Bladder augmentation and incontinence surgery

Some children are born with, or develop, bladders that do not function properly. These children may have a history of myelomeningocele (spina bifida), bladder exstrophy or bladder obstruction. If medication and clean intermittent catheterization (CIC) do not prevent leakage of urine or high bladder pressure that may damage the kidneys, we may recommend bladder augmentation with or without other types of surgery to stop incontinence.

What is bladder augmentation?
This is a procedure in which a piece of the bowel, stomach or ureter (the tube that carries urine from the kidney to the bladder) is used to enlarge the bladder. This allows the bladder to hold more urine at lower pressure.

What other types of surgery are used to stop urinary leakage?
Sometimes bladder augmentation is not needed or is not enough to prevent urinary leakage. In these cases, the incontinence can be stopped in one of two main ways:

• Procedures to tighten the urethra
  The urethra can be tightened by using a piece of tissue that is present in the abdominal wall (called fascia) to surround the urethra. Another way to stop leakage is to place an artificial sphincter around the urethra. The sphincter is activated by pumping a valve that is placed in the scrotum in boys or labia in girls. This causes water to fill up the sphincter and gently compress the urethra, preventing leakage. In some cases, the appendix, part of a ureter, or a fallopian tube can be transferred down to replace the urethra. The tissue is then sewn into the bladder so that no leakage can occur; therefore the bladder can only be emptied by catheterization (CIC). This is called a Mitrofanoff procedure.
• Continent diversion
  In some cases it is necessary or helpful to bring a channel to the skin for a child to catheterize through instead of using the urethra. This channel may be made up of appendix, ureter, a piece of bowel or fallopian tube. The channel is designed to prevent leakage and usually exits at the belly button.

Goals of bladder augmentation and incontinence surgery:

• increase bladder capacity
• decrease bladder pressure
• prevent kidney damage
• stop urinary leakage
• improve quality of life

Proper care of your child after surgery is crucial to success!

What is required prior to surgery?
In order to decide what procedure is best for your child, your doctor will need a recent kidney ultrasound, bladder X-ray, cystometrogram (CMG or bladder pressure test) and blood tests. A kidney scan may also be done. You will be asked to collect a urine specimen for culture using a sterile catheter 1 week prior to surgery. It is important that we get the results of this culture so we can start your child on antibiotics before coming to the hospital, if necessary. Starting 3 days prior to surgery, your child will need to start a bowel preparation routine to cleanse the bowel prior to surgery.

Bowel prep
If your child does not have kidney failure, you should do the following:

• 2 days prior to hospital admission
  Low residue diet - liquids and low fiber
  Magnesium citrate - 1 oz per 15 lb. weight in the morning
  Fleets enemas - given twice, repeat if no results
• 1 day prior to hospital admission
  Clear liquid diet - water, clear broth or juice, popsicles, pop (avoid caffeine)
  Magnesium citrate - as above
  Fleets enemas - as above

After admission to the hospital:
Your child will be given fluids in the vein, more enemas as needed and a special medicine to drink, if necessary, to further clean out the bowel. Sometimes a tube in the stomach is needed to give the fluid. A blood sample will be obtained and antibiotics will also be given prior to surgery.

What happens after surgery?
The surgical procedure will take at least 3 hours. Afterwards, your child may go to the intensive care unit overnight. A tube will drain the bladder and the new channel (Mitrofanoff) if present. Other tubes may be present as well, such as a tube in the nose (NG tube) to allow the bowel or stomach to rest as it is healing. All fluids, nutrients and medications will be recieved through the IV for the first few days at least. Only after the NG tube is removed will drinking be allowed. Pain medicine will be available to make your child as comfortable as possible. It is important to encourage your child to get out of bed and take deep breaths. You can expect your child to spend 7-10 days in the hospital.

What happens after my child leaves the hospital?
After your child is eating and pain can be managed with pills or liquid medicine, he/she will go home. The tube(s) in the bladder may remain there for 3 weeks or longer. While the bladder drainage tube is in, it is important to make sure that it drains freely. You may need to flush the tube periodically if it does not drain - if you cannot restore drainage, call us immediately. Your doctor may want to ensure that the bladder is healed (by doing an X-ray) and that you can do CIC easily before the bladder tube is removed. It is important to continue bladder relaxing medication and antibiotics after surgery if prescribed by your doctor.

Possible problems after surgery:
It is vital that you call us if you have any questions or problems after surgery. Some problems that can occur include:

• Infection. Redness, swelling, drainage, fever or worsening pain at the incision. Bacteria may grow in the bladder after surgery, but antibiotics are avoided unless fever, pain, blood in the urine or new urinary leakage are present.
• Incontinence. Leakage may persist after surgery, which in some cases is temporary. If leakage does not stop or returns, further tests and/or surgery may be needed in the future to correct the problem.
• Abdominal pain. Pain after surgery may mean blockage of the intestine, infection in the abdomen, blockage of a kidney or rupture of the bladder. Rupture can happen a year or more after surgery and is an emergency. If your child develops sudden pain, particularly with nausea, vomiting and/or fever, you should call us immediately and plan to come here immediately.
• Difficulty catheterizing. The Mitrofanoff channel may become difficult to catheterize. If so, we may need to use special catheters or dilate the channel. If difficulty persists, further surgery may be necessary.
• Other long term problems. Stones can develop in the bladder, but the risk of this can be reduced by irrigating the bladder daily with tap water or salt water (1 tsp. salt per cup water). Very rarely, a tumor may develop in the bladder. To check for this, we recommend looking in the bladder once a year starting 10 years after surgery.