bladder augmentation

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The patient is positioned supine. Either a Pfannenstiel or
low-midline (below the umbilicus) incision may be used
The midline approach can easily be extended
superiorly if exposure is difficult. The patient is placed in slight
Trendelenburg position, and the bladder is exposed. If the patient
requires a bladder neck procedure or ureteral reimplantation, it is
often helpful to avoid opening the peritoneum until these ancillary
procedures are completed. Leaving the peritoneum closed
early on and using a Bookwalter retractor maximizes exposure
by keeping bowel loops contained and avoids unwanted evaporative
loss. If either a Mitrofanoff or Monti channel is being
created, the peritoneum is opened to allow access to bowel at that
The bladder is widely split, starting 2 cm above the bladder
neck anteriorly and continuing over the dome to just above the
interureteric ridge posteriorly. To accommodate a stoma, it is
sometimes helpful to split obliquely, leaving the larger bladder
half on the side of the stoma. The bowel is then inspected, and
an ileal segment 20 to 30 cm in length is chosen.
The mesentery is taken down and the bowel is divided with
either gastrointestinal anastomosis (GIA) staplers or Kocher
clamps. Integrity of the ileum is reestablished and the mesenteric
window closed. The isolated segment is irrigated by partially
opening each end and flushing through with either genitourinary
irrigant or half-strength Betadine. The segment is next opened
completely on its antimesenteric side using cutting current of
the cautery with careful spot coagulation for bleeding points
The edges of the open bowel plate are then rotated into position
for a detubularizing reconfiguration Suturing is
carried out with 3-0 polydioxanone (PDS) or Vicryl in a running
fashion with occasional locking throws and knots tied on the
serosal (outside) surface. It is important that each suture bite
include slightly more serosa and muscularis than bowel mucosa,
so that the mucosa is rolled inward each time the suture is tightened.
When complete, the running suture line should not have
mucosa peeking between bites because this can predispose to
persistent urine leak. After the initial suture line is completed, the
bowel is folded again into the rough form of a cup. It
is important that these two suture lines are stopped at a point that
will leave the circumference of the “cup edge” roughly equal to
the circumference open bladder edge to facilitate a watertight
sutured closure.
Before the augment is sutured to bladder, a large-caliber suprapubic
tube should be placed to exit through bladder wall
Depending on bladder wall thickness, either 2-0 or 3-0
PDS or Vicryl may be used for suturing the augment into position.
It is simplest to start in the posterior midline with suture
running in each direction and continued until the augment is
sewn in place for one quarter of the circumference (in each direction)
and then tied Next, start in the anterior midline
and sew each direction in a running fashion until this closure line
meets the previous one on each side. This approach optimizes
exposure and allows the surgeon to carefully judge the rate of
advancement needed for optimal, watertight suturing. The augmented

bladder is then distended modestly via the suprapubic
tube and any leak closed with interrupted suture. A perivesical
Jackson-Pratt drain is placed.




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