Bladder augmentation with urothelial preservation

Purpose: Bladder reconstruction is performed because the characteristic properties of a healthy bladder are no longer present. The bladder manifests poor capacity, poor compliance and potential or actual changes in the upper tracts that may lead to damage. Augmentation procedures provide a means to improve capacity and compliance, and they may be performed with catheterizable channels to facilitate bladder emptying. Natural tissues or synthetic materials may be used but urothelial preservation is desirable. Demucosalized augmentation with a gastric flap and auto-augmentation with peritoneum are techniques that have been used in the last 5 years. Materials and Methods: We retrospectively evaluated the records of 13 patients who underwent demucosalized augmentation with a gastric flap and 8 who underwent augmentation with peritoneum from 1992 to 1995. Average age of the II girls and 10 boys was 8 years (range 6 to 12). The diagnosis was myelomeningocele in 15 patients, exstrophy in 2, and the VATER association, posterior urethral valves, spinal cord injury and nonneurogenic neurogenic bladder in I each. Concurrent procedures included appendicovesicostomy creation, a fascial sling or wrap and ureteroneocystostomy. Results: Mean followup is 50 months for patients who underwent demucosalized augmentation with a gastric flap and 47 for those who underwent augmentation with peritoneum. Outcome was defined as good-dry for 4 hours, catheterization without difficulty and a stable upper tract; poor-a secondary procedure (augmentation) required because the initial procedure did not improve bladder capacity, compliance, continence or the degree of hydronephrosis, and fair-dry for less than 4 hours, some problems with incontinence, or compliance 10 ml./cm. water or less. Of the patients who underwent demucosalized augmentation with a gastric flap the outcome was good in 5, fair in 4 and poor in 4 who required repeat augmentation. Of the 8 patients who underwent auto-augmentation with peritoneum the outcome was good in 5 and poor in 2, and 1 was lost to followup. Conclusions: Augmentation with urothelial preservation may result in a good capacity, compliant bladder in certain patients but a poorly compliant, small capacity bladder in others. Our overall results underscore the lack of understanding of the properties and characteristics of these bladders and of stromal-epithelial interaction that occurs after augmentation. Such an understanding is critical before this procedure can be recommended routinely.