Laparoscopic gastrocystoplasty for tuberculous contracted bladder.

The stomach is the preferred augmentation option for a contracted bladder in a patient with renal failure. A 49-year-old female presented with right solitary functioning kidney with tuberculous lower ureteric stricture and contracted bladder. Her creatinine was 2.8 mg%. By laparoscopic approach, right gastroepiploic artery based gastric flap was isolated using staplers and used for augmentation and ureteric replacement. At 6-month follow-up, her creatinine was 1.9 mg%, and bladder capacity was 250 ml. She had mild hematuria, which settled with proton pump inhibitors. Laparoscopic gastrocystoplasty is feasible and effective augmentation option in those with renal failure, giving the benefits of minimally invasive approach.

INTRODUCTION

Augmentation of the bladder is indicated in a small poorly compliant bladder with or without refractory overactivity.[1] The most common and most studied tissue used for augmentation is ileum. However, in patients with renal failure, with a serum creatinine >2 mg/dl, the use of ileum can result in worsening of acidosis and renal failure. Hence, the use of a stomach flap is one of the options when a dilated ureter is not available to do ureterocystoplasty.[1] We present the case report of laparoscopic gastrocystoplasty for ureteric replacement and bladder augmentation.

CASE REPORT

A 49-year-old female presented with right loin pain and urinary storage symptoms of 1-year duration. Clinical examination was unremarkable. She had right hydroureteronephrosis with lower ureteric stricture and thimble bladder [Figure 1a]. Her left kidney was small and contracted. Her serum creatinine was 2.8 mg%.

Figure 1

(a) Preoperative right nephrostogram and cystogram. (b) Postoperative cystogram

Cystoscopy and right retrograde pyelogram confirmed thimble bladder and right lower ureteric stricture. She had undergone right ureteric reimplantation for ureteric stricture 3 months back and was started on antituberculous treatment. Due to recurrent stricture, a percutaneous nephrostomy was placed. Since she had a contracted bladder with renal failure, gastrocystoplasty was planned.

Under general anesthesia, the patient was placed in reverse Trendelenburg position. Nasogastric tube was placed. Five ports were inserted initially, one each of 10 mm and 15 mm and three of 5 mm, to isolate a gastric flap based on the right gastroepiploic artery. The 10 mm port inserted in the supraumbilical region was used for the camera and the 15 mm port was used for stapler [Figure 2].

Figure 2

Port position for gastrocystoplasty

Using ultrasonic shears, a window was created in the middle of the greater curvature to insert the stapling device. Five 60 mm stapler cartridges were used to fashion the gastric flap along the greater curvature almost up to the fundus. Thereby, a gastric tube of about 25 cm long was isolated based on the right gastroepiploic artery along with the adjoining omentum. The isolated segment was narrow at the pyloric end (2 cm wide) and wider at the fundal end (5 cm). This segment was rotated down toward the pelvis.

Subsequently, the patient was placed in Trendelenburg position. Two more trocars were inserted in the suprapubic area and left flank to approach the right lower ureter and bladder. Right ureter was isolated and divided above the level of the stricture. A 6 F ureteric stent was inserted and the bladder was opened vertically. The staples on the gastric flap were excised and its narrow end was tubularized and sutured to the spatulated right ureter. The flap was tubularized till it reached the bladder and sutured to the vertically opened bladder using 3-0 Vicryl forming a patch to augment the bladder. A 22 Fr 3-way Foley catheter was placed in the bladder. The nephrostomy tube was changed and a drain was placed in the pelvis.

The total operating time was 420 min and estimated blood loss was 150 ml. She was started orally on postoperative day 2 and discharged on day 7. The post operative period was uneventful except for mild hematuria for which she was started on proton pump inhibitors to reduce the acid secretion in the stomach flap. The nephrostomy was clamped on day10 and the drain was removed on the 12th day after confirming improvement in hydronephrosis and the absence of intra-abdominal collection by ultrasonogram. A cystogram was obtained on the 30th day and urethral catheter was removed [Figure 1b]. Cystoscopy revealed well-healed and augmented bladder with gastric flap. The stent was removed after 8 weeks.

At 6 months follow-up, she was on proton pump inhibitors on a regular basis. Urinary frequency reduced to five to six times during the day and once at night. Her postoperative uroflowmetry showed a Qmax of 10 ml/s at voided volume of 156 ml with 30 ml residual urine [Figure 3]. She voided about 250 ml during each void. Serum electrolytes were normal. Nadir serum creatinine was 1.9 mg/dl. No change in the food intake and satiety was noted.

Figure 3

Uroflowmetry after 6 months of follow-up

DISCUSSION

Small bowel, especially the ileum, is the most commonly used segment for bladder augmentation.[1] However, in the presence of renal impairment with acidosis, nonabsorptive mucosa such as gastric mucosa or urothelium is preferred. Stomach is also used when ileum is deficient as in tuberculous involvement of ileum, pelvic irradiation, short gut syndromes, and cloacal exstrophy.[1]

Sinaiko et al. were the first to describe the use of gastrocystoplasty in an experimental study in 1956.[2] It was put into clinical use by Leong and Ong.[3] The stomach has predominantly (acid) secretory function and very minimal absorptive capacity, helpful in renal failure, thus avoiding dyselectrolytemia and acidosis. Mucus secretion is also less with stomach. The commonly used stomach segment is the body, based on the right or left gastroepiploic artery. Hematuria-dysuria syndrome is one of the distressing complications of gastrocystoplasty, with incidence up to 35%.[4] Proton pump inhibitors are helpful in decreasing the symptoms. Additionally, reversed serosal gastrocystoplasty and demucosalized gastrocystoplasty have been described.

Laparoscopic gastrocystoplasty was described by Docimo et al. in 1995.[5] However, very few reports are available since then. A minimally invasive approach by laparoscopy reduces the postoperative stay, ileus, and need for analgesics. Patients recover earlier when compared to open approach.

CONCLUSION

Gastrocystoplasty is a useful option for augmentation of bladder in specific indications such as renal failure and short ileum. Laparoscopic approach is a feasible and less morbid option for performing gastrocystoplasty.