Reconstructive surgery for OAB

Reconstructive
surgery for OAB
Dr John Heesakkers
Department of Urology
Radboud University MC
Nijmegen, NL
Bladder surgery for OAB
Aims:
•Low pressure
•Continence
•Compliance
•Capacity
Bladder surgery for OAB
Main types:
•Autoaugmentation
•Enterocystoplasty
•Continent pouch:
• Mitrofanoff valve
• Monti
•Ileum conduit
Detrusor myomectomy / autoaugmentation
Outcome of autoaugmentation in patients with
refractory idiopathic urge incontinence
% patients improved
70
66
60
56
50
40
30
34
20
10
0
Urodynamics
better
Symptoms better
Dry
Evidence: Level 4
[case series]
Review of outcome is based on: Leng (1999), Swami (1998), Tweedle (1999), Flynn (1999)
Enterocystoplasty
•The gold standard for bladder restitution
• Capacity
• Compliance
• Low pressure
• But: no emptying function
Indications for Entero cystoplasty
•A bladder capacity of less than 250ml
•Presence of hydronephrosis, decrease of kidney
functions
•Azotemia and frequent pyelonephritis
•Before /during/ kidney transplantation
•Side effect or refractory to pharmacological
therapy
Bladder enlargment
With cystectomy?
Bladder enlargment: type of
ileal cystoplasty
Surgical results after augmentation cystoplasty
Complications of enterocystoplasty
• Ureteral reimplantation stenosis 9-16%
• Continence 27- 65%
• Need for clean intermittent catheterization 8- 44%
• Stone formation
• Impairment of bone formation & mineralization
Stone formation after enterocystoplasty
• More in intestinal reservoir than gastrocystoplasty
• Staples, suture materials, metabolic abnormality, PH
value
• Mucus plays an important role
• PH conducive to crystallization of uric acid
• Calcium-phosphate ration is elevated in forming stone
in intestinal reservoir
Late complications of Enterocystoplasty
• Mucus production and obstruction
• Bacteriuria
• Stone formation
• Metabolic alteration
• Bowel dysfunction
• Secondary malignancy
Outcome of enterocystoplasty in patients with
refractory idiopathic urge incontinence
% patients improved
80
70
60
71
65
66
50
40
30
20
10
0
Evidence: Level 4
[case series]
Urodynamics
better
Symptoms better
Dry
Review of outcome is based on: Mundy (1985), Kockelbergh (1991), McInerney (1995), Hasan (1995),
Flood (1995), Awad (1998), Leng (1999)
Cutaneous continent cystostomy:
Mitrofanoff (appendix)
Intermittent catheterisation
Suprapubic continent stoma
Mitrofanoff orMonti
with or without closure of bladder neck
Especially for obese women in
wheelchair, unable to perform
IC transurethrally
Cystectomy women
Neobladder Studer type
Neobladder Studer type
Neobladder Studer type
Perioperative complications Cystectomy
(Novotny et al 2007)
• Mean post ok
‘93-’99
24 days
’99-’02
23 days
’02-’05
17 days
• Blood loss
1208 ml
• Bloodtransfusions
total 425 ml (83%)
intra 329 ml (64%)
Medical complications
• Mortality
0.3-4.5%
• Deep veen thrombosus
5 %
• Embolism
1.7%
• Sepsis
1.4%
• Subileus (no intervention)
3.9%
• Enterocolitis
2 %
Surgical complications
• Small bowel obstuction
4 (0.8%)
• Lymphocele
no intervention
28 (5.4%)
drainage
14 (2.7%)
• Wound dehiscence
secondary healing
20 (3.9%)
with revision
26 (5.0)
• Total complications
141 (27%)
• reintervention rate
6.2% (2%-17%)
Resolution of DO after POP surgery without concomitant
incontinence surgery in patients with POP & DO incontinence
% patients improved
80
70
57
60
53
50
40
38
30
20
10
0
Evidence: Level 4
[case series]
Urodynamics
better
Symptoms better
Dry
Based on: de Boer et al. Neurourol Urodyn 29:30, 2010 [review of 6 studies for urodynamics and 18 for
symptoms and becoming dry]
Conclusions:
- Reconstructive solutions exist for OAB / DO
- Bladder augmentation is gold standard; DRY ±
-
60% [level 4]
Other options available but prone to fail
Complications substantial ST LT
Real evidence lacking