RECONSTRUCTIVE UROLOGY

Gastrocystoplasty in patients with an areflexic low compliant bladder
Abdel-Azim MS, Abdel-Hakim AM
Urology Department, Cairo University, Cairo, Egypt
Eur Urol. 2003; 44: 260-5

• Aim: This study was performed with the aim of evaluating gastrocystoplasty as a method of management of patients with an areflexic low compliant bladder.
• Patients and Methods: We performed gastrocystoplasty in 30 patients (19 males and 11 females) with an areflexic low compliant bladder. The mean age of the patients was 23.4+/-11 years (range 4-32). The etiology of lower urinary tract dysfunction was myelodysplasia in 26 patients and spinal cord injury in 4. Twenty-three patients had normal renal function and 7 had impaired renal function (creatinine 2.0-5.0mg%). Additionally, 4 patients had an artificial urinary sphincter implanted and seven had an antireflux procedure performed.
• Results: Renal function remained stable or improved in 29 patients. Postoperatively, there was a 225% increase from mean preoperative capacity and a 52% decrease from the preoperative end filling pressure. Nineteen patients voided spontaneously and 11 used clean intermittent catheterization to empty the bladder. Twenty-five patients were continent with augmentation alone, four with augmentation and artificial sphincter implantation while one remained incontinent, as sphincter implantation could not be performed due to the young age of the patient. Five patients (17%) had transient hematuria and dysuria after augmentation. There were no mortalities and complications included prolonged urinary leakage in one patient and mild gastric bleeding in another two.
• Conclusion: The use of the stomach for augmenting the areflexic low compliant bladder is clearly advantageous over other tissues as it increases bladder capacity and compliance with consequent achievement of continence and preservation of upper tracts. An artificial urinary sphincter can be safely implanted in the same session. Because of its inherent fibromuscular properties, the gastric patch contributes to the force of urination resulting in better bladder emptying. Patients with impaired renal function are protected from hyperchloremic metabolic acidosis.
  
• Editorial Comment
  For a long time the areflexic low compliant urinary bladder with a dysfunctional urinary sphincter due to spinal cord trauma or congenital diseases such as myelodysplasia was treated with supravesical continent or incontinent urinary diversion. The rationale for treating patients with a supravesical diversion was to preserve renal function in the long term as well as to avoid further incontinence and its sequelae.
  Ileal and colonic segments are mainly used to augment small capacity bladders with an intact sphincter. However, colo- or ileocystoplasty alone can rarely restore volitional voiding in truly neurogenic lower urinary dysfunction and may be contraindicated in patients with impaired renal function.
  The authors of this paper tried to functionally restore the lower urinary tract in 30 young patients with myelodysplasia or spinal cord injury by using a pedicled gastric patch instead of an ileocolonic segment. It is remarkable that postoperatively 19/30 patients could void spontaneously with insignificant residual urine, incontinence was reduced to 1/30 patients with the help of an artificial urinary sphincter and deterioration of renal function occurred only in 1/30 patients.
  Whether the good results obtained in this study are due to the better compliance, different innervation and a larger smooth muscle mass of gastric patches compared to lower intestinal segments is difficult to judge from such a small study. But it clearly shows that we successfully can and therefore should make every effort to restore function of the native lower urinary tract instead of simply doing a supravesical urinary diversion in patients with a long life expectancy knowing the long term complications and socioeconomic consequences of a stoma bag in these patients.

Dr. Arnulf Stenzl
Professor and Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany