Evaluation and Management of Failed Bladder Reconstructions

Abstract

Bladder reconstructions are commonly performed in patients with neurogenic bladders with a high rate of complications. We seek to help guide the evaluation and management of these complications by reviewing the available data. Augmentation cystoplasty and concomitant procedures such as continent catheterizable channels, bladder neck closure, and bladder neck sling can provide long-term solutions for patients with poorly compliant, high-pressure bladders or refractory detrusor overactivity. While these techniques improve symptoms and protect against upper tract deterioration, patients are exposed to new risks including bladder perforation, increased malignancy rates, urolithiasis, surgical failures, and persistent symptoms. The overall rate of reoperation is high. Evaluation with urodynamics and endoscopy, when indicated, remain critical tools to protect this patient population. Use of clean intermittent catheterization has helped popularize bladder reconstructive surgery, but a strict regimen is required to minimize postoperative risks in the long term. Additionally, various surgical techniques can be utilized to manage complications after bladder reconstruction, and concurrent use of anticholinergics and onabotulinum toxin injections can further mitigate these reconstructive failures. Bladder reconstruction can provide excellent long-term solutions, but patients are at a high risk of long-term complications. Appropriate patient counseling, close follow-up, and timely evaluation are crucial in managing the long-term complications of bladder reconstruction surgery.

A Review of Botulinum Toxin A for the Treatment of Neurogenic Bladder

“…Long‐term, postoperative complications after augmentation cystoplasty include perforation, metabolic derangements, stone formation, renal deterioration, incontinence and malignancy . With regard to bladder stone formation, this population is at increased risk given urine stasis, mucus production, increased risk of UTI with urease positive organisms, and catheterizing through an abdominal channel .…”

“…With regard to bladder stone formation, this population is at increased risk given urine stasis, mucus production, increased risk of UTI with urease positive organisms, and catheterizing through an abdominal channel . Incidence ranges from 11% to 36% and prevention strategies are of upmost importance including mucus irrigation, strict adherence to catheterization regimens, and treatment of UTI and chronic infections . With regard to malignancy, while the exact incidence is unknown and likely underreported, it is known that patients with neurogenic bladder have a higher rate of bladder cancer, are diagnosed at a younger age, and commonly have more advanced staged cancer at presentation compared to the general population .…”