AUGMENTING THE AUGMENTED BLADDER - TREATMENT OF THE CONTRACTILE BOWELSEGMENT

Purpose: Bowel used for bladder reconstruction regardless of detubular ization occasionally retains its contractile properties. Of 323 patien ts who underwent primary enterocystoplasty we identified 19 who contin ue to have high pressure bladder contractions and required augmentatio n of the previously augmented bladder. Materials and Methods: Reason f or repeat augmentation, upper tract changes, original and secondary bo wel segments used, and urodynamic findings were evaluated in all patie nts. Current status and followup also were noted. Results: After initi al augmentation 8 patients had persistent incontinence, 5 bladder perf oration, 3 isolated upper tract changes, 2 incontinence and bladder pe rforation, and I incontinence plus intractable pain. Preoperative urod ynamics revealed detrusor pressures from 30 to 100 cm. water. All pati ents had adequate bladder outlet resistance. The original bowel segmen ts used were sigmoid in 12 cases, stomach in 4, ileum in 2 and cecum i n I. Bowel segments for reaugmentation were ileum in 16 cases and sigm oid in 3. Of the 11 patients with incontinence 10 are now dry. All cas es of upper tract changes resolved. Mean followup since re-augmentatio n 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 situa tions reaugmentation 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 alleviat e the contractions but it does decrease them and increase the volumes at which the contractions occur, making them no longer clinically or f unctionally significant.