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264 Challenging Concepts in Urological Surgery
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Table 27.1 Complications of urinary tract reconstruction with bowel
Immediate Early Late
Death (0– 3.2%)
Bleeding requiring
return to theatre
(0– 3%)
Bowel/ urine leak
(2– 10%)
Intestinal obstruction
(3– 5.7%)
Ventriculoperitoneal
shunt infection
(0– 20%)
Voiding dysfunction/ need for CISC (60%)
Mucus (10– 90%)
Mucus retention (15%)
Deterioration in renal function (0– 15%)
Incontinence: day (10%)
Incontinence: night (10– 47%)
Biochemical abnormality (metabolic hyperchloraemic
acidosis): biochemical (100%), overt acidosis (0– 19%)
Malignancy (0.6%)
Stones (10%)
Impaired bowel function (15%)
Rupture (1.9%)
Learning point Techniques to deal with ureteric obstruction
Minimally invasive
● Ureteric stents. This is unlikely to be successful in this ‘unsafe’ system without a significant increase
in frequency of CISC as bladder pressures in ‘dangerous’ bladders range from <200 mL capacity. They
would also require lifelong changes and increase the risk of UTI as there would be a foreign body in
the urinary tract.
● Percutaneous nephrostomies. The advantage would be to overcome the ureteric obstruction, and
take the unsafe bladder out of the equation, but they would require lifelong regular changes, and
would have deleterious effects on the patient’s quality of life.
Major surgery
● Ureteric reimplantation. This has the advantage that it bypasses the anatomical obstruction;
however, it is imperative that the reservoir the ureters have been implanted into is a low- pressure
system.
Expert comment Management options
In this case, the first treatment is to place a catheter to drain the bladder and then wait for a couple
of weeks to see whether or not the hydronephrosis reverts. If the hydronephrosis improves, then we
know that the problem lies at the external sphincter mechanism. If the hydronephrosis remains, it is
almost certain that the patient has developed bladder wall thickness obstruction. The management of
each of these aspects of his condition have been outlined previously in this case.
Definitive management performed
All the options were discussed with the patient with risks and benefits of each
intervention.
The patient opted for the operative intervention and underwent bilateral ureteric
re- implantation and double clam ileocystoplasty.
This was undertaken by open procedure. A laparotomy was performed. The bladder
was bivalved sagittally and a 25 cm piece of terminal ileum 30 cm from the ileocaecal
junction was isolated. This was detubularized and folded back on itself to make a cup
and attached to the bladder as described in Figure 27.2.7 In addition, bilateral ureteric
Figure 27.2 Clam ileocystoplasty— operative description. The bladder was bivalved sagittally and a
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piece of ileum was isolated, detubularized, and folded back on itself to make a cup and attached to the
7
bladder.
re- implantation was undertaken in the posterior bladder plate without the need for
tapering the ureters in a non- refluxing manner.
He made an excellent postoperative recovery, his creatinine postoperatively improved to 220 mmol/ L, and he was discharged home after about a week in the hospital.
He had his JJ stents and suprapubic catheter removed at 6 weeks and restarted the
CISC regimen.
265Case 27 Neurogenic bladder
Learning point Hydronephrosis and lower urinary tract dysfunction
● Hydronephrosis in patients with neuropathic bladders are usually due to abnormal lower urinary
tract function.
● Neuropathic bladders may store urine at high pressure, causing secondary vesicoureteric reflux and
subsequent deterioration in renal function.
● Long- standing neurourological lower urinary tract dysfunction can cause hypertrophy of
the bladder wall/ detrusor attempting to overcome increased outlet resistance; however, this
hypertrophy can obstruct the ureters at the VUJ, and cause an anatomical obstruction with
subsequent deterioration in renal function.
● If the cause of hydronephrosis and renal failure is purely due to reflux, reducing storage pressure
often reverses or halts renal deterioration. However, it is important to identify VUJ obstruction as in
this case reducing bladder pressure will not resolve the hydronephrosis in this situation.
Expert comment Management and follow- up
It is clear from the investigations and from the discussion that this gentleman had bilateral ureteric
obstruction due to a thick bladder wall and that the only solution to his problem would be either a
urinary diversion or a bladder reconstruction with ureteric reimplantation. As he wished to be ‘bag
free’, the double- clam augmentation ileocystoplasty with bilateral ureteric reimplantation was entirely
the appropriate approach to management.
The initial outcome from his surgery was that the bladder became ‘normal’ in terms of compliance. He
was performing intermittent self- catheterization to drain his bladder.
266 Challenging Concepts in Urological Surgery
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It was more likely than not that his deterioration in renal function which remained was due to
chronic renal disease caused by chronic (but relived) obstruction. The MAG3 renogram showed a
rising curve in one kidney and a flat curve in the other, consistent with what could be obstruction
but not confirmed by the nephrostogram. It was therefore appropriate for him to continue with the
conservative management and to check his serum creatinine levels, which will be an indicator of any
deterioration in renal function. Intervention was not necessary or appropriate.
His follow- up should now continue with measurement of his serum creatinine level every 3 months
and careful supervised follow- up in a specialist centre with scans of the urinary tract every year with an
annual video urodynamic study to ensure that his bladder pressures remain low. It is more likely than
not that this will be the case.
Whether or not he will require renal replacement therapy very much depends upon any further
deterioration in his renal function.
Follow- up
At the 3- month postoperative appointment, the patient was clinically much improved. He
was dry with no reported urgency. He had no further UTIs. He was very satisfied with the
outcome of his operation. However, his serum creatinine level remained at 228 mmol/ L.
A VCMG (Figure 27.3a) revealed a good- capacity ‘safe’ bladder with normal compliance. The screening images (Figure 27.3b) show a much- improved capacity, storing
urine at low pressure, without any prostatic reflux.
He had follow- up MAG3 renograms (Figure 27.4) which again showed poor
drainage bilaterally, but without standing columns in the ureters. His creatinine level
settled to a nadir of 223 mmol/ L.
Unfortunately, 3 months later, he had a UTI and his creatinine concentration further increased to 305 mmol/ L. The infection did settle with antibiotics but the serum
creatinine only decreased to 280 mmol/ L. After discussing his imaging and trend in
serum creatinine, a decision was taken to insert bilateral nephrostomies and his creatinine concentration further reduced to 250 mmol/ L. Subsequent nephrostograms,
however, showed no evidence of definite obstruction or significant standing columns.
The uroradiologists reported bilateral baggy systems probably secondary to chronic
obstruction.
Since he had bilateral nephrostomies in place, it was decided to undertake a Whitaker
test. This was performed and was reported as equivocal. The nephrostomies were
clamped, and subsequently removed without further deterioration in renal function.
Figure 27.3 Video cystometrogram. There is a good capacity bladder with normal compliance without
any reflux.
Figure 27.4 MAG3 renogram. There is poor drainage bilaterally, but without standing columns in the
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ureters.
He continues under follow- up with the nephrologists with a creatinine level that
hovers between 230– 270 mmol/ L depending if he gets a UTI. He is extremely satisfied
with the outcome, is continent, performing CSIC, and although he gets UTIs, they are
quite infrequent.
His nephrologists were of the opinion that he has a degree of intrinsic renal disease
and though at present there is no evidence of a significant obstruction, any insult to
his renal tract including UTI could lead to a rise in his serum creatinine level. He has
been informed that it is likely he would need renal replacement therapy in the future
though the timings are difficult to quantify.
267Case 27 Neurogenic bladder
Learning point Whitaker test
A urethral pressure- sensing catheter is introduced, and infusion of saline into the renal pelvis is
commenced at 10 mL/ min. The pressure in the renal pelvis region is subtracted from the bladder
pressure. The resultant pressure is then analysed according to the following values to determine if
ureteric obstruction is present:
● <15 cm: unobstructed.
● 15– 22 cm: equivocal.
● >22 cm: obstructed.
The Whitaker test8 has an advantage over nuclear medicine scans in those with very large
hydronephrosis and those with severe renal impairment as it does not rely on glomerular filtration for
excretion.
Monitoring
The optimal follow- up for patients such as these has never been categorically defined.
Certainly, patients with spinal cord lesions (such as myelodysplasia and spinal cord injury) are at higher risk of upper tract deterioration than other neurological conditions.
268 Challenging Concepts in Urological Surgery
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Table 27.2 Comparison of British versus European guidelines in neurourology follow- up
Surveillance
NICE EAU
High- risk
patients
Lower- risk
patients
EAU, European Association of Urology: NICE, National Institute for Health and Care Excellence; UDS, urodynamic
studies; US, ultrasound.
The follow- up should therefore be lifelong. There is a difference in opinion as to
what investigations, and at what interval, are indicated in national and international
guidelines. Table 27.2 summarizes the main similarities and differences in British and
European guidelines.
We adopted a follow- up protocol for this gentleman, with annual VCMG and ultrasound scans and MAG3 as indicated, or earlier if there is a clinical change. He remains
well 5 years post cystoplasty with no further deterioration in his biochemical renal
function.
Lifelong follow- up
[Clinical review interval not stated]
US every 1– 2 years
UDS— consider surveillance regimen
Do not rely on serum creatinine to
monitor renal function
Lifelong follow- up and ongoing risk
stratification
If a patient become high risk– for
surveillance as above
9
Lifelong follow- up
Clinical review annually
US at least once every 6 months
UDS— mandatory baseline investigation and
should be performed at regular intervals
Perform regular urinalysis
Annual blood chemistry
Lifelong follow- up
Follow- up at least every 2 years
Regular urinalysis
Significant clinical change should prompt
urgent intervention
A final word from the expert
Inappropriate bladder management in patients with neurological conditions can not only lead
to a poor quality of life due to infections and incontinence, but can also lead to irreversible
deterioration in kidney function leading to renal failure. As a consequence, the aims of the
treatment are generally different from the physician’s perspective when compared to the patient’s
perspective. The patient’s priorities are often ‘normality’ and continence, with the physician’s main
concern being protection of the upper tracts and maintenance or improvement of renal function.
There are a number of management options in these complex cases. However, none of the
treatments offer a ‘perfect’ solution. It is not unusual that the patient will trade one set of
problems for another and hence very careful counselling needs to be undertaken to establish
what the patient’s wishes and desires are and these need to be married to the long- term
optimization of the urinary tract. It is extremely important to tailor the definitive therapy
according to the individual circumstances. It would not be unusual to have some ‘compromises’
in deciding the management options to achieve a practical solution.
All major surgical options, including cystoplasty, are major undertakings that require a motivated
patient who is willing and able to comprehend the implications of this surgery not only on
the urinary tract but also on bowel function, and understand the need to perform intermittent
catheterization. Additionally, the patient needs to sign up to lifelong follow- up, understanding the
significant morbidity of this surgery but expecting to have the potential benefits in the long term.
5
269Case 27 Neurogenic bladder
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References
1. McGuire EJ, Woodside JR, Borden TA, Weiss RM. Prognostic value of urodynamic testing in
myelodysplastic patients. J Urol. 1981;126(2):205– 209.
2. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tamminen- Möbius TE. International
system of radiographic grading of vesicoureteric reflux. Pediatr Radiol. 1985;15(2):105– 109.
3. Blok B, Castro- Diaz D, Del Popolo G, et al. Neuro- urology. European Association of Urology.
2019. https:// uroweb.org/ guideline/ neuro- urology/
4. Biers SM, Venn SN, Greenwell TJ. The past, present and future of augmentation cystoplasty.
BJU Int. 2012;109(9):1280– 1293.
5. Hoen LT, Ecclestone H, Blok BF, et al. Long- term effectiveness and complication rates of
bladder augmentation in patients with neurogenic bladder dysfunction: a systematic review.
Neurourol Urodyn. 2017;36(7):1685– 1702.
6. British Association of Urological Surgeons. Enlargement of the bladder with a piece of bowel.
British Association of Urological Surgeons. 2019. https:// www.baus.org.uk/ _ userfiles/ pages/
files/ Patients/ Leaflets/ Enterocystoplasty.pdf
7. Greenwell TJ, Venn SN, Mundy AR. Augmentation cystoplasty. BJU Int. 2001;88(6):511– 525.
8. Whitaker RH. Methods of assessing obstruction in dilated ureters. Br J Urol.
1973;45(1):15– 22.
9. Ecclestone H, Hamid R. A comparison of UK versus European guidelines in neuro- urology.
J Clin Urol. 2018;11(2):109– 114.
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28
urethr
a
cystocele
rectocele
uterine descent
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CASE
Genitourinary
prolapse
Priyanka H. Krishnaswamy
Expert commentary Swati Jha
Case history
A 57- year- old lady was referred to the gynaecology clinic by her general practitioner as
she could feel a reducible lump per vagina. She was medically fit and well, having had
two normal vaginal deliveries in the past and no history of abdominal or pelvic surgeries.
She was told by her general practitioner during a routine smear test 5 years ago that she
may have a prolapse but did not want to be referred then as she had no symptoms. In the
past 6 months she felt a lump vaginally when she walked and ran. In the recent 3 months,
she became aware of this when she wiped herself in the toilet and felt that the lump got in
the way during sex. She did not have any pain or abdominal, bowel, or bladder problems.
Learning point Definition of pelvic organ prolapse
Pelvic organ prolapse (POP; Latin: prolapsus, ‘a slipping forth’) is the downward displacement of pelvic
organs into or beyond the vagina due to loss of the normal support mechanism1 which is an increasingly
common problem seen in the ageing population. Although as many as 50% of women older than age 50
have some degree of POP,2 <20% seek treatment.3 This may result from a number of causes, including a
lack of symptoms, embarrassment, or misperceptions about available treatment options.
Types of uterovaginal prolapse are classified anatomically (Figure 28.1).
1
Figure 28.1 Uterovaginal prolapse.
Adapted with permission from Haylen BT, Maher CF, Barber MD, Camargo S, Dandolu V, Digesu A, et al. An
International Urogynecological Association (IUGA)/ International Continence Society (ICS) joint report on the
terminology for female pelvic organ prolapse (POP). International Urogynecology Journal 2016;27:165– 94.
272 Challenging Concepts in Urological Surgery
Pubic symphysis
Obturator
internus m.
Rectum
Ant
. sacrococcygeal
ligament
Coccyx
Deep dorsal vein of clitoris
Transverse pelvic ligament
Urethra
Obturator canal
Vagina
Pubococcygeus m.
Ilioc
occygeus m.
Ischial spine
Coccygeus m.
Piriformis m.
Sacral promontory
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Uterine/ cervical prolapse is generally the result of poor apical support, which allows downward
protrusion of the cervix and uterus towards the introitus.
Anterior vaginal wall prolapse:
● Urethrocele is prolapse of the lower anterior vaginal wall, involving the urethra only.
● Cystocele is prolapse of the upper anterior vaginal wall, involving the bladder.
● Cystourethrocele when there is prolapse of the urethra as well as the bladder.
● Anterior enterocele is a herniation of the peritoneum and abdominal contents through the
anterior vaginal wall, most commonly after reconstructive surgery.
Posterior vaginal wall prolapse:
● Rectocele is prolapse of the lower posterior wall of the vagina involving the anterior wall of the
rectum.
● Enterocele is prolapse of the upper posterior wall of the vagina involving loops of small bowel.
Vaginal vault prolapse involves a descent of the vaginal vault after a hysterectomy.
Learning point Anatomy of the pelvic organs
The normal position, support, and suspension of the pelvic organs rely on an interdependent system
of bony, muscular, and connective tissue elements.
● The lordosis of the lumbosacral region of the spine places the posterior aspect of the pelvic inlet
(sacral promontory) 60° above its anterior aspect (pubic symphysis). Posterior angulation of the
vagina, which is enhanced by rises in abdominal pressure causing closure of the ‘flap valve’ as well,
prevents downward prolapse of the uterus and vagina.
● The muscles of the pelvic diaphragm (Figure 28.2) form a basin or covering of the pelvic outlet
and are often grouped together as the levator ani. The thickenings of the parietal fascia of the
bellies of the iliococcygeus muscles are known as the arcus tendineus fascia pelvis (fascial arches)
Figure 28.2 A view into the pelvic floor that illustrates the muscles of the pelvic diaphragm and
their attachments to the bony pelvis.
Reproduced with permission from Berek J S. Berek and Novak’s Gynecology. 15th ed. USA: Lippincott Williams
and Wilkins; 2012.
or white lines. These lines are the lateral attachment points for the pubocervical septum and apical
pb
gh
Ap
Aa
Ba
3 cm
C
D
Bp
tvl
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rectovaginal septum and serve the function of mid- vaginal lateral support.
● The connective tissues of the pelvis include the deep endopelvic connective tissue which consists
of three pairs of ligaments: uterosacral ligaments, transverse cervical ligaments and pubocervical
ligaments; two septae: pubocervical fascia and rectovaginal fascia; and one pericervical ring which
connects all the above- mentioned tissues.
Expert comment Classification of POP
The Pelvic Organ Prolapse Quantification (POP- Q) method5 is the internationally accepted standard
and is the classification system of choice of the International Continence Society, the American
Urogynecologic Society, and the Society of Gynecologic Surgeons. It has proven inter- observer and
intra- observer reliability and is the most commonly cited system in the medical literature (Figure 28.3).
273Case 28 Genitourinary prolapse
Learning point DeLancey’s
supports
DeLancey helps explain the levels
of normal uterovaginal support.
● Level 1: the cervix and
upper third of the vagina are
supported by the transverse
cervical and uterosacral
ligaments.
● Level 2: the mid portion of
the vagina is attached by the
pubocervical and rectovaginal
fascia (deep endopelvic
connective tissue) to the arcus
tendineus fascia pelvis.
● Level 3: the lower third of
the vagina is supported by
the pelvic diaphragm and the
perineal body.
4
Learning point Aetiology
Figure 28.3 The nine specific sites of measurement used in the POP- Q system. Aa, point on
the anterior vaginal wall that is 3 cm away from the external urethral meatus; Ap, point on the
posterior vaginal wall that is 3 cm away from the hymen; Ba, most dependent/ distal point on the
anterior vaginal wall; Bp, most dependent/ distal point on the posterior vaginal wall; C, distance
of the cervix/ vaginal cuff (after hysterectomy); D, distance of the posterior fornix (representing the
Pouch of Douglas), absent after a hysterectomy; gh, length of the genital hiatus; pb, length of the
perineal body; tvl, total vaginal length.
Reproduced with permission from Bump RC, Mattiasson A, Bø K, et al. The standardization of terminology of
female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10.
Clinical tip Evaluation of POP
● Comprehensive history: including prolapse, urinary, bowel, and sexual history. Use of a
standardized and validated quality- of- life assessment questionnaire which is a useful audit and
research tool that helps with patient- centred assessment and goals.
Examination: palpation of the abdomen is done first to exclude an abdominal mass or ascites. A Sims
6
of POP
Congenital
● Bladder exstrophy.
● Collagen defects (e.g. type IV
Ehlers– Danlos syndrome,
Marfan’s syndrome).
Childbirth
● Trauma.
● Denervation.
Raised intra- abdominal pressure
● Chronic obstructive airway
disease.
● Lifestyle: straining, constipation,
heavy lifting, obesity, smoking.
Menopause
● Oestrogen deficiency.
Iatrogenic
● Pelvic surgery (i.e. hysterectomy).
speculum is used to systematically identify each component of the prolapse. The position of the cervix
or the vault (after a hysterectomy), is also determined and a bimanual pelvic examination performed.
A rectal examination may be required to differentiate between a rectocele and an enterocele.
● The mechanical strength of the pelvic diaphragm is directly correlated with the ability to voluntarily
contract these muscles. Muscle activity is subjectively graded from 0 to 5 using the Modified Oxford
score (0, no contraction; 1, flicker; 2, weak; 3, moderate; 4, good (with lift); 5, strong).7 If no muscle
activity is detected, a more formal neurological and medical workup should be considered.
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