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Bladder Autoaugmentation (Detrusorectomy / Detrusor Myotomy)

Bladder autoaugmentation (also called detrusor myotomy or detrusorectomy) increases bladder capacity and compliance by excising or incising the detrusor muscle over the dome while leaving the underlying urothelium intact, aiming to create an epithelial diverticulum with improved storage capacity and compliance, without incorporating bowel into the urinary tract.[1][2] First described by Cartwright and Snow in 1989, it was developed to avoid the metabolic, mucus-related, and malignancy complications inherent to enterocystoplasty.[1]

EAU 2026 describes detrusor myectomy (auto-augmentation) as a procedure with a low surgical burden and low rate of long-term adverse effects that does not preclude further interventions. EAU gives a Strong recommendation to offer bladder augmentation for low compliance and/or refractory neurogenic detrusor overactivity; it does not separately grade detrusor myectomy.[20] Long-term results of autoaugmentation are inconsistent (see Controversial Durability).[5][17][21] Persistent or recurrent unsafe storage pressures require urodynamic reassessment rather than an open-ended wait for delayed benefit. Patients at high risk for upper-tract deterioration also need regular upper-tract imaging; EAU 2026 suggests ultrasonography approximately every six months for this group.[20]

Indications​

Autoaugmentation may be considered for selected patients with refractory low capacity, poor compliance, or neurogenic detrusor overactivity after a reliable emptying plan and appropriate less invasive storage treatments have failed or are unsuitable. For neurogenic detrusor overactivity after ineffective antimuscarinics, the EAU 2026 guideline gives a Strong recommendation for intradetrusor botulinum toxin A.[20] Common underlying conditions are neurogenic bladder (myelomeningocele, SCI, tethered cord, sacral agenesis), posterior urethral valves, and bladder exstrophy.[2][3][4]

Particularly considered when:[1][2][5]

  • The patient or family wishes to avoid bowel interposition and its metabolic and mucosal complications.
  • The patient has renal insufficiency (where enterocystoplasty acidosis would be poorly tolerated).
  • A simpler, extraperitoneal procedure that preserves the option for future enterocystoplasty is desired.
  • The patient has no anterior abdominal-wall anomalies, which the rectus muscle backing technique requires.[3]

Contraindications​

  • Severely fibrotic or thickened bladder. Urothelium may not prolapse adequately.
  • Anterior abdominal-wall anomalies (omphalocele, gastroschisis) preclude rectus-muscle backing.[3]
  • No reliable emptying plan. Catheterization may still be required. A simultaneous catheterizable channel is not itself a contraindication; combined operations have been reported.[18]
  • Severely small bladder capacity where the achievable degree of augmentation is insufficient.

Surgical Techniques​

1. Detrusorectomy (Cartwright–Snow)[1]​

  • Extraperitoneal or transperitoneal approach.
  • Detrusor muscle over the entire dome is excised; bladder epithelium is preserved.
  • Urothelium prolapses through the defect and forms a large epithelial bulge or diverticulum.
  • Storage improvement is variable and must be confirmed; myotomy incises muscle, whereas myectomy or detrusorectomy removes it.

2. Detrusorectomy with rectus muscle backing (Perovic)[3][6][7]​

Addresses the problem of urothelial retraction and shrinkage after simple myotomy.

  • Completely extraperitoneal approach (inferior midline or transverse incision).
  • In the Perovic technique, begin dissection with the bladder partly filled to identify the detrusor–urothelial plane, then nearly empty it as the urothelium prolapses to reduce injury.[6]
  • Detrusorectomy involves the entire upper half of the bladder.
  • Both rectus abdominis muscles dissected from their anterior and posterior sheaths.
  • Prolapsed urothelium sutured to the rectus muscles at multiple points to prevent retraction.
  • Rectus muscles provide structural backing; may facilitate voluntary emptying.
  • Long-term results (median follow-up 134 mo): median bladder capacity 419 mL (range 296–552); 14/23 patients voluntary voiding without PVR.[3]

In a urothelium-preserving overlay, a demucosalized seromuscular bowel patch supports the exposed urothelium. When preparing such a patch, removal of the muscularis mucosae and inner submucosa has been described to limit enteric mucosal regrowth; the supporting comparison was chiefly an animal study.[11]

  • Demucosalized gastric patch (Nguyen–Mitchell): in 11 pediatric patients, capacity increased from 109 to 236 mL and compliance from 3 to 9 mL/cmH₂O; no metabolic complications were reported over mean 23-month follow-up; mucus-free urine.[9]
  • Lima nonsecretory intestinocystoplasty (related mixed techniques): in 129 augmentations in 123 patients (104 sigmoid, 25 ileal), capacity increased by 329% and compliance 7-fold.[10] A silicone balloon was used in 105 augmentations; native bladder mucosa was preserved in the remaining 24. The authors observed no mucus, perforation, or neoplasia over median 51-month follow-up, and 13/129 augmentations (10.1%) failed.[10] An expanded, likely overlapping 269-patient cohort reported five spontaneous perforations and 35/269 failures (13%) over median 72-month follow-up.[22]
  • Mucosal-regrowth evidence: in an animal study, regrowth occurred in 4/5 sheep when muscularis mucosae and submucosa were preserved, versus none after deeper removal. A related 10-child clinical series reported no detected regrowth.[11]
  • A silicone balloon conformer in place 2 weeks postop may prevent mucosal shrinkage (8/10 continent with a conformer versus 1/12 without in a small comparative series).[12]

4. Seromuscular enterocystoplasty (SE)[13]​

Detrusorectomy combined with a seromuscular bowel patch (preserving submucosa). In a 10-child series after spinal trauma, mean capacity increased from 83 to 320 mL and end-filling intravesical pressure fell from 48 to 21 cm H₂O at three months; 9/10 used Valsalva voiding and none were incontinent.[13] Emptying pressures and upper-tract safety require assessment.

5. Laparoscopic autoaugmentation[14][15][16]​

  • Extraperitoneal retropubic approach is technically feasible.[15]
  • KTP-laser-assisted laparoscopic detrusorotomy showed poor durability, and both patients ultimately required enterocystoplasty.[14]
  • A single laparoscopic case for traumatic SCI reported continence at 6 mo and a bladder capacity of 510 mL on radio-urodynamics 2 mo later.[16]

Outcomes​

SeriesnFollow-upCapacityContinenceFailure
Cartwright & Snow[1]7ShortImproved 3/5Continence not specified (5/7 excellent clinical results)1/7 technical failure (14%)
MacNeily[17]17Median 75 moMinimal5/13 (38%) continent; 8/13 (62%) remained incontinent12/17 (71%) clinical failure
Hansen (myotomy)[4]25 childrenMedian 6.8 yr103 → 176 mL (5 mo)18/25 (72%) continent on CIC—
Djordjevic (rectus backing)[3]23Median 134 moMedian 419 mLContinence not reported; 14/23 voided without residual and 9 used CICFailure not defined; capacity increased in all 23 at median 27 mo
Dik (detrusorectomy)[18]35Mean 4.9 yrAge-adjusted volume increased in 13/35 (37%)19/25 (76%) with sling and/or Burch3/35 (9%) later ileocystoplasty
Rocha (myotomy + balloon)[12]10Long-term140 → 240 mL8/10 (80%; 2 on oxybutynin)2/10 unchanged; failure not defined
Lima (demucosalized bowel)[10]123 patients / 129 augmentationsMedian 51 mo↑ 329%Mixed outlet procedures; no stand-alone continence rate given13/129 (10.1%) augmentations
Nguyen (demucosalized gastric)[9]11 childrenMean 23 mo109 → 236 mL10/11 (91%) continent with CIC every 3–4 hours; 1 remained wet from low urethral resistance—
Stöhrer (adult autoaugmentation)[2]50Seven-year recruitment experience, not uniform follow-upIncreased; timing variableMost needed CICOne enterocystoplasty and one deafferentation; two additional failures attributed to psychological factors

Possible temporal pattern. In Hansen's series, bladder capacity was unchanged or decreased during the first 3 months, rose significantly by 5 months and stayed increased, and compliance continued to improve for up to 5 years. Stöhrer observed that low-dose anticholinergics appeared to speed the therapeutic effect.[2][4]

Tradeoffs Compared with Enterocystoplasty​

FeatureAutoaugmentationEnterocystoplasty
Bowel-mediated metabolic complicationsAvoided when no bowel mucosa is incorporated; unrelated metabolic disease remains possibleHyperchloremic acidosis, B₁₂ deficiency
Mucus productionNo bowel-derived mucus with pure myotomy or myectomy; incomplete demucosalization can permit enteric mucosal regrowth[11]Significant
Malignancy riskAvoids an entero-urinary junctionLong-latency risk reported; estimates vary by population
Bowel morbidityAvoids bowel resection in pure autoaugmentation; risk depends on access and concomitant surgeryResection and adhesions introduce bowel morbidity
Surgical complexityPure myotomy or myectomy may be extraperitoneal[15]; demucosalized bowel overlay is technically challenging[8]Major intraperitoneal
Operative timeIn the demucosalized gastric-overlay series, the authors reported longer operative time than conventional gastrocystoplasty or enterocystoplasty[9]No general comparison established
Preserves future optionsDoes not preclude enterocystoplasty—
Degree of augmentationLess predictable, smaller increaseGreater, more reliable
DurabilityVariable; may deteriorateMore durable

Complications​

  • Urothelial retraction and fibrosis. These are considered the main cause of failure and the rationale for rectus-muscle backing and demucosalized bowel overlay.[5][6][19]
  • Bladder perforation. One rupture occurred in Stöhrer's series of 50, probably from use of an artificial urinary sphincter. A reliable comparative perforation rate is not established.[2]
  • Postoperative leakage. In Dik's 35-child detrusorectomy series, two had bladder leakage; one required laparotomy for urinary ascites.[18]
  • Increased post-void residual. Most patients in Stöhrer’s adult series needed CIC after autoaugmentation, whereas 14/23 selected children with rectus backing voided without residual urine.[2][3] The diverticulum does not contract effectively, so emptying requires postoperative assessment.[2][3]
  • Delayed functional improvement. Improvement usually appears 1–6 months after surgery and occasionally takes more than 1 year. Patients must be motivated to wait.[2][4]
  • Failure and secondary surgery. Clinical failure, urodynamic failure, and conversion to enterocystoplasty are different outcomes. For example, MacNeily reported 12/17 clinical failures, but only four subsequent enterocystoplasties.[17]

Controversial Durability​

  • Negative long-term data. MacNeily reported 71% of 17 myelomeningocele patients were clinical failures at median 75 mo; 14/15 (93%) considered urodynamic failures; progressive hydronephrosis in 5; enterocystoplasty in 4. Concluded that autoaugmentation "cannot be endorsed for the management of congenital neuropathic bladder."[17]
  • Positive long-term data. Hansen (n=25, median 6.8 yr): sustained significant increases in capacity and compliance; normal renal function in all but 1; 18/25 (72%) became continent on CIC.[4] Djordjevic (23 children aged 4–13 yr, median 134 mo): median capacity remained increased at 419 mL; all 23 had increased capacity at median early follow-up of 27 mo, and nine used CIC.[3]
  • Systematic review. A 2024 meta-analysis of 8 retrospective pediatric case series (165 patients; median follow-up 1.75–11.1 years) found unchanged or improved capacity in 95% (95% CI 0.61–1.00) and improved compliance in 67% (95% CI 0.26–0.92). Major complications (stones, perforation) occurred in 5 patients (3%). The confidence intervals were wide.[21]
  • Critical review. Gurocak found that the clinical outcome of autoaugmentation "does not appear to be durable", with smaller and shorter-lived compliance gains than enterocystoplasty. The review also names low morbidity and the absence of bowel-related side effects as definite advantages, and patient selection as the most important step for success.[5]

Patient Selection — Keys to Success​

Best candidates for autoaugmentation:[2][3][5][12]

  • Detrusor hyperreflexia (overactivity) rather than pure fibrotic low compliance.
  • Adequate baseline bladder capacity (the procedure improves compliance more reliably than capacity). In children with spinal dysraphism, the January 2025 joint guideline says preoperative capacity of 75–80% of the age-expected volume seems necessary for success, while noting conflicting reports.[23]
  • No anterior abdominal-wall anomalies (for rectus backing).
  • Motivated to wait for potentially delayed functional improvement.
  • Willing to perform CIC postoperatively.
  • Renal insufficiency that makes enterocystoplasty metabolically risky.
  • Prefers a procedure that avoids bowel incorporation and preserves the option for future enterocystoplasty.

Technique Selection​

  • Simple detrusor myotomy or myectomy is less extensive than bowel augmentation, but durability is variable. Current pressures, upper-tract risk, and the consequences of waiting for a response guide selection.
  • Detrusorectomy with rectus muscle backing has favorable long-term results in a selected 23-patient series. Superiority over other techniques is unproven.[3] The earlier 7- and 19-patient publications overlap with this cohort.[3]
  • Urothelium-preserving bowel overlay places a demucosalized bowel patch over native urothelium for structural support while aiming to avoid bowel-mucosa contact with urine.[8][9]
  • Silicone balloon conformer. In a small comparative series (10 children with a conformer, 12 without), a conformer left in place for 2 weeks was associated with better outcomes of simple autoaugmentation, possibly by preventing early mucosal shrinkage.[12]

References​

1. Cartwright PC, Snow BW. "Bladder Autoaugmentation: Early Clinical Experience." The Journal of Urology. 1989;142(2 Pt 2):505-8. doi:10.1016/s0022-5347(17)38798-0

2. Stöhrer M, Kramer G, Goepel M, et al. "Bladder Autoaugmentation in Adult Patients With Neurogenic Voiding Dysfunction." Spinal Cord. 1997;35(7):456-62. doi:10.1038/sj.sc.3100441

3. Djordjevic ML, Vukadinovic V, Stojanovic B, et al. "Objective Long-Term Evaluation After Bladder Autoaugmentation With Rectus Muscle Backing." The Journal of Urology. 2015;193(5 Suppl):1824-9. doi:10.1016/j.juro.2014.11.081

4. Hansen EL, Hvistendahl GM, Rawashdeh YF, Olsen LH. "Promising Long-Term Outcome of Bladder Autoaugmentation in Children With Neurogenic Bladder Dysfunction." The Journal of Urology. 2013;190(5):1869-75. doi:10.1016/j.juro.2013.05.035

5. Gurocak S, De Gier RP, Feitz W. "Bladder Augmentation Without Integration of Intact Bowel Segments: Critical Review and Future Perspectives." The Journal of Urology. 2007;177(3):839-44. doi:10.1016/j.juro.2006.10.064

6. Perovic SV, Djordjevic ML, Kekic ZK, Vukadinovic VM. "Bladder Autoaugmentation With Rectus Muscle Backing." The Journal of Urology. 2002;168(4 Pt 2):1877-80. doi:10.1097/00005392-200210020-00052

7. Perovic SV, Djordjevic ML, Kekic ZK, Vukadinovic VM. "Detrusorectomy With Rectus Muscle Hitch and Backing." Journal of Pediatric Surgery. 2003;38(11):1637-41. doi:10.1016/s0022-3468(03)00579-7

8. Dewan PA. "Autoaugmentation Demucosalized Enterocystoplasty." World Journal of Urology. 1998;16(4):255-61. doi:10.1007/s003450050063

9. Nguyen DH, Mitchell ME, Horowitz M, Bagli DJ, Carr MC. "Demucosalized Augmentation Gastrocystoplasty With Bladder Autoaugmentation in Pediatric Patients." The Journal of Urology. 1996;156(1):206-9. doi:10.1016/s0022-5347(01)66001-4

10. Lima SV, Araújo LA, Vilar FO. "Nonsecretory Intestinocystoplasty: A 10-Year Experience." The Journal of Urology. 2004;171(6 Pt 2):2636-39. doi:10.1097/01.ju.0000112782.00417.5e

11. Dewan PA, Close CE, Byard RW, Ashwood PJ, Mitchell ME. "Enteric Mucosal Regrowth After Bladder Augmentation Using Demucosalized Gut Segments." The Journal of Urology. 1997;158(3 Pt 2):1141-6. doi:10.1016/s0022-5347(01)64406-9

12. Rocha FT, Bruschini H, Figueiredo JA, et al. "Use of an Inflatable Silicone Balloon Improves the Success Rate of Bladder Autoaugmentation at Long-Term Followup." The Journal of Urology. 2011;185(6 Suppl):2576-81. doi:10.1016/j.juro.2011.01.029

13. Dayanç M, Kilciler M, Tan O, et al. "A New Approach to Bladder Augmentation in Children: Seromuscular Enterocystoplasty." BJU International. 1999;84(1):103-7. doi:10.1046/j.1464-410x.1999.00144.x

14. Poppas DP, Uzzo RG, Britanisky RG, Mininberg DT. "Laparoscopic Laser Assisted Auto-Augmentation of the Pediatric Neurogenic Bladder: Early Experience With Urodynamic Followup." The Journal of Urology. 1996;155(3):1057-60. doi:10.1016/s0022-5347(01)66390-0

15. McDougall EM, Clayman RV, Figenshau RS, Pearle MS. "Laparoscopic Retropubic Auto-Augmentation of the Bladder." The Journal of Urology. 1995;153(1):123-6. doi:10.1097/00005392-199501000-00044

16. Siracusano S, Trombetta C, Liguori G, et al. "Laparoscopic Bladder Auto-Augmentation in an Incomplete Traumatic Spinal Cord Injury." Spinal Cord. 2000;38(1):59-61. doi:10.1038/sj.sc.3100939

17. MacNeily AE, Afshar K, Coleman GU, Johnson HW. "Autoaugmentation by Detrusor Myotomy: Its Lack of Effectiveness in the Management of Congenital Neuropathic Bladder." The Journal of Urology. 2003;170(4 Pt 2):1643-6. doi:10.1097/01.ju.0000083800.25112.22

18. Dik P, Tsachouridis GD, Klijn AJ, Uiterwaal CS, de Jong TP. "Detrusorectomy for Neuropathic Bladder in Patients With Spinal Dysraphism." The Journal of Urology. 2003;170(4 Pt 1):1351-4. doi:10.1097/01.ju.0000081954.96670.0a

19. Manzoni C, Grottesi A, D'Urzo C, et al. "An Original Technique for Bladder Autoaugmentation With Protective Abdominal Rectus Muscle Flaps: An Experimental Study in Rats." The Journal of Surgical Research. 2001;99(2):169-74. doi:10.1006/jsre.2001.6098

20. European Association of Urology. EAU Guidelines on Neuro-urology. 2026. Bladder augmentation and follow-up. Official guideline.

21. Aubert O, Kelly G, Lottmann HB, et al. "Outcomes of Detrusorectomy in Neurogenic Bladders: A Systematic Review and Meta-Analysis." Journal of Pediatric Urology. 2024;20(4):707-714. doi:10.1016/j.jpurol.2024.04.020

22. Dantas RAF, Calisto FCFS, Vilar FO, Araujo LAP, Lima SVC. "Nonsecretory intestinocystoplasty: postoperative outcomes of 25 years." Int Braz J Urol. 2019;45(4):681-685. doi:10.1590/S1677-5538.IBJU.2018.0595

23. Abrahamson K, Bogaert G, Dellenmark-Blom M, et al. "EAU–ESPU–ERN eUROGEN–ERN ITHACA–ERN ERKNet–IFSBH Guidelines on spinal dysraphism in children and adolescents." Clinical guideline. EAU Guidelines Office, Arnhem, Netherlands; 2024 (PDF dated January 2025). Official PDF.