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.