Monday, March 11, 2013

Augmentation Cystoplasty (part 8)


Candidates for bladder augmentation have 2 less invasive surgical options available to them that may be considered before augmentation cystoplasty is carried out:
·         Cystoscopic injection of onabotulinumtoxinA
·         Sacral nerve stimulation (SNS; also referred to as sacral neuromodulation)[20]
OnabotulinumtoxinA injections are used in some patients with overactive bladders and may benefit bladder-augmentation candidates. Some small studies have shown significant increases in bladder volumes, often exceeding those seen with oral medications.[21, 22, 23] However, this treatment may not be adequate or durable in patients with extremely reduced bladder compliance or volume. These injections have improved quality-of-life scores in many patients who have neurogenic incontinence despite oral anticholinergic therapy.[24]
SNS is a minimally invasive technique that has markedly improved bladder volume, urge symptoms, and incontinence rates in patients with detrusor overactivity and urge urinary incontinence. It has also been shown to help patients with urinary retention who have high residual volumes after voiding.
In the first stage of SNS, tunneled leads are placed, usually in the S3 foramen. After a trial of efficacy with an external device, the implantable neuromodulator is implanted in the second stage. Initial experience has shown SNS to be promising as a means of averting major surgery in adult and pediatric patients who would otherwise be candidates for augmentation cystoplasty. Long-term follow-up is limited, but the available evidence suggests that SNS should be a durable option.[25]
When medical treatment, behavioral modifications, and other less invasive options all fail, formal surgical therapy with augmentation cystoplasty is warranted. Failure is defined as debilitating urinary symptoms (eg, frequency, urgency, or incontinence) or high bladder-storage pressures (>40 cm H2 O) that risk damage to the renal parenchyma.
Counsel patients regarding the risks, benefits, requirements, and lifestyle impact of the operation. When deciding among urinary conduit diversion, orthotopic bladder substitution, and augmentation cystoplasty, take into account the patient’s renal function, serum acid or base status, and potential need for dialysis. Also consider procedures that can be performed as alternatives or as adjuncts to augmentation cystoplasty, including sling procedures, urethral lengthening, appendicovesicostomy, and bladder neck closure.

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