Opportunities for augmentation cystoplasty revision without additional bowel harvest: “Hourglass” deformity or non-detubularized augment

Abstract

Introduction: We describe our experience performing bladder augmentation revision without additional bowel harvest for certain suboptimal cystoplasty configurations.
 Methods: We identified patients with prior bladder augmentation who underwent augmentation revision without additional bowel harvest at our institution. These patients were identified to have either “hourglass” deformity or non-detubularized augment previously. Revision was performed using an open technique by detaching the prior augment and performing detubularization and/ or completion cystotomy as needed. Baseline characteri0stics, perioperative courses, and followup information were reviewed. Preand postoperative cystography and urodynamics were assessed.
 Results: Seven patients underwent bladder augmentation revision without the use of additional bowel. Three patients were found to have a non-detubularized augment, while the other four had a narrow connection from the native bladder to augment. Cystography demonstrated correction of “hourglass” deformity for the four patients, and urodynamics revealed resolution of phasic contractions after detubularization. Six of seven patients reported significant improvements in symptoms, such as frequency, urgency, and incontinence. One patient ultimately required Indiana pouch urinary diversion. All patients are performing intermittent catheterization at last followup.
 Conclusions: Patients with a prior bladder augmentation with inadequate urine storage should have testing to identify the possibility of a non-detubularized augment or “hourglass” deformity. These patients can be safely offered a revision without the need for additional bowel harvest.

Case – Persistent vesico-cutaneous fistula in an “hour-glass” deformity ileocystoplasty: Successful repair using abdominal wall perforator flaps

“…If the initial cystotomy is too small, the anastomosis may narrow, resulting in an 'hourglass deformity'. 1 There are few studies on sequelae and management of hour-glass deformity postaugmentation. The largest is a case series of seven patients who underwent removal of the ileal augment, enlargement of the cystotomy, and re-anastomosis of the ileal patch.…”

“…Post-operative follow-up demonstrated resolution of the hour-glass deformity and improvement in voiding pressures. 1 A study on need for re-augmentation in patients with bladder exstrophy found the formation of an hour-glass deformity to be an indication for re-augmentation in 1 out of 17 patients. 2 Patients with bladder exstrophy are challenging given their small native bladder making enlargement of the original cystotomy difficult.…”

“…A narrowing can develop at the vesico-intestinal anastomosis resulting in an "hour-glass deformity"; this is a rare complication with few studies describing clinical implications and treatment. 1 We present a case of a 35-year-old male with a history of bladder exstrophy and ileocystoplasty who presented with an hour-glass deformity with a large stone in both the augmented and native bladder. Following open cystolithotomy, he developed a vesico-cutaneous fistula requiring a complex repair.…”