Augmenting the augmented bladder: Treatment of the contractile bowel segment

Purpose: Bowel used for bladder reconstruction regardless of detubularization occasionally retains its contractile properties. Of 323 patients who underwent primary enterocystoplasty we identified 19 who continue to have high pressure bladder contractions and required augmentation of the previously augmented bladder. Materials and Methods: Reason for repeat augmentation, upper tract changes, original and secondary bowel segments used, and urodynamic findings were evaluated in all patients. Current status and followup also were noted. Results: After initial augmentation 8 patients had persistent incontinence, 5 bladder perforation, 3 isolated upper tract changes, 2 incontinence and bladder perforation, and I incontinence plus intractable pain. Preoperative urodynamics revealed detrusor pressures from 30 to 100 cm. water. All patients had adequate bladder outlet resistance. The original bowel segments used were sigmoid in 12 cases, stomach in 4, ileum in 2 and cecum in 1. Bowel segments for reaugmentation were ileum in 16 cases and sigmoid in 3. Of the 11 patients with incontinence 10 are now dry. All cases of upper tract changes resolved. Mean followup since re-augmentation is 52 months. Conclusions: If the outcome of bladder augmentation is less than optimal, it is important to reevaluate the bladder dynamics. In rare instances these patients may continue to have high pressure contractions with a functionally small bladder capacity. In such situations re-augmentation with an additional bowel segment is an excellent alternative to a difficult clinical problem and provides good results in the vast majority of cases. This treatment may not totally αlleviate the contractions but it does decrease them and increase the volumes at which the contractions occur, making them no longer clinically or functionally significant.