cause significant bleeding, which can be controlled by transurethral resection of tumor and fulguration with electrocautery in most cases. In patients with metastatic or unresectable bladder tumors and severe hematuria, local radiation can be used to palliate the symptoms. In some cases, cystectomy or urinary diversion by means of percutaneous nephrostomy or conduit urinary diversion may be the only viable option.

A wide range of drugs and industrial toxins can also give rise to hemorrhagic cystitis. Aniline and toluidine dyes are well known to be associated with this side effect. Treatment is largely conservative, as the cystitis is self-limiting and resolves after removal of the offending agent. Antibiotics such as nitrofurantoin, ether, and accidental insertion of spermicidal contraceptives into the urethra can also result in severe hemorrhage from the bladder. Conservative treatment with adequate hydration, bladder irrigation, and discontinuing the causative agent would suffice as treatment for most cases.

Chemotherapeutic agents are a major cause of hemorrhagic cystitis. Busulfan, commonly used for treatment of leukemia, can give rise to hemorrhagic cystitis. Administration of N-acetylcysteine (mucomist), used to treat some other forms of chemically induced cystitis, would only worsen the condition. Most other measures are also ineffective in this situation. Intravesical administration of Thiotepa can result in this complication, which can occur up to 6 months after cessation of therapy. Alkylating agents such as cyclophosphamide and isophosphamide, which are employed in chemotherapeutic regimens for various solid tumors and lymphoproliferative disorders, are common culprits for hemorrhagic cystitis. The incidence ranges from 2% to 40%, and significant mortality rates have also been reported. It is dose dependent and related to the route of administration of the chemotherapeutic agent (higher with intravenous administration). It is more severe in dehydrated patients. Acrolein, which is a liver metabolite of cyclophosphamide, is the principal inciting agent and acts by direct contact with the bladder mucosa. Histologic changes that occur in the bladder are similar to those seen with radiation and include edema, ulceration, neovascularization, hemorrhage, and necrosis. Prophylactic hydration and the use of protective agents such as mucomist or 2-mercaptoethane sulfonate (Mesna) can reduce the incidence of this complication. Systemic administration of mucomist can decrease the antineoplastic effect of cyclophosphamide.

Treatment of Hemorrhagic Cystitis

Mild hematuria can be managed by vigorous hydration and oral administration of agents such as aminocaproic acid or conjugated estrogens, which inhibit fibrinolysis and promote coagulation.

Moderate hematuria can be treated with continuous saline irrigation through a Foley catheter after all clots have been evacuated. In some situations such as with radiation cystitis, irrigation with cold saline for 24 to 48 hours may prove more effective. If hematuria persists, continuous bladder irrigation with 1% alum (potassium or ammonium aluminum sulfate) is helpful. The alum acts as an astringent and precipitates the surface proteins. Aluminum levels must be monitored, particularly in patients with renal insufficiency. Severe acidosis and encephalopathy can occur in such patients as a result of high aluminum levels. Periodic intravesical instillation of prostaglandins (PGE2, PGF2a) and PGF2a analogs (Carboprost) have also proved effective. They decrease the inflammatory response and reduce the hemorrhage. They can be used prophylactically or therapeutically. Prostaglandin E2 has been used in a dose of 0.75 mg in 200 cc of normal saline instilled for 4 hours. The effective dose of PGF2a has been 1.4 mg in 200 cc of normal saline. Carboprost has been used in a dose of 0.8 mg/dl diluted in normal saline instilled for 1 hour at 6-hour intervals with good results in 62% of patients according to one study.8 Instillation of silver nitrate (0.5% to 1% solution) for short periods of time followed by saline irrigation of the bladder to remove residual silver nitrate is also an effective technique.

Persistent severe hemorrhage that has not subsided in spite of the above-mentioned measures can be treated with intravesical instillation of carbolic acid (phenol) or 1% formalin. This requires general anesthesia. Phenol is instilled in a dose of 30 cc of a 100% solution mixed with an equal volume of glycine for 1 minute. This is washed out with 95% ethanol (60 cc) and saline to prevent methemoglobinemia. It is necessary to rule out vesicoureteral reflux by performing a voiding cystourethrogram before using formalin, as it can cause fibrosis and scarring of the ureters and renal pelvis. If need be, the ureters can be occluded with Fogarty balloon catheters to prevent reflux while formalin is instilled. Fifty milliliters of 1% formalin (0.37% formaldehyde) diluted with saline should be instilled for 4 to 10 minutes. This should then be washed out with saline, and the saline irrigation is continued for 24 hours. The external genitalia are covered with towels or Vaseline to prevent irritation.

In recalcitrant cases, use of medical antishock trousers and cryotherapy have been reported. Embolization of the hypogastric arteries with autologous clot, Gelfoam, coils, or ethanol can also be resorted to in such cases. This may result in temporary gluteal claudication. Open ligation of the hypogastric artery can also be performed. Supravesical urinary diversion by means of percutaneous nephrostomy tubes or ileal or sigmoid conduit urinary diversion with or without cystectomy remains as a final but viable option.

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VESICAL TRAUMA

Vesical injury can occur as a result of blunt or penetrating trauma to the lower abdomen and pelvis. It is more commonly associated with blunt trauma such as that sustained from motor vehicle accidents, falls, blows, and during contact sports. Penetrating trauma resulting in vesical injury occurs from gunshot wounds and knife wounds. Bladder injuries can also be iatrogenic from transurethral surgery, gynecologic procedures, laparoscopy, and other intra-abdominal surgery. Bladder injury, particularly bladder rupture, is associated with pelvic fractures in 75% to 83% of patients. However, only 5% to 10% of patients with pelvic fractures will have associated bladder rupture. There is also a high incidence (>85%) of injuries to other organs in patients with bladder rupture. Concomitant bladder rupture is found in 10% to 29% of patients who present with rupture of the posterior urethra, and this is the most common injury to the genitourinary tract associated with bladder rupture. The mortality rate in patients with bladder rupture ranges from 11% to 44% and is mainly attributable to other associated organ injuries.

Anatomy

In children, the bladder is mainly an abdominal organ located behind the anterior abdominal wall. Growth of the bony pelvis allows the bladder to assume its position behind the pubic symphysis by the end of the sixth year of life. In its extraperitoneal location, the bladder is protected by the bony ring of the pelvis. It is attached to the pelvic bones and the lateral pelvic wall by means of various ligaments. The superior surface (dome) of the bladder in women and the dome and a portion of the base of the bladder in men are covered by parietal peritoneum. A fibrous cord, the median umbilical ligament, extends from the apex of the bladder to the umbilicus and is a remnant of the urachus. The dorsolateral ligamentous attachments of the bladder contain the nerves and vascular supply to the bladder. The fascial attachments between the bladder and the pubic bones are termed the pubovesical ligaments in women and the puboprostatic ligaments in men. Ligamentous attachments also connect the bladder anteriorly and laterally to the pelvic side wall.

The arterial supply to the bladder is derived from the superior, middle, and inferior vesical arteries, which are branches of the anterior division of the internal iliac (hypogastric) artery. The vesical venous plexus drains into the internal iliac veins. The sympathetic nerve supply to the bladder originates in the thoracolumbar sympathetic trunks and is via the superior hypogastric plexus to the pelvic plexus, where it joins with the parasympathetic nerves. The parasympathetic nerve supply is from the sacral parasympathetic outflow to the pelvic plexus and then to the bladder.

Mechanism of Injury

Bladder injury occurs as three predominant types: contusion with only intramural injury and extraperitoneal or intraperitoneal bladder rupture. The exact incidence of bladder contusion is not known because of the lack of large studies involving this type of bladder injury. It is a partial-thickness tear of the bladder mucosa with ecchymosis of the bladder wall. It is often associated with a “teardrop” bladder, which occurs as a result of the presence of compressive pelvic hematomas from pelvic fractures. It is usually self-limiting and rarely requires treatment. Extraperitoneal bladder rupture occurs less frequently than intraperitoneal rupture (34% versus 58% of cases). Combined intra- and extraperitoneal rupture is seen in 8% of cases. It was initially believed that bladder rupture, especially extraperitoneal rupture, resulted from the traumatic dislodgement of the bladder from its points of attachment. Penetration of the bladder wall by fragments of the fractured pelvic bones was also thought to be another possible etiologic mechanism. However, Carroll and McAninch noted that only 35% of bladder ruptures in their series were accompanied by ipsilateral pelvic fractures. Hence, it is likely that the bladder may sustain an extraperitoneal rupture when it suffers from a bursting-type injury. In intraperitoneal rupture, the dome of the bladder, which is the weakest portion of the wall, usually gives way, resulting most often in a horizontal tear.

Diagnosis

Patients with bladder injury usually complain of lower abdominal pain and tenderness. Such an injury should be suspected in any patient with a pelvic fracture. Most patients with bladder trauma, including those with bladder contusions, will have gross or microscopic hematuria. Patients with contusion alone are usually able to void, whereas those with a ruptured bladder are often unable to void spontaneously. Acidosis with prerenal azotemia and elevated blood urea nitrogen is sometimes noticeable when there is a delay in diagnosis.

Presence of blood at the urethral meatus mandates performing a retrograde urethrogram. This is performed to rule out urethral injury before catheterization or instrumentation. If the retrograde urethrogram is normal, a urethral catheter is placed, and a retrograde cystogram is obtained. This is performed by instilling at least 250 to 400 cc of water-soluble contrast (cystografin) in the bladder under gravity to ensure adequate distension and visualization of possible areas of rupture. One of the principal reasons for false-negative cystograms is instillation of an inadequate amount of contrast in the bladder. Static anteroposterior, oblique, or lateral films are obtained with the bladder full, and a washout film is obtained after drainage of the contrast material from the bladder. These additional films are useful in evaluating patients with posterior wall ruptures, which may be obscured in the anteroposterior view by a contrast-filled bladder. The drainage film also helps detect residual extravasation.

The cystogram is usually normal in the presence of a bladder contusion. Intraperitoneal rupture results in ill-defined spillage of contrast into the peritoneum. The extravasated contrast may outline loops of bowel or accumulate in the paracolic gutters, beneath the diaphragm or over the bladder, in an hourglass pattern. Extraperitoneal rupture is seen as streak-like extravasation of contrast confined to the pelvis on retrograde cystogram. Corriere and Sandler further distinguished extraperitoneal ruptures as simple (confined to the perivesical space) or complex (extravasation into scrotum, retroperitoneum, abdominal wall, etc.). Displacement of the bladder by a pelvic hematoma can result in a “teardrop”-shaped bladder on cystogram.

Recently, examination of a contrast-filled bladder during CT scan has been used as a method of assessing injury. This is particularly applicable in patients who first undergo abdominal CT scans to rule out suspected visceral injuries. In these situations, the ability to simultaneously evaluate the bladder would obviate the need for an additional plain-film cystogram. However, during routine abdominopelvic CT scan, the bladder may not be adequately distended to allow evaluation for rupture. Mee et al. reported on two patients who were evaluated for bladder rupture on CT scan. Both patients received intravenous and oral contrast, and their Foley catheters were clamped to allow bladder filling. In spite of this, one of the patients had a false-negative result. The bladder rupture was subsequently visualized on plain-film cystography in both cases. The results of CT cystography are better when the bladder is filled in a retrograde fashion with large volumes of contrast (>350 cc). Intraperitoneal bladder rupture can be distinguished from extraperitoneal rupture on CT scan. Presence of contrast around the bladder and in the paracolic gutters on either side and around abdominal viscera such as the liver indicates intraperitoneal rupture. In the case of extraperitoneal rupture, contrast extravasation is usually seen around the bladder, in the presacral space and in the retroperitoneum anterior to the great vessels. Bladder contusions may be seen on CT scan as intramural hematomas. In spite of the improved accuracy of CT scans, plain-film cystography is still the diagnostic modality of choice for detecting bladder ruptures. The accuracy of CT cystography may be significantly improved if retrograde bladder filling with adequate amounts of contrast is employed. In these situations, its accuracy may even approach that of plain-film cystography. Computed tomographic cystography may be particularly useful in the select group of patients who undergo a CT scan as their initial radiologic evaluation and are unable to undergo routine cystography because of the nature of their injuries or time constraints.

Intraoperatively, bladder rupture can be diagnosed by extravasation of saline, sterile milk, methylene blue, or indigo carmine, which is instilled in the bladder through a Foley catheter. In some situations, an intravenous pyelogram may be required to rule out other ureteral or renal injuries.

Indications for Surgery

  1. Intraperitoneal bladder rupture.

  1. Bladder rupture or perforation sustained during another surgical procedure.

  1. Extraperitoneal bladder rupture in the presence of other intra-abdominal injuries requiring surgical intervention.

  1. Extraperitoneal bladder rupture with the bladder being inadequately drained by urethral catheter drainage.

Alternative Therapy

Alternative treatments of bladder trauma are predominantly Foley catheter drainage, which is indicated in patients with bladder contusions and extraperitoneal extravasation. Injuries occurring during other procedures such as laparoscopic surgery may be repaired laparoscopically.

Surgical Technique

Intraperitoneal Bladder Rupture

Intraperitoneal bladder rupture requires immediate surgical repair. The abdomen is opened through a vertical lower midline incision, which affords better exposure and is extendable in case a laparotomy is required. The rupture, which is usually placed horizontally on the dome of the bladder, is identified. In some situations, this may require instillation of saline or dye in the bladder through a previously placed urethral catheter. In cases where additional extraperitoneal ruptures are suspected, the opening in the bladder wall can be extended to allow better visualization of the interior and bladder neck. These extraperitoneal tears can be closed from inside the bladder in one or two layers using running absorbable suture (3-0 chromic or polyglycolic/polygalactic acid). The intraperitoneal rupture(s) are closed in at least two layers using running 3-0 chromic or polyglycolic/polygalactic acid suture. The mucosa, muscle, and peritoneum are all closed in separate layers. The bladder is filled with saline after completion of the closure to evaluate for leaks. If any leaks are detected, they can be closed using interrupted figure-of-eight sutures.

In some situations, bony spicules that have penetrated the bladder wall may need to be removed before closure of the bladder. In cases of penetrating trauma or erosion of the bladder wall by pelvic abscess, nonviable tissue must be debrided, and the edges of the perforation freshened prior to closure. In these cases, the tissue may be extremely friable, and a single-layer closure may need to be performed. The ureteral orifices should be identified and observed to ensure normal efflux of urine. This may be done after administration of intravenous indigo carmine to facilitate visualization. If efflux of urine is not seen, proximal ureteral obstruction, especially by fractured bony fragments, should be ruled out. This can be done by performing a retrograde or intravenous pyelogram on the operating table.

An 8-Fr Malecot suprapubic catheter is placed through a separate cystotomy to drain the bladder. Care must be taken not to disturb the pelvic hematoma that is invariably present. Disruption of the pelvic hematoma may give rise to significant bleeding. This can be controlled by packing the area with Gelfoam, Surgicel, or laparotomy tapes. The abdomen can be temporarily closed with the packing in place for about 24 hours, and the packing removed at the time of reexploration. In extreme cases, angiographic embolization of the pelvic vessels may be necessary.

A ½-inch Penrose drain is placed adjacent to the bladder and left in place for 48 hours. In some cases, if the pelvic hematoma has not been disturbed, and the bladder closure is truly watertight, drains can be omitted altogether. The abdominal fascia and skin are closed in the usual fashion.

In patients with small bladder ruptures, we have opted to drain the bladder postoperatively via a urethral catheter and have noted no significant adverse effects. The catheter is left in place for 7 to 10 days. A gravity cystogram is obtained at the end of this time to ensure absence of extravasation. The catheter is then removed if no extravasation is evident on cystogram.

Iatrogenic bladder injury, if suspected to have occurred during other operative procedures, should be documented by instillation of methylene blue or indigo carmine in the bladder and noting any extravasation. The rupture or tear can be closed primarily in two or three layers using absorbable suture as in other cases of rupture. Bladder perforations sustained during laparoscopic procedures can be diagnosed by noting distention of the urethral catheter drainage bag with gas. These injuries can be repaired as described previously by laparotomy or even laparoscopically.

Extraperitoneal Bladder Rupture

Until the 1970s, extraperitoneal bladder rupture was managed as an intraperitoneal rupture. Since then several studies have demonstrated that these injuries can be managed nonoperatively. Corriere and Sandler successfully managed 41 patients with extraperitoneal bladder rupture by prolonged urethral catheterization alone. All patients healed the bladder injury spontaneously without complications. Since then, other studies have duplicated these results.

Isolated extraperitoneal rupture can be treated by simple urethral catheter drainage. Once urethral injury has been ruled out by means of a retrograde urethrogram, a urethral catheter is placed. The catheter is left in place for 10 to 14 days. Repeat cystograms are performed at the end of this period. If no extravasation is observed, the catheter can be removed. If any contrast extravasation is evident on the cystogram, catheter drainage is continued. Cystograms are repeated at weekly intervals until no extravasation is demonstrable. A majority of extraperitoneal ruptures treated in this manner will heal by 2 weeks, and almost all will show healing within 3 weeks.

Severe bleeding with clots or sepsis should prompt surgical exploration even in cases of extraperitoneal rupture. If patients are undergoing laparotomy for other intra-abdominal injuries, it is reasonable to repair extraperitoneal ruptures surgically.

Outcomes

Complications

Some patients may notice persistent urgency and increased frequency of micturition after repair of bladder ruptures. These symptoms are usually temporary and tend to subside with time. Vesical neck injuries increase the risk of subsequent incontinence, and attention should be paid to careful repair of these injuries. Infection of pelvic hematomas can result in abscess formation requiring prolonged drainage and antibiotic treatment. This can be prevented to some extent by taking care to avoid disrupting the hematoma intraoperatively. Unrecognized injury to adjacent structures can lead to subsequent vesicovaginal or vesicoenteric fistula formation. Otherwise, this complication is uncommon.

Complications such as clot retention and pseudodiverticulum formation are seen in fewer than 10% of patients treated with catheter drainage alone for extraperitoneal rupture. Significant sepsis, delayed healing, formation of bladder calculi, and vesicocutaneous fistula formation have been noted to occur in patients treated with urethral or suprapubic catheter drainage for extraperitoneal rupture. These patients most often had poorly functioning catheters or did not receive prophylactic antibiotics. Hence, it is important to ensure that urethral catheters are functioning adequately when used in these situations. Use of larger catheters and resorting to immediate open repair if catheters remain nonfunctional after 24 to 48 hours will help avoid these complications. Prophylactic antibiotics with gram-negative coverage, when administered for the duration of catheterization, will help prevent urinary tract infections.

Results

Open repair with adequate closure of the rupture is almost uniformly successful in all patients treated in this manner, and 74% to 87% of patients managed with urethral catheter drainage for extraperitoneal rupture will show evidence of healing by 10 to 14 days. The remainder will heal with an additional week to 10 days of catheter drainage.

Vesicoenteric Fistula

Although rare in daily clinical practice, the diagnosis of an acquired communication or fistula between the urinary tract and the intestines is always a challenge to the ingenuity and clinical acumen of the urologist and, later, to the good surgical judgment as to whether surgery is indicated or not, and whether to do it in a single or in several stages. Most manifestations of the condition occur toward the urinary tract, with passage of fecal matter and flatus from the gut to the bladder rather than in the opposite direction, directing these patients toward a urologist who will initiate the proper workup and participate actively in the surgical care.

Vesicoenteric fistulas are usually the consequence of inflammatory processes of the bowel, mainly diverticulitis; colorectal cancer and, more rarely, carcinoma of the bladder; trauma; and iatrogenic fistulas between bladder and sigmoid colon as a result of prostatic surgery, either endoscopic or open.

Diverticulitis has long been identified as the most common cause of vesicoenteric fistula, ranging in incidence from 36% to 85%, with an average of 50%, with colonic malignancy, granulomatous bowel disease, and radiation therapy accounting for the majority of the remainder in a large series.1,5 Before 1950, one in 3,000 surgical hospitalizations and 23% of patients who required surgery for diverticulitis had vesicoenteric fistulas reflecting late diagnosis and treatment.3 Diverticulosis occurs in at least half of patients older than 60 years old. Inflammation of these mucosal outpouches occurs 1.5 to 3.0 times more frequently in men than in women, whereas vesicocolonic fistula is up to five times as often in men as in women, indicating that the uterus may play a role in the prevention of fistulization to the bladder. Moreover, in women with diverticulitis, vaginocolonic fistulas are much more frequent than vesicolonic fistulas, 7.5:1.0, further supporting the role of the uterus as a protective anatomic barrier.

Colorectal adenocarcinoma is the cause of fistula in 10% to 16% of cases, being the second most frequent entity after diverticulitis. Half of these neoplastic fistulas are vesicosigmoideal. Other pelvic neoplasias, such as bladder and cervical carcinoma, are less frequent causes of fistula, ranging in incidence between 5% and 10% each. Enterovesical fistula is a rare complication of pelvic radiotherapy for gynecologic cancer, with recurrent neoplasia being the most common cause of fistulization, though some patients without recurrence will develop a fistula. High-risk factors for radiation morbidity include previous surgery, pelvic inflammatory disease, adjuvant hyperbaric oxygen, or locally high doses of radiotherapy caused by suboptimal geometry and technique. The range of radiation morbidity is variable, some patients had small fistulas, others had extensive fistulization and radionecrosis. The site of the radiation-induced fistula varies: colovesical fistulas, enterovesical fistulas, and some patients with fistulas involving both the small and large bowel. Rarely, the cause of the vesicoenteric fistula is transitional-cell carcinoma of the bladder.

Inflammatory bowel disease accounts for approximately 3.5% of cases of vesicoenteric fistulas, with Crohn’s disease being the most common cause. Generally, patients with Crohn’s disease were an average of 20 years younger than the patient with cancer or diverticulitis. Crohn’s disease is more likely to produce multiple fistulas: ileovesical, ileoascending colonic, and ileosigmoidal. Other less common inflammatory processes associated with vesicoenteric fistulas include appendiceal abscess, tuberculosis, and actinomycosis.

DIAGNOSIS

Clinical Manifestations

Despite the fact that most vesicoenteric fistulas are the result of primary bowel disease, patients most often have urologic symptoms, with a significant absence of localizing intestinal symptoms in up to half of patients. A wide range of symptoms exist that are of variable intensity but generally of insidious nature, making the diagnosis of a fistula elusive and delayed.

Gastrointestinal symptoms of vesicoenteric fistulas include abdominal pain, diarrhea, constipation, intestinal obstruction, and acute abdomen, which are manifestations of the underlying pathology. Urologic symptoms may be lower tract such as bladder irritation, frequency, urgency, dysuria, and hematuria; those related to recurrent urinary tract infections; and upper tract with accompanying systemic symptoms, fever, and chills.

The most relevant and pathognomonic manifestations, pneumaturia and fecaluria, passage of gas and feces, respectively, per urethra, occur in 40% to 83% of patients and immediately point toward the diagnosis. However, their absence does not rule out the entity; moreover, even if present, these symptoms may be overlooked or not recognized if the patient is not directly questioned or instructed to search for them carefully. Pneumaturia occurs twice as commonly as fecaluria because the passage of solid particles through the fistula is difficult. Interestingly, passage of urine per rectum is rare because of the higher colonic pressure and occurs only after a diverting colostomy or in association with severe bladder outlet obstruction. Bladder irritative symptoms associated with known diverticulosis and bouts of diverticulitis or Crohn’s disease should arouse suspicion of a prodromic stage of a vesicoenteric fistula.

Positive physical findings are few. An abdominal mass is felt in a third of patients, and abdominal tenderness and guarding, indicating local peritonitis, is seen in one-third to half of the patients. Rarely, one can find a cutaneous fistula and acute scrotum secondary to urinary tract infection. Urinalysis may show striated muscle fibers (rhabdomyocytes) derived from undigested meat residue from stool, in addition to the usual findings of urinary infection. Urine cultures generally grow a single species, predominantly Escherichia coli, instead of the falsely expected mixed growth. Temporary closure of the fistula by edema may render a urine culture negative in 5% to 10% of patients.

Preoperative Assessment

Once the diagnosis of vesicoenteric fistula is entertained, it is important to document both the presence and site of the fistula. Although it is more frequently found between the sigmoid colon and bladder, other locations (ileal, appendicular, colic, rectal, and Meckel’s diverticulum) must be ruled out. Additionally, any involvement of adjacent viscera needs to be identified.

Enterovesical fistula is a challenging entity, the etiology of which may be suspected from the patient’s history or physical assessment. The definite diagnosis of enterovesical fistula can remain difficult despite the many methods of diagnosis, including functional, imaging, and endoscopic studies.

Functional Studies

  1. Activated charcoal, nonabsorbable through intestinal mucosa, administered orally or through the defunctionalized end of a colostomy, produces charcoaluria. This method is easy, inexpensive, noninvasive, and yields the highest rate of positive results.

  1. Visible dyes (phenazopyridine, methylene blue, indigo carmine, Congo red) administered through enemas in undiverted patients or through urethral or suprapubic catheter, searching for stained stools.

  1. Search for pneumaturia with the patient voiding in a water-filled tub.

  1. Oral nonabsorbable radioisotope, e.g., 51Cr-labeled sodium chromate, producing quantitated radioactivity in urine over 2 to 3 days.

Imaging Studies

  1. Intravenous pyelogram is generally of little help. Rarely, one sees dye in the colon; more frequently, some nonspecific abnormalities related to the primary process or associated inflammatory process, gas in urinary tract, bladder wall irregularities, ureteral strictures, or hydronephrosis.

  1. Retrograde and voiding cystogram—twice as successful as an intravenous pyelogram in diagnosing this condition, 35% to 44%—and one of the mandatory methods of evaluation.

  1. Retrograde pyelogram, used only if there is any suspicion of ureteral involvement in the process.

  1. Barium enema is unequivocally positive in only 20% to 42% of cases. However, it remains a very important study to delineate the process that is producing the fistula. Postevacuation films may enhance the sensitivity of the study. Also, the patient can be instructed to collect the voided urine in a plastic or glass container over a few hours in an attempt to see the barium directly or by means of a radiograph of the container. A more refined version of this concept is the Bourne test, in which a drop of sediment of centrifuged urine is placed on an x-ray cassette and compared radiologically with a control urine sample.

  1. Abdominal ultrasound has been used to diagnose complications of Crohn’s disease such as bowel loop wall thickening, abscess, lymph node enlargement, and vesicoenteric fistulas. Abdominal ultrasound has been found to yield the first diagnostic information on inflammatory bowel with a high correlation to surgical findings. Also, it can differentiate pelvic complications of these intestinal conditions.

  1. Upper gastrointestinal (UGI) series rarely are indicated unless the colon workup is normal or there is a suspicion of a complex fistula involving the ileum.

  1. Computed tomographic scan (CT) of abdomen and pelvis is a very useful study, with the following positive findings in the cases examined: air within the bladder in 83%, thickening of the intestine and bladder wall at the site of the fistula in 100%, and paravesical mass in 87%. This justifies it as a preliminary step in any suspected case of vesicoenteric fistula.9 A CT finding consistent with the diagnosis of appendicovesical fistula is calcification of a thickened bladder wall adjacent to the cecum on noncontrast CT, which is a fecalith in the lumen of the fistula. A CT scan of the abdomen and pelvis is, therefore, recommended in the evaluation of the majority of patients with suspected enterovesical fistulas.

  1. Magnetic resonance imaging (MRI) has been used in patients with Crohn’s disease to evaluate cutaneous, deep perineal, or enterovesical fistulas or abscesses, with good correlation with clinical examination under anesthesia. It is more likely that a negative MRI correlates better with other ancillary methods.

Endoscopic Studies

  1. Cystoscopy is, by far, the most valuable study to diagnose and localize the fistula, with a success rate of 32% to 87%. Nine of ten cystoscopies show mucosal abnormalities, feces, particulate matter, barium, and the so-called Pugh’s villous reaction, papillomatous epithelial growth, which sometimes can be misdiagnosed as low-grade transitional cell carcinoma. The fistula or suspicious area usually is located in the high left posterolateral wall when the primary cause is diverticulitis or cancer (colonic, vesical, or uterine). The fistula is usually located in the right or anterior wall in cases of Crohn’s disease or lesions of the cecum or appendix. It sometimes is possible to catheterize the suspect tract and obtain radiographic studies. Likewise, whether or not an obvious fistulous opening is visualized, a biopsy specimen can be taken from the suspect area to rule out an urothelial, gynecologic, or intestinal malignancy. From 10% to 20% of patients with vesicoenteric fistulas have completely normal endoscopic results.

  1. Endoscopic procedures of the lower gastrointestinal tract, colonoscopy or proctosigmoidoscopy, are of limited help. Perhaps the insufflation of air during these procedures may help uncover pneumaturia. These studies are indicated to evaluate the large bowel, to assess the magnitude of the primary problem (diverticula, neoplasia) and its sequelae (obstruction, mass) and to plan an optimal operation. Also, even if the fistula is the result of inflammatory bowel disease, there can be a concurrent bowel neoplasm in 3% to 14% of cases.

In summary, cystoscopy (60%) and cystography (44%) seem to be the most sensitive diagnostic studies. Computerized axial tomography scanning, cystoscopy, charcoaluria, and barium enema are useful in making the diagnosis. The IVP and colonoscopy are generally not useful procedures for the diagnosis of VE fistulas.6 Other imaging techniques, though less effective for diagnosis, were useful in assessing the status of the GI tract and, sometimes, determining the etiology of the fistula.

INDICATIONS FOR SURGERY

Surgical therapy aimed toward resolution of the primary process and abnormal communication is required and feasible in most cases. Ideally, the surgeon should consider a primary resection in properly selected patients, without risking the repair or the life of the patient. All possible etiologies can be treated this way. A selection of criteria regarding patient selection and characteristics of the fistula and the bowel anastomosis must be met for primary (one-stage) resection to be successful .

ALTERNATIVE THERAPY

On occasions, especially when the vesicoenteric fistula does not meet all above-mentioned criteria, it may be wise to treat preliminarily with a diverting colostomy in order to control the inflammatory process and avoid the continuance of infection and sepsis. Generally, this is done alone, and future procedures are planned. Traditionally, when a diverting colostomy has been done as a first stage, a second operation resolves the primary bowel process and the fistula proper (bowel resection plus partial cystectomy), and the colostomy is preserved rather than closed to protect the intestinal anastomosis. The closure of the colostomy can be done 4 to 6 weeks later as a third stage, to take full advantage of it. Although it is safe, at present this extended multistaged approach does not seem cost-efficient. Ideally, once the diverted patient is fully recovered of the acute event, one can proceed with excision of the fistula and reconstruction, with closure of the colostomy in the same session if local conditions allow it, in order to avoid a third operation.

During a single-stage operation, an unexpected intraoperative finding may induce a change of plans and convert a one-stage procedure to a multistaged operation. In this case, the main problem, the fistula, is excised, bowel and bladder reconstruction is accomplished, and then the anastomosis is protected by a colostomy, which will be closed as a second stage. All these alternatives should be fully discussed with the patient.

In debilitated patients with reasonable and comfortable life expectancies, a palliative colostomy may be the only procedure considered. In extremely debilitated patients, especially if there is unresectable or metastatic neoplasia, an expectant and supportive medical management (intermittent antibacterial treatment) may be all that is indicated. In one series one-tenth of the patients were not candidates for operation, and one-fourth of the patients did not undergo complete operative resolution and restoration of enteric and urinary continuity.

SURGICAL TECHNIQUE

Regardless of the site of the vesicoenteric fistula, the bowel needs to be prepared mechanically and bacteriologically. The patient is started in a low-roughage diet several days before entering the hospital, and cathartics and enemas are administered the day before surgery. Nonabsorbable oral antibiotics are given starting 24 hours for prophylaxis against both gram-negative and anaerobic bowel flora. It is advisable to initiate a program of parenteral hydration and antibiotic prophylaxis several hours before surgery, using drugs that cover gram-negative bacteria and, in the case of a colon fistula, anaerobics. If the patient is severely malnourished, oral or parenteral hyperalimentation can be started days to weeks before surgery and maintained through the postoperative period.

Surgery is started by a midline or paramedian incision in all cases, regardless of whether a prior fecal diversion has been done, to allow a transperitoneal approach with careful assessment of the inflammatory mass and intervening viscera as well as the remainder of the bowel and other intra-abdominal organs. This incision affords cephalad extension if needed. The abdomen is entered, and all adhesions are lysed; small bowel contents are removed from the pelvis. The area of the fistula is identified, and the intestine is sharply dissected from its attachment to the bladder. In patients with Crohn’s disease, the indication for surgery was the fistula alone in a third of the cases and the fistula plus another complication of the disease in two-thirds of the patients.8 These include enteroenteral, ileogenital, and enterocutaneous fistulas and intra-abdominal abscesses. The surgical team must be prepared for this eventuality. If the patient has not been diverted previously, the surgeon must decide either to proceed with a primary reconstruction without colostomy or, if the conditions are less than ideal, to protect the anastomosis with a colostomy. In case of a previous colostomy, one either takes advantage of the colostomy and plans to close it several weeks after the reconstruction or closes it immediately as mentioned.

Surgical treatment of a vesicoenteric fistula ideally consists of the excision of the diseased bowel, partial resection of the involved bladder, and interposition of a vascularized tissue between the two viscera. Urinary diversion is ordinarily attained with a urethral catheter. The use of a suprapubic catheter is optional and depends on the confidence of the surgeon in the vesical repair, local and urethral conditions, and presumed duration of urinary leakage. In case of ureteric involvement, stenting or ureteroureterostomy may be required. Bowel anastomosis is done in the standard one- or two-layer fashion or with a bowel stapler.

After both systems are reconstructed, it is advisable to fill the potential dead space between them with a vascularized tissue to support the repair and improve tissue healing, which is impaired by inflammation and infection. An omental flap is ideal to accomplish this task, either by simply fixing it between bladder and bowel with tacking sutures if the omentum is long or by creating a pedicle flap based in the right gastroepiploic artery, separating the left gastric attachments. Also, one may interpose flaps of peritoneum, muscle, or fibroadipose tissue in less serious cases. Gold foil and lyophilized human dura have been used in some cases. Colovesical fistulas associated with diverticulitis can be treated laparoscopically in a one-stage repair. It has been suggested that this operation is safe, has minimal pain, absent ileus, and a short postoperative stay.

Inflammatory bowel disease, especially Crohn’s disease, may produce filiform tracts, which can make the fistula localization difficult. Moreover, these patients are subject to more recurrences. Therefore, although simple separation of bowel and bladder with bowel resection and oversewing of the bladder wall may suffice, it may be better to proceed with a limited partial cystectomy. The involved bladder is resected to allow a two- or three-layer closure with absorbable sutures, bringing together edges of fresh, noninflamed tissue. If the defect seems too large, one may resort to rotated bladder flaps or rearrangements of bladder tissue as the ventrodorsal repair, wherein a longitudinal cystotomy is closed in a transverse manner. Rarely, a small bowel graft may be necessary to cover an unusually large defect, and in some cases, the cystotomy has been left open, and a urethral catheter left in place for at least 1 week with healing and no late recurrences.

Repair of Rectovesical Fistula (York-Mason Procedure)

A special situation may arise when the fistula involves the bladder and rectum instead of the sigmoid colon, as observed after injuries sustained during prostatic surgery and pelvic fractures. Repair of these fistulas using a posterior sagittal, transanal, transrectal (modified York–Mason) approach has been advocated with excellent results. This repair is possible without colostomy in a patient who has undergone a complete mechanical and bacteriologic bowel prep. Before surgery, a combined cystoscopy and rectal examination are performed to localize the fistula and establish all anatomic relationships with the ureteral orifices, urinary sphincter, and anorectal anatomy. One can insert a catheter or guide wire through the fistula to facilitate dissection.

The patient is placed in the prone jackknife position, with buttocks spread apart. An incision is made from the anal verge to the sacrococcygeal articulation, dividing all muscular bundles of the posterior anus and the entire thickness of the posterior rectal wall and tagging them with sutures for accurate reconstruction at the end of the procedure. Once the fistula is located, it is excised down to its junction with the bladder or prostate, removing all inflammatory tissues to optimize the closure of both defects. Both organs are closed in two layers of absorbable sutures. The first rectal wall layer involves muscle and submucosa, and the second, rectal mucosa in an everting fashion. Sometimes a demucosalized rectal flap can be used to buttress this repair. Then, the dorsal rectal and anal mucosa are closed with a chromic running suture. Careful approximation of the dentate and pectinate lines is desirable. The anal sphincter is reconstructed with the previously placed tagged opposing sutures tied together. Drains are removed on the fifth postoperative day; however, discharge can be accomplished on the second postoperative day. Vesical drainage is effected with a Foley catheter as in any vesical reconstruction.

This approach is simple, rapid, and performed through fresh tissues uninvolved in the inflammatory process and is a significant improvement over the transabdominal, transvesical, or transperineal approaches, where the depth of these pelvic organs makes these procedures difficult and lengthy. Postoperative pain is minimal, and no instances of fecal incontinence or anal strictures were reported in this series.

OUTCOMES

Complications

Any intervention involving an intestinal anastomosis needs to be protected by nasogastric suction for several days until the ileus resolves, generally in 3 to 5 days, heralded by the passage of flatus or by a bowel movement. Complications include bowel anastomotic leaks with resultant peritonitis, external fecal fistula or pelvic abscess, prolonged ileus, or bowel obstruction. In the event of any of these complications, surgery may again be indicated, perhaps in the form of fecal diversion, and appropriate drainage or repeat reconstruction may be necessary.

Results

When the vesicoenteric fistula is caused by inflammatory disease (diverticulitis, Crohn’s disease, etc.), it is likely that a one-stage bowel resection and closure of the fistula can be done (66%). In patients with a colonic malignancy, pelvic abscess, or with postradiation changes, it is more prudent to close the fistula in stages with fecal diversion and later closure. Comparisons between groups of patients treated with a single-stage versus two-stage repair showed lower morbidity in the patients who underwent one-stage repair, concluding that single-stage repair can be achieved with low morbidity and mortality in many candidates.6 In another series, there was no statistical difference in the complication rate between groups treated with single- and multistage repair. The recurrence rate of vesicoenteric fistula following surgical repair is up to 6.5% of patients, especially if the fistula is the result of inflammatory bowel disease other than diverticulitis (Crohn’s disease) or of pelvic neoplasia (prostate, colon, or endometrium). Surgical procedures that resect necrotic fistulized bowel and result in complete separation of the gastrointestinal and genitourinary tracts provided the best results in patients with radiation-induced enterovesical fistulas.

Vesicovaginal Fistula

Vesicovaginal fistulas (VVFs) have been recorded as a clinical entity since ancient times. The American surgeon Sims is commonly credited with having performed the first successful surgical repair of a VVF, as reported by him in 1852.

Vesicovaginal fistulas are extremely distressing as well as disabling to the patient. In industrialized soci-eties, VVFs occur most frequently as a result of iatrogenic injury at the time of gynecologic surgery, in particular hysterectomy. Other causes of VVFs are technically difficult surgical procedures or impaired wound healing (as a result of infection, neoplasia, previous radiation therapy, foreign bodies, or pelvic trauma) that is frequently complicated by medical conditions such as diabetes mellitus or atherosclerosis. In underdeveloped countries, especially in some parts of Africa, however, the most common cause of VVF is obstetric injury. The mechanism involved in prolonged labor is pressure necrosis of the bladder where it is caught between the obstructed head of the infant and the pubic bone.

DIAGNOSIS

The classic symptom of VVF is continuous leakage of urine per vaginam, with varying degrees of severity. This may develop immediately following the surgical procedure or be delayed, as in necrosis of the tissue or after radiation therapy, in the latter case months or even years after such treatment because of progressive obliterative endarteritis with resultant ischemia.

For diagnosis, a careful history, including the details of prior surgery, and a thorough physical examination are the usual prerequisites. An excretory urogram is advantageous in order to evaluate the upper urinary tract, particularly looking for associated ureteral injuries. The exact location and the size of the fistula and its relationship to the ureteral orifices are usually identified by cystoscopic examination. Vaginoscopy is very helpful in exactly localizing the fistula. If cystoscopy and vaginoscopy are performed at the same time, a ureteral catheter can be threaded through the fistula from the bladder into the vagina, thereby facilitating the recognition of the fistulous tract. Using both endoscopic inspections, it is important to determine the mobility of the fistulous segment of the bladder and also the degree of inflammation surrounding the fistula. In a patient with a history of prior pelvic neoplasia, a biopsy of the fistula site is mandatory to rule out recurrent tumor.

Small fistulas that may escape detection by cystoscopy or vaginoscopy can be demonstrated by the following maneuver: a gauze sponge is placed into the vagina, and methylene blue or indigo carmine is instilled into the bladder. In case a fistula is present, the tampon will turn blue. Blue coloring after intravenous administration of indigo carmine is not necessarily diagnostic for the presence of a VVF because with this maneuver the leakage can also be induced by a ureterovaginal fistula.

INDICATIONS FOR SURGERY

The successful laparoscopic repair of VVF was reported recently. The vast majority of VVFs, however, need repair by a surgical method, either transvaginally or by the suprapubic route. The choice of surgical approach is subject to the personal inclination of the urologist. Provided sound surgical principles are adhered to, i.e., complete excision of diseased tissue and reconstruction of the bladder using healthy, well-vascularized tissues, any surgical repair will succeed.

Controversy still remains concerning the timing of fistula repair. Among patients with VVF there is quite understandably a strong desire for an expedient repair. The conventional wisdom, however, is to delay surgical intervention for 3 to 4 months. When ischemic necrosis complicated by inflammatory reaction of the tissue gives rise to the defect, delayed repair is obligatory. In clean iatrogenic injuries, e.g., in the course of hysterectomy, however, there is no disadvantage in early repair, i.e., as soon as possible after the fistula is discovered.

ALTERNATIVE THERAPY

A variety of treatment options exist for the closure of a VVF. In fistulas of very small caliber it may be worthwhile to attempt a conservative approach. This can be done by curettage or cauterization of the fistulous tract or by application of silver nitrate as well as by simple drainage of the bladder via a transurethral catheter for a prolonged period of time. Such a conservative trial would certainly not prejudice future surgery and seems indicated in cases where delayed repair of the VVF is contemplated.

There are several reports of successful closure of a VVF by introducing a fibrin clot into the fistula either cystoscopically or transvaginally or both ways.

SURGICAL TECHNIQUE

Successful treatment of VVF depends largely on careful preparation of the patient and on the ability of the urologist to vary the operative technique according to the requirements of each individual patient and to perform the technical details with meticulous precision.

Transvaginal Repair

Generally, the transvaginal approach to repair a VVF is simpler and less disturbing to the patient. The majority of patients with VVF can be treated by the vaginal route. Indications for using this approach are as follows:

  • Fistulas less than 3 to 4 cm in diameter
  • Tissues pliable
  • Vaginal size normal or larger than normal
  • No cancerous tissue involved
  • No previous extensive radiotherapy

The advantages of the transvaginal approach include:

  • Avoidance of an abdominal incision
  • Minimal blood loss
  • Reduced postoperative morbidity
  • Less postoperative discomfort to the patient
  • Decreased length of hospitalization

A disadvantage of performing the transvaginal procedure is the relative lack of familiarity with the surgical anatomy of this region by many urologists.

Before repair, cystoscopy is carried out to confirm the position of the VVF and its relation to the ureteral orifices. Bilateral ureteral catheters are inserted, irrespective of the position of the fistulous tract. If possible, a ureteral catheter is introduced through the fistula into the vagina. After the removal of the cystoscope, an 18-Fr Foley catheter is inserted transurethrally, and the three previously mentioned ureteral catheters are tied to it just outside of the urethral meatus. Then the patient is placed in the hyperflexed dorsal lithotomy position. A weighted vaginal speculum is inserted, and the labia minora are sutured to the inner thighs in order to obtain good exposure. A small Foley catheter is placed through the fistula into the bladder. In small fistulas the cystoscopically introduced ureteral catheter can be used advantageously in pulling the tip of the Foley catheter tied to its tip into the bladder. After its balloon has been inflated, traction can be applied to the catheter, which provides an additional means for exposure.

The vaginal mucosa is incised circumferentially around the opening of the fistula, and the cicatricial or necrotic tissue of the fistulous tract is excised to the margin of fresh, healthy tissue after removal of the catheter. The defect is closed in three layers. The first layer, utilizing 3-0 polyglactin or polyglycolic acid sutures, ties the submucosa of the bladder thus approximating the mucosa without injuring it. The second layer, using the same suture type, ties the muscularis and the adventitia of the bladder. The third layer, utilizing 2-0 or 0 polyglactin or polyglycolic acid sutures, knits the vaginal mucosa. It is advisable to close successive layers in perpendicular directions, i.e., vertically versus transversely, in order to avoid overlapping suture lines. When difficulties arise, sutures with a 5/8; needle can be of advantage. Although no drain is used, a tampon is placed into the vagina and extracted on the second postoperative day. The ureteral catheters are left in place and connected to urine-collecting bags. They are withdrawn on the third postoperative day. The Foley catheter is removed 7 to 10 days after surgery. Alternatively, a suprapubic tube can be utilized. Uninterrupted catheter drainage during this time is of utmost importance. Antibiotics are given as long as the urethral or the suprapubic catheter is in place. The patient is instructed to abstain from intercourse for approximately 2 months.

If the tissue to be closed is tenuous, or if the transvaginal repair is difficult, a vascularized fibrofatty labial segment can be utilized for interposition between bladder and vagina. This segment, called the Martius flap,3 is easy to harvest because of its convenient location. Through a separate incision in the lateral aspect of the labia majora the underlying fat pad is mobilized and then pulled through a subcutaneous tunnel into the vaginal incision. There it is interposed between bladder and vagina with absorbable sutures.

Suprapubic Approach

Indications for a suprapubic approach include:

Associated pelvic pathology

Cases where ureteral reimplantation may be required

Limited access because of a high retracted fistula in a narrow vagina

Some cases with multiple fistulous tracts

Complications related to previous irradiation

The confirmation of the location of the fistula by cystoscopic examination is the same as when the transvaginal approach is used. The patient is placed in a supine position, and a lower midline incision is made. The perivesical space is mobilized, and the peritoneum is retracted cephalad from the dome of the bladder. The bladder is opened by a longitudinal midline incision and then split posteriorly and downward toward the fistula. The ureters may be catheterized if desired. The fistulous tract is excised all the way into the vagina. The opening of the vagina is closed with interrupted 2-0 absorbable sutures (Vicryl or Dexon) in one or two layers. In uncomplicated cases the bladder is then closed in two layers with continuous sutures of the same material. It is important to mobilize the vagina as well as the bladder flaps widely in order to avoid any tension on the suture lines.

In previously irradiated tissue or in complicated cases, instead of simple closure of the vagina and the bladder, it is safer to use interposition of an omental graft in order to prevent recurrent fistula formation.

The blood supply of the omentum from the left gastroepiploic artery and branches of the splenic artery, and from the right gastroepiploic artery and the gastroduodenal artery, can be observed by transillumination. This dual blood supply permits mobilization of the omentum from the greater curvature of the stomach. In some cases it is possible to extend the lower margin of the omentum down to the fistula without mobilization of the omentum from above. In most cases, however, is has to be dissected from the transverse colon. Either the left or the right gastroepiploic artery is divided between 3-0 silk ligatures close to the stomach until a well-vascularized omental flap is created, long enough to be brought down to the pelvis without tension. The omental apron is transferred to the pelvis extraperitoneally, dorsal to the ascending colon. A portion of the flap is interposed between anterior vaginal wall and posterior bladder wall and tacked in position with absorbable sutures. The omentum must extend well beyond the margins of the repairs.

Either a urethral catheter or a cystotomy tube can be used for bladder drainage. If ureteral catheters had been inserted, they should be left in place to keep the wound free of urinary drainage. Retrovesical drains are placed, and then the incision is closed in the usual fashion. The ureteral catheters and the drains are removed around the fifth postoperative day. The removal of the suprapubic tube or the urethral catheter takes place 2 weeks postoperatively.

For interposition between bladder and vagina, a peritoneal flap can be used instead of omentum. It is usually readily available. In large fistulas, however, particularly in radiogenic ones, a pedicled omental apron is the optimal tissue. In a small, uncomplicated VVF a simple closure in layers, as described previously, will usually suffice without the necessity of resorting to the use of peritoneum.

OUTCOMES

Complications

Most authors agree that the vast majority of VVFs can be successfully repaired transvaginally. It is of particular advantage that the complication rate is definitely less when this route is used rather than the suprapubic, transabdominal approach.

The complication of most concern is a recurrent urine leak. One can try to manage it by reinserting a catheter in order to drain the bladder for 3 or 4 weeks. If this fails to close the fistula, a new attempt at reconstruction is inevitable. Reasons for failed repair are insufficient debridement of nonviable and scar tissue before closure, excessive tension on the suture lines, inadequate closure of dead space, postoperative bladder distension, e.g., because of a plugged catheter, abscess formation, and poor tissue healing as a result of persistent or recurrent neoplasia or radiation-induced damage.

After an abdominal approach, it is not uncommon to encounter a significant period of ileus, particularly following extensive omental mobilization. Delayed healing and wound infections occur more frequently after transabdominal fistula repair than following the transvaginal procedure. Bowel obstruction secondary to adhesions is a typical, if infrequent, complication of the transabdominal procedure. It is not seen when the transvaginal method is used.

Results

At the author’s institution, 64 vesicovaginal fistulas were treated during the 30-year period between 1966 and August 1996. The 64 VVFs were caused by abdominal hysterectomy in 42 cases, vaginal hysterectomy in 12, radiation therapy in seven, obstetric complications in two, and colporrhaphy in one patient. In 60 patients (94%), the transvaginal approach was used; in four patients the transabdominal route (6%). Fourteen of the 60 patients had had prior attempts to repair the VVF. Of these 14 patients, six had undergone a transabdominal attempt, five a transvaginal procedure, and three a combined transvaginal and transabdominal surgery. In 55 of the 60 transvaginally repaired VVFs (92%), the primary closure was successful. In five patients (8%), a secondary transvaginal procedure became necessary for a successful closure.

The vast majority of vesicovaginal fistulas can be closed with a proper surgical approach and meticulous attention to detail by the urologist. In those few unfortunate patients in whom every attempt fails to successfully repair the fistula—which is usually the result of irradiation—urinary diversion can become necessary as a last resort to improve their quality of life.

Bladder Augmentation

Bladder augmentation is the addition of a segment of bowel to the in situ bladder to increase capacity, improve compliance, or abate uncontrollable detrusor contractility. It is frequently used in the reconstruction of neurogenic bladders that have failed medical therapy or other conservative therapies. Augmentation cystoplasty has replaced cutaneous urinary diversion in this group of patients because of decreased morbidity of the procedure, fewer postoperative complications, the widespread use of clean intermittent catheterization (CIC), and improved postoperative quality of life. Additionally, it has been shown that patients with cutaneous urinary diversions, draining continuously via any segment of bowel, have a worse long-term outcome with regard to infections and upper tract deterioration than patients with a large low-pressure reservoir that uses the urethra as the continence mechanism. In some cases, such as chronic, intractable interstitial cystitis with a small bladder capacity and severe symptoms, a supratrigonal cystectomy may be performed, and the bladder replaced by a bowel segment.

Although we prefer ileum in most cases, many different bowel segments have been used, each with its own specific advantages and disadvantages. However, no bowel segment is clearly superior in all circumstances. The most important factor is detubularization of the bowel to reduce intravesical pressure from peristalsis or mass contractions.

In most cases of neuropathic vesical dysfunction, the simplest low-pressure continent reservoir to construct involves the addition of bowel to augment the in situ bladder, utilizing the patient’s own urethra as the continence mechanism.

DIAGNOSIS

Before consideration is given for an augmentation cystoplasty, all medical therapies and conservative treatments directed at improving detrusor compliance and increasing capacity should be exhausted. When these therapies have failed, the basic evaluation includes a cystometrogram, preferably using fluoroscopy, to evaluate bladder compliance, status of the bladder neck (open or closed at rest), and presence of vesicoureteral reflux. The bladder’s functional characteristics such as capacity and compliance can sometimes dictate the type and length of bowel required.

The evaluation of urethral function is problematic, particularly in patients with poor compliance or a defunctionalized bladder, where the urethra may deceptively appear worse than it truly is. The abdominal leak point pressure (ALPP) is a good method of determining urethral resistance to abdominal pressure as an expulsive force.5 If, in addition to the augmentation cystoplasty, one of the goals of the operative procedure is to achieve continence, the abdominal pressure required to cause leakage is essential. If that pressure is very low, 0 to 60 cm H2O, then a sling procedure, an artificial urinary sphincter, or an injectable agent will be required to prevent leakage. If the resistance to abdominal pressure is high, perhaps 140 to 150 cm H2O or more, then no procedure to improve urethral function is usually necessary. In the middle range, 60 to 140 cm H2O, any of the above treatments and perhaps a urethral suspension in women, can be used to treat stress incontinence. It is important to recognize that creation of outlet resistance that completely resists intrareservoir pressure is inherently dangerous to the upper tracts and may contribute to rupture of the augmentation.6 An upright cystogram, which demonstrates that continence is maintained at the bladder neck, can be a useful adjunct to the ALPP. Even if both studies are done and the urethra appears functional, leakage may still occur after augmentation cystoplasty when the bladder is very full and high intra-abdominal pressure is applied.

Another important urethral function is that it must function as a compliant voiding conduit. If the patient is neurologically normal and voiding is anticipated after augmentation cystoplasty (as in selected patients with interstitial cystitis), the urethra should open normally on a voiding urodynamic study. Voiding pressures less than 30 to 40 cm H2O usually indicate that the conduit opens normally with voiding, and CIC may not be required postoperatively. Voiding pressures greater than 40 cm H2O generally indicate poor conduit function, and the patient will often require CIC after the augmentation cystoplasty.

It is now clear that ureteral size (or dilation) has little to do with ureteral function, whereas, if ureteral peristalsis is present, as seen by ultrasound, fluoroscopy, or during a Whitaker perfusion test, the ureters will function adequately when placed into a low-pressure reservoir.

INDICATIONS FOR SURGERY

Bladder augmentation is a useful technique for the following indications:

  • Uncontrolled bladder contractility, most commonly for multiple sclerosis, spinal cord injury, and idiopathic urge incontinence.
  • Poor bladder compliance for neuropathic conditions after pelvic radiation therapy, intravesical chemotherapy, prolonged catheter drainage, or from untreated obstructive uropathy.
  • Prolonged bladder defunctionalization after long-term cutaneous vesicostomy drainage or bilateral cutaneous ureterostomy.
  • Patients previously diverted who are candidates for undiversion into a large, low-pressure reservoir.

    Patient selection remains an important issue before augmentation cystoplasty. Chronic renal failure (documented by creatinine clearance) is a relative contraindication to an augmentation because both small and large bowel resorb many urinary solutes that may deleteriously alter the metabolic status of the patient. In these patients, the use of stomach has been recommended.

    All patients should be able, both mentally and physically, to perform CIC before a bladder augmentation, even if postoperative voiding is anticipated. This is especially important at both age extremes. If any question exists, it is better to place a cutaneous catheterizable stoma or, alternatively, a noncontinent stoma.

    No bowel segment is clearly superior to another in all circumstances, and the segment used is usually based on surgeon preference. In some circumstances, restrictions may exist, however. Stomach should probably not be used in patients with peptic ulcer disease, and large bowel should not be used if a history of ulcerative colitis, previous colon cancer, or diverticulitis exists. Similarly, in cases of extensive pelvic radiation, transverse colon or stomach may be preferable to small bowel. Finally, consideration for preservation of the ileocecal valve should be given in patients with myelodysplasia, as significant problems with diarrhea and fecal incontinence have been reported.

    ALTERNATIVE THERAPY

    In autoaugmentation of the bladder (also called partial detrusor myomectomy), the detrusor muscle over the dome and anterior wall is excised, which allows the bladder epithelium to distend outward, thereby improving storage capacity and detrusor compliance. In our experience, the gains in bladder capacity and compliance in patients with neuropathic voiding dysfunction are small, and we do not recommend its routine use in this group of patients. We continue to use this technique in selected patients with intractable urge incontinence, with favorable results.

    For patients in whom a simple, low-pressure cutaneous diversion is preferable, a noncontinent ileovesicostomy (bladder “chimney”) can be performed. Schwartz and colleagues reported excellent long-term results in 23 patients, with few complications.

    Nonautologous tissues (Gore-Tex, Dacron, bovine dura, pericardium, etc.) have all been utilized to augment the bladder; however, complications with the anastomosis, infections, or stone formation preclude their routine use.

    SURGICAL TECHNIQUE

    Preparation of the patient is important, and all patients should undergo preoperative bowel preparation. In the neuropathic patient, chronic constipation is usually a problem, and 2 to 3 days of clear liquids and a full mechanical bowel preparation the day before the procedure will be necessary to insure removal of all solid stool. Nonneurogenic conditions and the use of small bowel for the augmentation may allow a less rigorous prep. If large bowel is used, oral nonabsorbable antibiotics such as neomycin and erythromycin base should be considered. Note that sometimes the desired segment of bowel is found intraoperatively to be unsuitable, and therefore, a full bowel prep is recommended for the majority of cases. A preoperative dose of IV antibiotics is also given with special consideration given to those patients with implanted prosthetic materials such as a ventriculoperitoneal shunt or orthopedic hardware.

    Other considerations include preoperative normalization of any metabolic or electrolyte disorders, documentation of sterile urine, and, in selected cases where colon will be used, a preoperative barium enema or colonoscopy.

    After preparation of the skin from xiphoid to genitalia, a urethral catheter is placed, a midline (preferably) or Pfannenstiel incision is made, and the retropubic space is dissected until the bladder is free of adhesions. In general, if a procedure to improve continence is necessary, it is performed first. Additionally, if low-pressure vesicoureteral reflux has been documented preoperatively, ureteral reimplantation should be considered. The ureters should be reimplanted into the bladder or into a colonic augmentation, as ureteral reimplantation into the ileum is tenuous and is not as favorable. We do not reimplant functional ureters that reflux with high bladder pressures because augmentation will decrease bladder pressures. A self-retaining retractor is placed, the bladder is filled with saline, and the peritoneum is dissected off the bladder to the level of the trigone (Fig. 26-1). Using electrocautery, a U-shaped incision is made on the bladder starting 3 cm above the ureters, effectively creating an anteriorly based bladder flap (Fig. 26-2). This technique avoids the hourglass configuration that can develop, making the augmentation little more than a poorly draining bladder diverticulum. The peritoneum is opened last to minimize third-space fluid loss and urine contamination of the peritoneal cavity. A 25- to 30-cm segment of ileum at least 15 cm away from the ileocecal valve is selected and marked with sutures. The ileum should easily reach the bladder without tension. The mesentery is cleared from both ends to create a window, and the ileum is divided using a standard stapling device.

    The exact amount of ileum required varies among patients, but enough should be used to allow a minimum of 4 hours between catheterizations after the bowel is fully stretched over the ensuing months. Ileal continuity is then achieved using one of the hand-sewn or stapled techniques, and the mesenteric defect is closed. The ileal ends are oversewn with a running 2-0 chromic catgut to exclude the staples (to prevent stone formation), and the antimesenteric surface of the bowel is opened using electrocautery. Towels should be placed under the bowel, and the opened ileum irrigated into a kidney basin until clear. The posterior wall of the ileum is folded back on itself and sutured together using running 2-0 chromic catgut. The required size of the augmentation opening is roughly measured, and the superior, anterior wall is partially closed with running 2-0 chromic catgut to match this opening. A large-bore suprapubic (SP) tube is placed through the bladder wall before placement of the augmentation on the bladder. The SP tube allows reliable postoperative drainage and irrigation of mucus until the suture lines are healed. The ileal segment is then sewn onto the opened bladder using running 2-0 chromic catgut with the initial suture placement. A closed suction drain is placed near the suture line and brought through the skin on the side opposite the SP tube. The patient is closed in the usual manner. If a continence procedure has been performed, it is imperative that a catheter can be easily passed, otherwise the patient will be unable to catheterize postoperatively.

    Although this technique is our preferred technique, other methods of performing an augmentation exist. One such method involves splitting the bladder sagittally from just above the bladder neck and ending near the level of the ureters posteriorly to form a clam. A 25- to 30-cm segment of ileum is isolated and divided completely along the antimesenteric border. The posterior wall of the augmentation is closed with running 2-0 chromic catgut and is then either anastomosed to the bladder as a “patch” or folded again and partially closed to form a “cup.” A cup is especially useful if the patient’s own bladder is very small but sometimes requires the use of up to 40 cm of bowel. In both cases, the anastomosis is started on the posterior wall until it is approximately one-third closed, and then the anterior wall is closed. The lateral walls are closed last, and any redundant bowel is closed to itself.

    Postoperative care is generally straightforward. Fluid and electrolyte management is important because of large third-space losses and drainage from the nasogastric tube, which remains in place until bowel function returns. The drain is removed after a few days, when drainage tapers off. The bladder is irrigated at least three times per day with 30 to 60 ml of saline to clear mucus. A cystogram is performed at 2 to 3 weeks, and the Foley is removed if no extravasation is noted. The patient begins CIC with the SP tube in place until the patient is proficient at CIC. At 3 to 4 weeks, the SP tube can usually be removed, and the patient continues CIC every 2 to 3 hours during the day and twice at night. Sometimes the augmentation takes several months to stretch, during which time frequent CIC is necessary. This may be distressing to the patient; however, liberal use of anticholinergics can help in many cases. Daily irrigation to clear mucus is essential, especially for the first few months. As capacity increases, the intervals can increase, with most patients able to go 4 to 5 hours between catheterizations during the day and once at night. Patients who are able to void must document consistently small postvoid residuals. Routine electrolytes, creatinine, BUN, and upper tract studies should be performed at regular intervals.

    OUTCOMES

    Complications

    A recent long-term study of 122 patients by Flood and colleagues reported an overall 28% early and 44% late complication rate in this difficult group of patients.3 Most of the complications were minor and involved prolonged ileus, transient urinary extravasation, or stomal problems. Surgical interventions were necessary in only 15% of patients and were mainly stomal revisions.

    Small bowel obstructions occur in approximately 3% of patients. This is similar to the rate reported in urinary diversions. Bladder or kidney stones vary from study to study depending on the patient population and surgical techniques used. Stones commonly form secondary to retained mucus or exposed staples as a nidus. Routine bladder irrigation, treatment of infections, and staple exclusion at time of surgery minimize stone formation.

    Reservoir perforation is perhaps the most feared complication with reported rates of approximately 6%.Fatalities are uncommon if diagnosed early.

    Metabolic problems such as metabolic acidosis or vitamin B12 deficiency that are not medically treatable are uncommon if patients are properly selected and followed with appropriate labs.

    Carcinogenesis in all bowel segments has been reported. Although the risk to any individual patient is small, surveillance after 10 years should be considered.

    Voiding dysfunction is common even in nonneurogenic patients after augmentation cystoplasty. In a review by Flood and colleagues, 89% and 67% of neurologically intact men and women, respectively, required lifelong CIC. These numbers reinforce the need to counsel patients on the high likelihood for lifelong CIC and preoperative demonstration of proficiency at CIC.

    Results

    A tabulation of success or failure after augmentation depends on the original reason for performance of the procedure. In patients with neuropathic bladders requiring improved compliance and capacity, an augmentation is almost uniformly successful. An augmentation is less successful in treating the symptoms of interstitial cystitis and, by itself, does not guarantee continence, especially in patients with high rates of intrinsic sphincter deficiency (ISD) such as myelomeningocele and radiation cystitis. A preoperative urethral evaluation is essential in diagnosing ISD in these patients.

    Bladder Diverticulectomy

    A bladder diverticulum is the protrusion of mucosa through the detrusor muscle fibers as a result of a structural defect (congenital or primary diverticulum) or of chronic dysfunction of bladder voiding (diverticulum secondary to obstructive pathology of the lower urinary tract). The diverticulum wall is composed of the following layers from inside out: mucosa, subepithelial connective tissue or lamina propria, isolated and thin muscle fibers, and adventitial tissue. The most frequent causes provoking an increase in bladder voiding pressure and the eventual formation of diverticulum are benign prostatic hyperplasia, urethral strictures, contracture or sclerosis of the bladder neck, urethral valves, and vesicosphincteric dyssynergy. The diverticula are located in the weakest points of the bladder, such as the ureteral hiatus (paraureteral or Hutch diverticulum) and both posterolateral walls.

    DIAGNOSIS

    Diverticula are most commonly found on ultrasonography performed for the study of a prostatic syndrome in men or repeated urinary infections in women. Echography is highly useful for assessing whether a diverticulum is inhabited by lithiasis or tumor, although endoscopic examination should be performed if intradiverticular pathology is suspected or hematuria is present. Cystograms obtained by excretory urography or by retrograde instillation of contrast medium may provide the same information as ultrasonography with regard to the number, location, size, and urinary retention volume of the diverticulum. However, a voiding cystourethrogram with lateral and oblique projections will be indispensable when a urethral obstructive cause is suspected or in congenital cases to rule out possible vesicoureteral reflux.

    Differential diagnosis should be established with the “pseudodiverticular” images observed in cystograms: bladder ears, hourglass bladder, and vesical hernias. On ultrasound, they should be differentiated from urachal cysts, prostatic utricle cysts, or Müllerian duct cysts and blind-ending bifid ureters. Other less-frequent congenital anomalies should also be considered, such as vesicourachal diverticulum, incomplete bladder duplication, and septation of the bladder, which may be mistaken in both examinations.

    INDICATIONS FOR SURGERY

    The presence of intradiverticular disease (tumor or lithiasis), spontaneous diverticular rupture, or complications related to the size (³4 cm diameter) or location of the diverticulum are absolute indications for open surgery. A large diverticulum may be the cause of deficient voiding and chronic urinary infection or obstruction of the ureter and even of the posterior urethra in children, whereas paraureteral or hiatal diverticulum are usually associated with different degrees of reflux.

    With the aim of improving vesical voiding, we recommend the simultaneous resection of all bladder diverticula, even those of small size (1 to 3 cm diameter) if the patient must undergo open prostatectomy, cystolithotomy, ureteroneocystostomy, or Y-V plasty of the bladder neck. Similarly, a vesical diverticulum should never be operated on without previously or simultaneously correcting the cause of obstruction, whether anatomic or functional (neurogenic bladder), that provoked it.

    ALTERNATIVE THERAPY

    A “wait-and-see” approach may be adopted in children with asymptomatic small-sized (rare) congenital or paraureteral diverticula and with low-grade associated reflux. Saccules and small diverticula may be treated successfully by electrocoagulation of their mucosa with the ball electrode when the primary obstructive disease is endoscopically resolved. However, we do not consider the laparoscopic approach to a diverticulum to be indicated because it will not solve the cause and will prolong surgery.

    SURGICAL TECHNIQUE

    The bladder is approached via an infraumbilical midline extraperitoneal laparotomy incision. The dissection is carried into the space of Retzius with a sponge stick, and anterior bladder wall and vesical neck are identified. After reflecting the peritoneum from the bladder dome, we normally perform transverse cystotomy at this level, as it provides better exposure of bladder contents and facilitates placement of a small self-retaining retractor and additional stay sutures. The trigone, both ureteral meati, the bladder neck, and all possible diverticular orifices are clearly visualized from the bladder dome opening.

    In cases of intradiverticular tumor, we instill 30 mg of mitomycin by urethral catheter before the surgery and carefully protect the surgical field with moist sterile cloths to avoid possible tumor contamination during diverticulectomy. The bladder mucosa should also be thoroughly inspected to rule out papillary tumors that may have gone unnoticed on the previous endoscopic examination.

    Diverticulum excision has been described in three different approaches: extravesical (V. V. Czerny, 1896), intravesical (H. H. Young, 1906), and the intravesical and extravesical combination (G. Marion, 1913). The most commonly used procedures and the points of technique that we use are the following.

    Intravesical Diverticulectomy

    If the diverticulum is small (£5 cm diameter), we perform intravesicalization and eversion of its wall, grasping and tractioning its bottom gently with an Allis or Pean-type clamp inserted through its neck. If this maneuver is performed carefully, and fibrosis secondary to infection is absent, the majority of these diverticula are rapidly and easily removed. The mucosa of the everted diverticular neck is divided using electrocautery, and the defect of the bladder wall is sutured with 3-0 chromic catgut using separate submucosal and muscular sutures. In case of a saccule, a fine ligature of the neck and resection of its everted mucosa will suffice.

    If this maneuver is not feasible because of peridiverticular adhesions, we proceed to sharply split the mucosa around the diverticular orifice and dissect with scissors as far as the periadventitial space. In this way, the diverticular neck remains separated from the bladder wall and is pulled toward the vesical cavity with Allis-type clamps. At the same time, the adventitial adhesions that fix the diverticular sac are freed gently with a small moist gauze, and the sac is drawn into the bladder. The bladder wall is then closed as mentioned previously.

    Combined Intravesical and Extravesical Diverticulectomy

    In a large diverticulum complicated with peridiverticulitis or in a paraureteral location, it is obligatory to place a 7- or 8-Ch ureteral catheter in the corresponding side before dissection. This will avoid an inadvertent lesion of the ureter or at least facilitate its immediate repair. These diverticula must be excised by a combined intra- and extravesical approach, first identifying and dissecting the diverticular neck. For this, the maneuver of inserting the surgeon’s index finger into the diverticulum and gently tractioning the upper face of its neck toward the surface is very useful. We also recommend completely filling the diverticular sac with a moist gauze to unfold its wall and delimit its margins as accurately as possible. Dissection must begin at the diverticular neck, which is sectioned extravesically with electrocautery and separated from the bladder wall, whose orifice is sutured with 3-0 chromic catgut using extramucosal separate stitches.

    Tractioning the edges of the diverticular mouth toward the surface with Allis-type clamps allows the sac wall to be dissected from neighboring tissue with scissors and a small moist swab. It should always be borne in mind that the ureteral course may have been modified by the great diverticular volume, and the ureter may be closely adhered to its wall if repeated infectious processes have occurred. This dissection will be very difficult if great peridiverticulitis is present, and it is more advisable simply to denude it of its mucosal lining with fine scissors or with the cutting current and the ball electrode from inside the diverticular cavity and then place a suction drain within it (first described by Pousson in 1901 and Geraghty in 1922). The bladder wall is closed with absorbable 3-0 interrupted sutures. We leave an aspirating drain in the Retzius space and a urethral 18-Fr Foley catheter, which may both be removed after 5 or 6 days.

    OUTCOMES

    Complications

    The most serious specific complication of excision of a bladder diverticulum is an injury to the juxtavesical or pelvic ureter during dissection of large diverticulum. With prior placement of an ipsilateral ureteral catheter, this lesion will not go unnoticed by the surgeon and can be easily sutured with absorbable 5-0 or 6-0 separate stitches if it is a partial or incomplete section. If the ureter has been severely damaged, or its section is complete and near the vesical hiatus, the distal ureter must be abandoned, and it is preferable to carry out ureteral reimplantation following the technique of Leadbetter–Politano with or without vesical lateralization to the psoas muscle (“psoas hitch”). End-to-end suture of ureteral edges must never be performed in precarious conditions because it is highly likely that it will be complicated by urinary fistula or ureteral stenosis, which will further aggravate the situation. If the ureteral lesion is more extensive and located higher, and the bladder in turn is reduced in size and of limited mobility, we prefer to perform transureteroureterostomy and ureteral suture with the aid of the surgical microscope.

    Less serious complications include vesical urine leakage, which may cease spontaneously if the Foley catheter is maintained for some more days, providing the obstructive pathology has been resolved. If a urinary fistula is established, we advise closing it with a flap from the bladder wall itself.

    Results

    The excision of the diverticulum is generally curative for that particular lesion, although correction of the underlying cause (e.g., outlet obstruction) is required to prevent formation of additional diverticulum.