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Abstract
Hypocompliant bladder is the bladder that can not maintain low intravesical pressure during bladder filling. This may result from inadequate vesicoelastic properties of the bladder or damage to the sympathetic or parasympathetic nerve supply of the bladder. Various etiological factors may lead to detrusor hypocomliance including neurogenic bladder diseases, chronic bladder infections, interstitial cystitis, radiation cystitis, defunctionalized bladder, or idiopathic detrusor overactivity.
Detrusor hypocompliance is considered a serious condition because it carries the risk of damaging the upper tracts. Multiple therapeutic approaches have been developed for the treatment of this disorder including medical treatment, bladder overdistension, local injection with botulinum toxin, and surgery for resistant cases. Surgical options are either bladder dennervation or bladder augmentation. Bladder augmentation is considered the gold standard surgical approach which can be done either by detrusorotomy with the creation of a bladder diverticulum or by using a bowel segment as a patch to augment the bladder. Traditionally, bladder augmentation is done by open surgery with good results. However, laparoscopy has been recently introduced as an alternative for open surgery with the advantages of minimizing operative morbidity, shortening hospital stay, and providing excellent cosmesis.
The primary aim of this study is to evaluate the safety and efficacy of laparoscopy in the management of hypocompliant bladder. The secondary aim is to set a basis for case selection for laparoscopic autoaugmentation.
Thirty adult patients with urodynamically-proved hypocompliant bladder were included in the study and divided into 2 groups; 15 patients each. The first group underwent laparoscopic bladder autoaugmentation at the urology department, Alexandria Main University Hospital, Egypt; while the second group underwent laparoscopic bladder augmentation using bowel segments at the urology department, Cleveland Clinic Hospital, USA. All the patients underwent thorough preoperative evaluation including full history taking, validated questionnaires, physical examination, laboratory, radiological, urodynamic, and cystoscopic evaluation. Postoperative follow up was performed on a regular basis at 6 month, 12 month, and 2 years postoperatively. The follow up regimen included repeating the preoperative questionnaires, radiological, and urodynamic studies.
Group I (Laparoscopic Autoaugmentation) included 10 males and 5 females with a mean age of 25.5 ± 7.3 years. Aetiology of bladder hypocompliance was spinal cord injury (SCI) in 5 patients, myelomeningocele in 4, idiopathic detrusor overactivity (IDO) in 3, transverse myelitis in 1, spinal cord tumor in 1, and chronic bilharzial cystitis in 1. Operatively, Transperitoneal approach was performed in 6 patients while the extraperitoneal one was performed in 9. Mean operative time was 119.1 ± 54.6 minutes and mean blood loss was 113.7 ± 43.5 ml. Accidental mucosal injury happened in two patients with neurogenic bladder that was closed successfully with intracorporeal suturing using 2/0 Vicryl sutures. In the patient with chronic bilharzial cystitis, multiple mucosal injuries occurred and detrusorotomy failed to produce an adequate diverticulum leading to conversion of the procedure to open enterocystoplasty. Oral feeding was resumed after 6 hours from the procedure in all patients except for the enterocystopalsty one and the patients were discharged home from 2 to 7 days postoperatively.
The patients were followed up at 6 month, 1 year, and 2 years postoperatively. Twelve out of the fifteen patients (80%) showed significant improvement, 2 (13.3%) remained unchanged and considered as a failure, while the last patient (6.7%) was not included in the follow up because he was converted to open enterocystoplasty. UDI-6 score and AUA-QoL scores showed significant improvement over the follow up period (p-value 0.002 and 0.041, respectively). Postoperative radiological evaluation showed improvement of the upper tract deterioration which was detected preoperatively. In the IVU series, the total hydronephrotic units improved from 10 to 5 at 2 years follow up, while in the VCUG series; out of 6 refluxing units 3 became normal at 2 years follow up.
Twelve patients had significant postoperative improvement in all the urodynamic parameters including maximum cystometric capacity (MCC), bladder compliance (C), detrusor pressure at maximum capacity ( Pdet max ) and detrusor overactivity (DOA) (p-values < 0.05). In the two patients who did not show any improvement, the preoperative MCC was very small (72 ml and 85 ml), bladder compliance was also very low (2 ml/cmH2O and 3 ml/cmH2O, Pdet max was very high (120 cmH2O and 115 cmH2O), and DOA was marked.
Group II (laparoscopic bladder augmentation using bowel) included 3 males and 12 females with a mean age of 40.4 ± 12.48 years. Aetiology of bladder hypocompliance was multiple sclerosis in 8, spinal cord injury in 4, and transverse myelitis in 3. Procedures included ileocystoplasty (4), sigmoidocystoplasty (3), and ileocecocystoplasty with a continent catheterizable ileal stoma (8). Mean total surgical time was 5.8±1.42 hours and the mean time for laparoscopic suturing was 1.9±0.51 hours. Blood loss did not exceed 300 mL during any of the procedures. The only intraoperative complication was a trocar-induced rectus sheath hematoma during the course of a sigmoidocystoplasty that was controlled laparoscopically. Mean time to resume oral feeding was 1.9±0.92 days and the average hospital stay ranged from 2 to 10 days.
Patients were followed up at 6 month, 1 year, and 18 months postoperatively. All the 15 patients showed significant improvement. Mean UDI-6 score changed significantly from 86.5 ± 10.28 preoperatively to 15.7± 5.03 at 18 months follow up (p-value 0.001). Mean AUA-QoL score changed from 5.0 ± 0.93 preoperatively to 1.4± 0.51 at 18 months follow up (p-value 0.011). There was no clinically significant difference in the bowel control score before and after the procedure (p-value= 0.30).
At 18 month follow up, postoperative IVU series showed a total number of hydronephrotic units of 2 compared to 13 preoperatively. In the postoperative VCUG series, out of 11 refluxing units found preoperatively, 9 units became normal at 18-months postoperatively.
All the patients completed the urodynamic follow up 6 month, 1 year, and 18 months postoperatively and all showed significant improvement in all the parameters (MCC, C, , Pdet max and DOA) (p-values < 0.05). Bladder capacity and compliance increased about three times the preoperative values.