Bladder Augmentation: Overview of Surgery and Hospital Stay
Description of surgery
When the bladder spasm pills or Botox injections fail, or when the bladder is severely contracted and has pressures that may lead to kidney failure, surgery to expand the bladder volume and decrease the pressures is often the best method of treatment. This surgery is known as bladder augmentation. In this surgery, a patch of bowel is brought down to the bladder and used to dramatically increase the volume of the bladder. This eliminates problems with bladder spasms and urinary incontinence and creates a large capacity low-pressure reservoir for urine. Think of it like a large dome added to a building where the bladder is the building. The bladder capacity after augmentation is usually about 500 ml, or 16 ounces. People need to perform intermittent catheterization to drain the bladder after augmentation. The surgery is done through a vertical (a.k.a. midline) or horizontal (a.k.a., Pfannenstiel) abdominal incision. The bladder is cut in the midline from the front to the back so that it opens like a clamshell. This cut accomplishes two purposes. First, it makes an opening where the bladder augment will be sewn in. Second, by cutting the bladder muscles it breaks up the bladder spasms and helps relieve urinary incontinence and protects the kidneys from high pressures. Normally, when the bladder spasms it creates a concentric squeeze that can push the urine out the urethra, causing leakage, or push the urine back toward the kidneys, causing kidney damage. By dividing the bladder in the middle we dissociate the muscles on the left half from those on the right half, meaning that if the muscle spasm they won’t be able to create a concentric squeeze, they will really just be wiggling in place. A 25 cm (10 inch) section of small intestine (or, rarely, large intestine) and its blood vessels are then cut out from the other intestine. The other intestine is put back together again with stitches so that the stool flows through normally. The 25cm section of intestinal tube is then opened lengthwise. This turns the tube into a long skinny rectangle. That rectangle is then folded on itself in an “S” configuration and stitches are placed to hold it in that shape. This “S” reconfiguration turns the long skinny rectangle of intestine into a square. That square of intestine is still attached to its blood vessels, like strings on a parachute. It is then sewn to the clam-shelled bladder opening. The intestinal augment doubles or triples the size of the bladder meaning you can hold urine for longer periods of time (typically 4-6 hours) and helps lower the pressures in the bladder, reducing incontinence and protecting the kidneys. A Mitrofanoff or Monti tube can be created at the same time as the bladder augmentation (see separate description of this surgery). At the end of the surgery 2 catheters are inserted to help keep the bladder empty during the healing process so that urine does not leak between the stitches. Typically, one catheter comes out the urethra and one is a suprapubic catheter that comes out the abdominal wall. If a Mitrofanoff or Monti was created with the augment then one of the catheters will be through that and the other can either be the urethral or suprapubic catheter. Both are removed one month after surgery and the person is taught to catheterize their bladder to empty it. The skin is closed at the end of the surgery with either dissolvable stitches or non-dissolvable staples. When staples are used, these are removed about 2 weeks after surgery.
After bladder augmentation surgery people usually remain in the hospital for 5-9 days. We know you are ready to go home when you have good pain control with pills, are able to eat and are back to your baseline level of mobility.
There will be several people seeing you every day in the hospital. These may include: nurses, nursing assistants, dieticians, physical therapists, occupational therapists, social workers, surgeons, medical doctors, nurse practitioners, physician assistants, residents and medical students. At a teaching hospital like this one, the residents and medical students are central members of the care team. Your surgeon may not be able to see you every day in the hospital because they work in several different hospitals and clinics each day; so they have to rely on their team of doctors to help manage you after surgery. Rest assured that this team is communicating with your surgeon multiple times a day and that as the captain of the team your surgeon is making the decisions about your care.
When we operate on the intestines they tend to go to sleep for a few days. If you try to eat right away you are likely to vomit. So, we typically allow you to have just sips of water and ice chips for the first two days. Once you feel hungry and not bloated with gas we know that your intestines are waking up. Then we try a diet of clear liquids (juice, soda, Jello and soup broth). If this goes well, then we try a regular diet.
When we operate on the intestines they tend to go to sleep for a few days. This, plus the fact that you may not have eaten normally right before and after surgery means that you might not have a bowel movement for a few days. If you normally need help from things like enemas in order to have a bowel movement, then please explain this to the doctors or nurses in the hospital. We can make sure you are on the medicines you need in order to have a bowel movement. When you do have a bowel movement the first few may be loose because of the recent intestinal surgery plus the alterations in your diet.
Some people opt for an epidural or a nerve block before surgery. This can help with pain control in your abdominal incision for the first few days. You may have a pain pump or pain button, also called Patient Controlled Analgesia (PCA). This is a button that you push that automatically delivers a narcotic pain medicine through your IV. If you cannot push the pain button or prefer not to have one, then an alternative is that a nurse can deliver pain medicines through the IV as needed. You may also get an IV form of non-narcotic pain medicines to allow you to take fewer narcotics. Once your intestines start working we will have you try taking pain pills by mouth (a.k.a., orally). Oral pain medicines work longer than IV forms and are, of course, the type that need to be working for you in order to go home
At the end of the surgery 2 catheters are inserted to help keep the bladder empty during the healing process so that urine does not leak between the stitches. Typically, one catheter comes out the urethra and one is a suprapubic catheter that comes out the abdominal wall. If a Mitrofanoff or Monti was created with the augment then one of the catheters will be through that and the other can either be the urethral or suprapubic catheter. Both are removed one month after surgery and the person is taught to catheterize their bladder to empty it. Both catheters will be attached to their own bag after surgery. By the time you go home we may cap or plug one of the catheters and keep the other attached to one bag. Whether the catheter is plugged or attached to a bag, it is important to flush (a.k.a., irrigate) both catheters twice a day to remove mucous and prevent clogging of the catheter. The flushing can be done with sterile saline. You will be taught by the nurses and/or doctors how to flush the catheters.
There will be a dressing over your incision after surgery. This will be removed 2 days after surgery and the incision can be left open to air. If there are staples then these will be removed about 2 weeks after surgery. If you go home with them then you can arrange to have us or your local doctor remove them.
At the end of surgery, a tube is placed that is on the outside of the bladder and comes through the abdominal wall through a small puncture hole. This tube is called a JP drain and it attaches to a suction cannister that looks like a grenade. The JP drain suctions out any urine or blood that may accumulate outside the bladder; it is removed before the patient leaves the hospital. After removing the drain, a bandage will be placed over the hole and it can be removed in 2 days. The hole in the skin closes on its own in 1-2 days.
At first, it can be hard to move around or transfer out of bed after surgery due to the pain of the incision. But, it is important to try to get back to your baseline level of activity after surgery. By moving around, you help prevent bed sores and pneumonia, and you help wake up the intestines. Physical therapists may see you in the hospital to help you regain mobility. Some people will need to go to a rehabilitation center after the hospital in order to get further help with mobility; the physical therapists will help determine your level of need and their documentation will help ensure that your insurance company will pay for any rehabilitation care you need.