Debate: Augmentation Cystoplasty has encouraging outcomes in the management of Intractable IC/BPS

In favour of the topic

We perform reconstructive surgery, augmentation cystoplasty alone (ACA) in patients with intractable IC/BPS when all other treatment modalities have failed. The bladder is bivalved in sagittal plane and 15-20 cm of ileum is interposed between two halves of bladder. No resection of bladder is performed. 

Advantages of ACA Over Other Surgical Procedures 

• No major dissection is involved, so there is minimum morbidity in comparison to other available surgical options. Post-operative recovery is very fast.
• No complication of uretero-enteric anastomosis like ureteric stricture or vesico-ureteric reflux (VUR) leading to pyelonephritis.
• Very small segment of ileum is used, so there is no chance of metabolic disturbances after surgery even in long term.
• Patients void normally with minimal residue.
• As no major dissection is done, no nerves or vessels are dissected and therefore no effect on sexual function post-surgery, especially in males.
• Post-surgical complications are minor and managed easily.

Clinical Experience

Since January 2012 we have performed ACA in 14 patients with intractable IC/BPS. Two patients died due to causes unrelated to surgery, so data from 12 patients (8 females and 4 males) were analyzed and their present condition was assessed on a 7-point GRA scale. Patients with moderate and marked improvement were considered responders. The mean age was 48 (23 -61) years at the time of surgery. Average pre-surgery maximal bladder capacity (MBC) under anesthesia was 310 ml (100-600). Seven patients had Hunners lesion (HL). Mean follow-up was 3.38 years and the median was 3 years. Ten patients voided with minimal residue and two patients needed clean intermittent catheterization. 

Results

Successful results are present in 12/12 patients even in long term, with 11 patients being symptom-free and 2 patients with marked improvement as per GRA. The efficacy of ACA is maintained even in the long term with the first patient still being symptom free after 10 years. The results of surgery are not affected by MBC under anesthesia, presence and absence of HL, severity of symptoms, and duration of illness. 

Disadvantages and complications of Other Surgical Options 

Subtotal Cystectomy with Cystoplasty: Increased morbidity, increased residual urine, voiding with abdominal straining, possibility of VUR and pyelonephritis, impaired sexual function due to extensive surgery, metabolic complications as 35-40 cm of intestines are used, and voiding with abdominal pressure.

Cystectomy with Orthotopic Neobladder: Very extensive morbid surgery, high residual urine, inability to void naturally, uretero-enteric stricture, metabolic complications, impaired sexual function, absent bladder sensation, and reoperation for complications.

Ileal conduit with cystectomy: complications of cystectomy and ureteral stricture, absent bladder sensation, body disfigurement, and need for permanent stoma.

Urinary Diversion only: Complications depending on diversion, need of stoma bag or intermittent catheterization, body disfigurement, metabolic complications with continence pouch, and uretero-enteric stricture.

Conclusion

Results of the reconstructive surgery are good, ranging from 70- 90% of cases. In my small series of 12 cases, all the patients are happy and report a much better quality of life. These impressive results with minimum complication profile make ACA surgery a procedure of choice. 

Against the topic

IC/BPS is not a life-threatening condition. So why are we discussing whether to perform procedures such as partial cystectomy plus bladder enlargement (PC+BA)? A recent meta-analysis of 20 eligible studies evaluated a total of 450 patients, of which 218 underwent PC+BA (Osman et. al., 2021). The others were submitted to total cystectomy or urinary diversion with bladder preservation. The mean follow-up of the studies was almost 4 years. Symptoms improvement or cure was reported in 70.7% of cases. However, 17 patients (7.8%) persisted with pain and underwent total cystectomy. Of the main complications, 21 cases of sepsis, two of intestinal obstruction, and one of bowel leakage, were described, with no reported case of death related to the procedure. We need to interpret these results carefully. Looking at the results another way, 30% of the patients have maintained the symptoms despite undergoing an extensive operation. Also, the 70% rate of improvement in symptoms does not mean that the patients have no symptoms anymore. Although the rate of early reoperation is low after bladder augmentation, the complication rate is high in the long run (Biers et. al., 2012) The mean follow-up in the studies is only 45 months (Osman et. al., 2021), which is low for this type of surgery. B12 Vitamin deficiency, stones, and need of re-augmentation can be present, but these factors are usually diagnosed long after surgery, sometimes as long as 10 years after surgery during the follow-up phase. Another concern is bladder perforation, which is well-documented in patients with myelomeningocele who have had their bladders augmented, which may occur at any time in life in up to 13% of cases (Cetinel et. al., 2016). Cystectomy may be associated with higher improvement of the symptoms than that of PC+BA, but requires a resection of a longer bowel segment, longer operative time, and is associated with an increased chance of complications, as reported in this meta-analysis.

In another series of 26 patients with a follow-up range between 89 and 264 months, 95.6% of the subjects reported feeling “very much better” and “much better”, which is a very subjective way of measuring the improvement of symptoms (Queissert et. al., 2022). The rate of early complications requiring revision was 7.4%, while11% required ongoing bicarbonate treatment. About one-half of the patients are on CIC, which affects a patient´s quality of life in various ways. In conclusion, PC+BA may be worthwhile for some patients, but we still cannot be sure who are ideal candidates for this treatment. Better studies are needed that include a long follow-up, a control group, and a more precise way of measuring outcomes, including a chart report of the daily pelvic floor symptoms.

References

Osman, NI, Bratt, DG, Downey, AP, Esperto, F, Inman, RD, Chapple, CR. A Systematic Review of Surgical Interventions for the Treatment of Bladder Pain Syndrome/Interstitial Cystitis. Eur Urol Focus 2021; 7(4): 877-85. doi: 10.1016/j.euf.2020.02.014.

Biers SM,  Venn SN,  Greenwell TJ. The past, present and future of augmentation cystoplasty. BJU Int. 2012 May; 109 (9):1280-93

Çetinel B, Kocjancic E, Demirdag Ç. Augmentation cystoplasty in neurogenic bladder. Investig Clin Urol, 2016; 57(5): 316-23.

Queissert, F, Bruecher, B, Ophoven, V and Schrader, AJ.  Supratrigonal cystectomy and augmentation cystoplasty with ileum or ileocecum in the treatment of ulcerative interstitial cystitis/bladder pain syndrome: a 14-year follow-up. Int Urogynecol J. 2022; 33(5):1267-1272. doi: 10.1007/s00192-022-05110-y.