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Ileocecal Cystoplasty (Ileocecocystoplasty)

Ileocecal cystoplasty is a form of augmentation cystoplasty that uses ileocecal bowel to enlarge the bladder. In Indiana-type CCIC, detubularized cecum and ascending colon form the augment, while terminal ileum is tapered into a catheterizable channel.[24] Its principal advantage over standard ileocystoplasty is the ability to simultaneously create a continent catheterizable channel using the ileocecal valve mechanism, while the colonic wall can support a constructed submucosal ureteral tunnel. Ureteral antireflux function is not supplied automatically by the native ileocecal valve.[1][2] Mainz Pouch I and Indiana-type continent cutaneous ileocecocystoplasty (CCIC) use different configurations and continence mechanisms.[1]

Indications​

Indications include selected neurogenic patients with detrusor overactivity and/or poor compliance refractory to or intolerant of less invasive therapy .[27] For idiopathic OAB, the 2024 AUA/SUFU guideline says clinicians may offer augmentation cystoplasty or urinary diversion to severely impacted patients who have not responded to all other therapeutic options .[28] Ileocecal reconstruction may be selected when:[2][3][27][28]

  • A continent catheterizable stoma is needed because urethral catheterization is inaccessible or impractical; augmentation may be limited if native capacity is adequate. Before choosing CCIC, confirm that the patient or a dependable caregiver can perform regular channel catheterization.[2][27]
  • Ureteral reimplantation when separately indicated: a cecal or ascending-colon submucosal tunnel is a Mainz option; Sutton's CCIC series preferred reimplantation into native bladder when feasible. The need for simultaneous reimplantation with augmentation in high-grade reflux remains unclear.[1][2][29]
  • The appendix is unavailable for a Mitrofanoff channel (the ileocecal valve itself can serve as the continence mechanism).

Before ileocecal harvest, review bowel disease and prior resection, nutritional and renal status, and the expected course of catheterization ability.[24]

Reported indications include neurogenic bladder (including SCI and myelodysplasia) and bladder exstrophy.[4] In IC/BPS, major surgery is an option for carefully selected patients with bladder-centric symptoms or, rarely, an end-stage small fibrotic bladder after other therapies fail .[26] The cited ileocecal series involved severe ulcerative disease. Before a trigone-preserving augment, assess trigonal involvement and tolerance of trial catheterization; painful or unacceptable catheterization may favor a different reconstruction.[5][26]

Surgical Technique​

Before reservoir construction, assess outlet competence and plan concomitant continence surgery when indicated; 11/23 patients in Sutton's CCIC series received urethral closure, sling, or bladder-neck injection.[2]

  1. Segment isolation. In the original Mainz configuration, cecum and two ileal loops form the reservoir. Indiana-type CCIC uses a colonic augment and a tapered terminal-ileal channel with an ileocecal continence mechanism. Segment lengths, detubularization limits, and colonic mobilization depend on the selected design.[6]
  2. Bowel continuity restoration: perform the ileocolonic (ileoascending) anastomosis. A 2024 retrospective series reported an ileocolic anastomotic leak in 2/56 CCIC patients (3.6%); a reinforced stapled ileocolic anastomosis was associated with fewer anastomotic leaks than a single-layer ileocolic anastomosis across CCIC and right-colon-pouch cases, without establishing a universal anastomosis method.[30]
  3. Detubularization. Open the bowel forming the reservoir along its antimesenteric border. In a Mainz reservoir, the cecum and two ileal loops are detubularized; in Indiana-type CCIC, retain the terminal ileal limb for tapering into a catheterizable channel.[1][24] Early nondetubularized ileocecal series found cecal or volume-dependent contractions in 8/13 urodynamically assessed patients (62%) in Mayo’s series and all 10 patients (100%) in Sidi’s intact-ileocecal group; reflux accompanied cecal contractions in some Mayo patients.[7][8][9]
  4. Reconfiguration: opened segments folded and sutured into a spherical, low-pressure pouch.
  5. Bladder preparation and anastomosis: bivalve the native bladder for conventional clam augmentation. Luangkhot's modified neurogenic-bladder series used a posterior-based bladder flap anchored to the psoas for a wide anastomosis; the cited ulcerative IC/BPS series instead performed supratrigonal cystectomy and joined the pouch to the preserved trigone.[4][5]
  6. Continent catheterizable channel (when performed as continent cutaneous ileocecocystoplasty, CCIC). The ileocecal valve can be used as the continence mechanism. Indiana-type CCIC tapers the ileal channel and reinforces the ileocecal continence mechanism with interrupted imbricating slow-dissolving sutures.[24] Mainz-type ileoileal nipple intussusception is a distinct option, not the same as leaving a native valve intact. Alternatively, the appendix can be tunneled submucosally into the cecal wall as a Mitrofanoff-type channel.[1][10][11]
  7. Ureteral reimplantation: when needed, ureters reimplanted into the cecal or ascending-colon wall via a standard submucosal tunnel.[1]

Minimally invasive approach. A hand-assisted laparoscopic CCIC has been described using a Pfannenstiel incision as the hand port and the umbilicus as the future stoma site; a retrospective comparison of 32 hand-assisted versus 21 open procedures found fewer 90-day Clavien grade 2 or higher complications (18.8% versus 47.6%). The open group had more prior augmentation/channel surgery.[6]

Outcomes​

  • Bladder capacity: mean 185 to 595 mL in one series; +277 mL average in another.[2][4]
  • Mean maximum detrusor pressure: decreased from 53 to 16 cm H₂O (p<0.0001).[4]
  • Continence: Sutton reported urethral and stomal continence in 22/23 CCIC patients at mean 26.9 months (21/22 assessed in the follow-up table); 11/23 also had concomitant urethral-outlet procedures, so this is a combined-reconstruction outcome.[2] Luangkhot reported continence in 20/21 adults after modified ileocecocystoplasty at mean 3.1 years.[4] In the mixed Mainz series, 32/34 augmentation patients were dry day and night; its substitution and diversion outcomes are separate.[12]
  • Upper-tract protection: in a historical 129-patient mixed-segment augmentation or replacement cohort, 91% maintained or improved renal function in combination with clean intermittent catheterization at average 44-month follow-up.[13]
  • Voluntary voiding: among 26 followed women with severe ulcerative IC/BPS after supratrigonal cystectomy, 12/18 ileocecal recipients versus 2/8 ileal recipients emptied voluntarily (passive voiding or abdominal straining; p = 0.036) at a cohort median of 171 months.[5]

A retrospective series of over 800 continent cutaneous Mainz Pouch I diversions, rather than native-bladder augmentations, reported 92.8% day-and-night continence at mean 7.6 years.[14]

Advantages Over Ileocystoplasty​

FeatureIleocecal CystoplastyIleocystoplasty
Catheterizable channelTapered ileum plus a surgically constructed/reinforced valve mechanism in CCICSeparate channel may be added when needed
Antireflux ureteral reimplantation (when indicated)Cecal or ascending-colon tunnel is possible in selected Mainz reconstructions; CCIC may use native bladderNative-bladder reimplantation is also possible; neither augment automatically requires it [1][2][29]
Secondary procedure for channel leakage, obstruction or stenosis4/31 CCIC vs 15/30 tunneled channels in one retrospective adult comparison [15]—
Metabolic acidosisRisk depends on segment, contact time, renal function, and emptyingNo established augmentation-specific advantage from the cited neobladder trial
EmptyingDepends on outlet, native bladder, and catheterization strategy—
Surgical complexityGreater (hepatic flexure mobilization)Less extensive dissection
Bowel morbidityLoss of ileocecal valve → diarrhea riskPreserves ileocecal valve

In a retrospective 61-adult multicenter study at median 16-month follow-up, a secondary procedure for stomal leakage, channel obstruction or stomal stenosis was required in 4/31 CCIC versus 15/30 tunneled-channel patients (OR 6.4, 95% CI 1.8–28 for tunneled channels). Postoperative complications were 51.7% after CCIC and 40% after tunneled channels.[15]

Complications​

  • Delayed bladder perforation. Peritonitis or clinical deterioration after augmentation warrants urgent assessment for perforation; management depends on stability and the extent of extravasation.[3][25]
  • Postoperative complications. In a contemporary multicenter series of 114 adult CCIC (median follow-up 40 months), 15.8% had major complications at 3 months. Additional related surgery was needed in 42.1%, and 20.2% had at least one channel revision, most commonly for obstruction (13.2%) or incontinence (3.5%). 9.6% abandoned the catheterizable channel.[19]
  • Vesicoureteral reflux. In Mitchell’s mixed-segment series, reflux in the ileocecal cystoplasty group was the most common surgical complication. In Mayo’s nondetubularized ileocecal series, reflux was observed at capacity with a cecal contraction in 4/13 urodynamically assessed patients (31%).[7][13]
  • Persistent cecal contractions. With non-detubularized segments, volume-dependent contractions were universal in Sidi's series (all 10 intact ileocecal segments, compared with 12% of sigmoid cup-patch reconstructions)[8], and Mayo reported cecal contractions in 8 of 13 patients despite adequate anticholinergic doses.[7] Goldwasser found contractions more common with tubular than with detubularized reconstruction.[7][8][9]
  • Reservoir stones and access: in a retrospective CCIC cohort published in 2024, 7/56 patients (12.5%) underwent bladder or reservoir stone removal more than 90 days after surgery (median follow-up 46 months).[30] Wiesner's related Mainz Pouch I diversion series reported calculi in 10.8% of intussuscepted ileal-nipple reservoirs and 5.6% of appendix-stoma reservoirs.[14] Transstomal stone treatment can damage the continence mechanism; EAU notes that percutaneous or open access is typically preferred when a continent channel is present.[30][14][31]
  • Stomal stenosis in related continent diversion: Wiesner reported stenosis in 23.5% of appendix stomas and 15.3% of intussuscepted ileal nipples after Mainz Pouch I diversion.[14]
  • Metabolic disturbances. Hyperchloremic acidosis remains a concern.[16] The cited 60-patient randomized comparison studied orthotopic neobladders after cancer cystectomy.[16] Clinically significant acidosis primarily seen with pre-existing renal insufficiency.[13]
  • Bowel-related complications from ileocecal segment harvest:
    • Diarrhea. Loss of ileocecal valve shortens transit time and impairs bile-salt reabsorption, leading to mixed secretory-osmotic diarrhea, fat malabsorption, steatorrhea. Functional reconstruction of the ileocecal valve has been described to mitigate.[17][18]
    • Vitamin B₁₂ deficiency. Terminal ileal incorporation and prior ileal disease/resection increase risk; monitor over time rather than treating a fixed 30 cm boundary as a guarantee of safety.[17][20]
    • Cholelithiasis: bile-salt derangements increase pigment-stone propensity.[17]
    • Hyperoxaluria and urolithiasis. Fat malabsorption leads to free oxalate absorption, then calcium-oxalate stones.[17]
  • Hernia. Open CCIC requires a long midline laparotomy, leading to high rates of ventral and parastomal hernias; the hand-assisted laparoscopic approach was specifically designed to address this.[6]

Malignancy Risk​

An ileocecal-specific equivalence to other augmentation types has not been established. Adenocarcinoma was the most common histologic type (51.6% of post-augmentation malignancies in a systematic review); a separate, selected 10-case pathology series found signet-ring features in 9 of 10 selected non-urothelial carcinomas.[21][22] About half of the tumors arise at the entero-urinary anastomosis, and the mean latency is approximately 19 years.[21][22] Whether augmentation itself is an independent risk factor remains debated; one matched cohort study of 153 augmented patients with congenital bladder dysfunction and matched catheterization controls found no significant difference (4.6% versus 2.6%, p=0.54).[23]

Long-Term Follow-Up​

  • Annual history, examination, symptoms, and review of reliable emptying; a continent cutaneous channel requires catheterization. Review mucus management and the saline irrigation plan; the 2026 EAU urolithiasis guideline recommends regular irrigation for augmented or continent reservoirs without a history of autonomic dysreflexia to reduce stone recurrence .[2][31]
  • Annual metabolic panel (electrolytes, bicarbonate, renal function).
  • Annual urinary tract imaging, usually renal ultrasound, for hydronephrosis and stones.
  • Periodic vitamin B₁₂ levels.
  • In adults with neurogenic lower urinary tract dysfunction who have undergone bowel reconstruction, perform cystoscopy for gross hematuria or symptomatic recurrent UTI .[27]
  • Repeat urodynamics at an appropriate interval after treatment when impaired storage or voiding places the upper tracts at risk .[27]
  • Channel assessment for stenosis or continence issues.[3][19]

References​

1. Thüroff JW, Alken P, Riedmiller H, et al. "The Mainz Pouch (Mixed Augmentation Ileum and Cecum) for Bladder Augmentation and Continent Diversion." The Journal of Urology. 1986;136(1):17-26. doi:10.1016/s0022-5347(17)44714-8

2. Sutton MA, Hinson JL, Nickell KG, Boone TB. "Continent Ileocecal Augmentation Cystoplasty." Spinal Cord. 1998;36(4):246-51. doi:10.1038/sj.sc.3100500

3. Cheng PJ, Myers JB. "Augmentation Cystoplasty in the Patient With Neurogenic Bladder." World Journal of Urology. 2020;38(12):3035-3046. doi:10.1007/s00345-019-02919-z

4. Luangkhot R, Peng BC, Blaivas JG. "Ileocecocystoplasty for the Management of Refractory Neurogenic Bladder: Surgical Technique and Urodynamic Findings." The Journal of Urology. 1991;146(5):1340-4. doi:10.1016/s0022-5347(17)38086-2

5. Queissert F, Bruecher B, van Ophoven A, 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." International Urogynecology Journal. 2022;33(5):1267-1272. doi:10.1007/s00192-022-05110-y

6. Stout TE, Roth JD, Gor RA, Pariser JJ, Elliott SP. "Technique and Outcomes of Hand-Assist Laparoscopic Continent Cutaneous Ileocecocystoplasty." Urology. 2021;152:200. doi:10.1016/j.urology.2021.01.019

7. Mayo ME, Chapman WH. "Ileocecal Bladder Augmentation in Myelodysplasia." The Journal of Urology. 1988;139(4):786-9. doi:10.1016/s0022-5347(17)42637-1

8. Sidi AA, Reinberg Y, Gonzalez R. "Influence of Intestinal Segment and Configuration on the Outcome of Augmentation Enterocystoplasty." The Journal of Urology. 1986;136(6):1201-4. doi:10.1016/s0022-5347(17)45282-7

9. Goldwasser B, Barrett DM, Webster GD, Kramer SA. "Cystometric Properties of Ileum and Right Colon After Bladder Augmentation, Substitution or Replacement." The Journal of Urology. 1987;138(4 Pt 2):1007-8. doi:10.1016/s0022-5347(17)43483-5

10. Webster GD, Bertram RA. "Continent Catheterizable Urinary Diversion Using the Ileocecal Segment With Stapled Intussusception of the Ileocecal Valve." The Journal of Urology. 1986;135(3):465-9. doi:10.1016/s0022-5347(17)45693-x

11. Carroll PR, Presti JC. "Comparison of Plicated and Stapled Continent Ileocecal Stoma." Urology. 1992;40(2):107-9. doi:10.1016/0090-4295(92)90504-p

12. Thüroff JW, Alken P, Riedmiller H, Jacobi GH, Hohenfellner R. "100 Cases of Mainz Pouch: Continuing Experience and Evolution." The Journal of Urology. 1988;140(2):283-8. doi:10.1016/s0022-5347(17)41584-9

13. Mitchell ME, Piser JA. "Intestinocystoplasty and Total Bladder Replacement in Children and Young Adults: Followup in 129 Cases." The Journal of Urology. 1987;138(3):579-84. doi:10.1016/s0022-5347(17)43264-2

14. Wiesner C, Bonfig R, Stein R, et al. "Continent Cutaneous Urinary Diversion: Long-Term Follow-Up of More Than 800 Patients With Ileocecal Reservoirs." World Journal of Urology. 2006;24(3):315-8. doi:10.1007/s00345-006-0078-y

15. Redshaw JD, Elliott SP, Rosenstein DI, et al. "Procedures Needed to Maintain Functionality of Adult Continent Catheterizable Channels: A Comparison of Continent Cutaneous Ileal Cecocystoplasty With Tunneled Catheterizable Channels." The Journal of Urology. 2014;192(3):821-6. doi:10.1016/j.juro.2014.03.088

16. Khafagy M, Shaheed FA, Moneim TA. "Ileocaecal vs Ileal Neobladder After Radical Cystectomy in Patients With Bladder Cancer: A Comparative Study." BJU International. 2006;97(4):799-804. doi:10.1111/j.1464-410X.2006.05996.x

17. Steiner MS, Morton RA. "Nutritional and Gastrointestinal Complications of the Use of Bowel Segments in the Lower Urinary Tract." The Urologic Clinics of North America. 1991;18(4):743-54. doi:10.1016/s0094-0143(21)00375-x

18. Fisch M, Wammack R, Spies F, et al. "Ileocecal Valve Reconstruction During Continent Urinary Diversion." The Journal of Urology. 1994;151(4):861-5. doi:10.1016/s0022-5347(17)35107-8

19. Cheng PJ, Keihani S, Roth JD, et al. "Contemporary Multicenter Outcomes of Continent Cutaneous Ileocecocystoplasty in the Adult Population Over a 10-Year Period: A Neurogenic Bladder Research Group Study." Neurourology and Urodynamics. 2020;39(6):1771-1780. doi:10.1002/nau.24420

20. Hashash JG, Elkins J, Lewis JD, Binion DG. "AGA Clinical Practice Update on Diet and Nutritional Therapies in Patients With Inflammatory Bowel Disease: Expert Review." Gastroenterology. 2024;166(3):521-532. doi:10.1053/j.gastro.2023.11.303

21. Biardeau X, Chartier-Kastler E, Rouprêt M, Phé V. "Risk of Malignancy After Augmentation Cystoplasty: A Systematic Review." Neurourology and Urodynamics. 2016;35(6):675-82. doi:10.1002/nau.22775

22. Anderson JA, Matoso A, Murati Amador BI, et al. "Invasive Poorly Differentiated Adenocarcinoma of the Bladder Following Augmentation Cystoplasty: A Multi-Institutional Clinicopathological Study." Pathology. 2021;53(2):214-219. doi:10.1016/j.pathol.2020.07.005

23. Higuchi TT, Granberg CF, Fox JA, Husmann DA. "Augmentation Cystoplasty and Risk of Neoplasia: Fact, Fiction and Controversy." The Journal of Urology. 2010;184(6):2492-6. doi:10.1016/j.juro.2010.08.038

24. Levy ME, Elliott SP. "Reconstructive techniques for creation of catheterizable channels: tunneled and nipple valve channels." Transl Androl Urol. 2016;5(1):136-144. doi:10.3978/j.issn.2223-4683.2016.01.04

25. Lee T, Kozminski DJ, Bloom DA, Wan J, Park JM. "Bladder perforation after augmentation cystoplasty: determining the best management option." J Pediatr Urol. 2017;13(3):274.e1-274.e7. doi:10.1016/j.jpurol.2016.12.027

26. Clemens JQ, Erickson DR, Varela NP, Lai HH. "Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome." J Urol. 2022;208(1):34-42. doi:10.1097/JU.0000000000002756

27. Ginsberg DA, Boone TB, Cameron AP, et al. "The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-up." J Urol. 2021;206(5):1106-1113. doi:10.1097/JU.0000000000002239

28. Cameron AP, Chung DE, Dielubanza EJ, et al. "The AUA/SUFU guideline on the diagnosis and treatment of idiopathic overactive bladder." Neurourol Urodyn. 2024;43(8):1742-1752. doi:10.1002/nau.25532

29. European Association of Urology. "EAU Guidelines on Neuro-urology: The Guideline." 2026. Guideline

30. Fendereski K, Daryabari SS, Stockard R, et al. "Bowel complications and anastomotic leak after ileocolic anastomosis in urinary diversion surgery: a comparative 12-year retrospective single-center study." Transl Androl Urol. 2024;13(11):2468-2481. doi:10.21037/tau-24-453

31. European Association of Urology. "EAU Guidelines on Urolithiasis: Bladder Stones." 2026. Guideline