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Ileocecal Cystoplasty (Ileocecocystoplasty)

Ileocecal cystoplasty is a form of augmentation cystoplasty that uses a detubularized segment of cecum and terminal ileum to enlarge the bladder. Its principal advantage over standard ileocystoplasty is the ability to simultaneously create a continent catheterizable channel using the ileocecal valve mechanism, and to provide a built-in antireflux mechanism for ureteral reimplantation into the cecal wall.[1][2] The best-known formalization of this technique is the Mainz Pouch I (Mixed Augmentation Ileum aNd Zecum).[1]

Indications​

Indications mirror those of ileocystoplasty — a poorly compliant or overactive bladder refractory to conservative management — but ileocecal cystoplasty is particularly favored when:[2][3]

  • A continent catheterizable stoma is needed (e.g., wheelchair-bound patients who cannot catheterize per urethra).
  • Ureteral reimplantation is required — the thick-walled cecum/ascending colon provides a reliable submucosal tunnel for antireflux implantation.[1]
  • The appendix is unavailable for a Mitrofanoff channel (the ileocecal valve itself can serve as the continence mechanism).

Common underlying conditions include neurogenic bladder (SCI, myelodysplasia), bladder exstrophy, and refractory IC/BPS.[4][5]

Surgical Technique​

The standard technique:[1][4]

  1. Segment isolation: ~10–15 cm of cecum/ascending colon and two adjacent ileal loops of similar length isolated on their mesentery; requires mobilization of the hepatic flexure of the colon — longer incision than for ileocystoplasty.[7]
  2. Bowel continuity restoration: ileocolonic (ileoascending) anastomosis.
  3. Detubularization: cecum and ileal segments opened along their antimesenteric borders. Critical — early series that left the segment intact (non-detubularized) demonstrated persistent cecal contractions in 57–100%, contributing to incontinence and reflux.[8][9][10]
  4. Reconfiguration: opened segments folded and sutured into a spherical, low-pressure pouch.
  5. Cystotomy and anastomosis: native bladder bivalved; reconfigured patch anastomosed.
  6. Continent catheterizable channel (when performed as continent cutaneous ileocecocystoplasty, CCIC): the ileocecal valve can be used as the continence mechanism. The terminal ileum is tapered (plication or stapling) and the ileocecal valve is left intact or intussuscepted to create a continent nipple valve. Alternatively, the appendix can be tunneled submucosally into the cecal wall as a Mitrofanoff-type channel.[1][11][12]
  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 — fewer 90-day complications than open (18.8% vs 47.6%, p=0.03) with comparable long-term outcomes.[7]

Outcomes​

  • Bladder capacity: mean 185 → 595 mL in one series; +277 mL average in another.[2][4]
  • Detrusor pressure: significant reduction (e.g., 53 → 16 cm H₂O).[4]
  • Continence: 90–95% across multiple series.[2][4][13]
  • Upper-tract protection: renal function maintained or improved in ~91%.[14]
  • Voluntary voiding: in IC/BPS, ileocecal augmentation may increase the proportion who can void spontaneously without CIC compared to ileal augmentation alone.[5]

The Mainz Pouch I experience in over 800 patients demonstrated an overall continence rate of 92.8% at mean 7.6-year follow-up.[15]

Advantages Over Ileocystoplasty​

FeatureIleocecal CystoplastyIleocystoplasty
Built-in continent channelIleocecal valve provides natural continence mechanismRequires separate Mitrofanoff/Monti channel
Antireflux ureteral reimplantationThick cecal wall allows reliable submucosal tunnelThinner wall; alternative reimplantation needed
Channel revision rateLower (13% required secondary procedure)Higher with tunneled channels (50%)
Metabolic acidosisPossibly lower (cecal mucosa absorbs less chloride)Possibly higher
Post-void residualLower in comparative studiesHigher
Surgical complexityGreater (hepatic flexure mobilization)Less extensive dissection
Bowel morbidityLoss of ileocecal valve → diarrhea riskPreserves ileocecal valve

A key advantage is the lower rate of channel-related reoperations: in a multicenter comparison only 13% of CCIC patients required a secondary procedure for the catheterizable channel vs 50% with tunneled channels (Mitrofanoff/Monti) — OR 6.4 (95% CI 1.8–28).[16]

Complications​

  • Channel-related complications: Contemporary multicenter series of 114 adult CCIC (median 40 mo) — 42.1% required additional related surgery, most commonly for channel obstruction (13.2%) or incontinence (3.5%); 9.6% abandoned the catheterizable channel.[20]
  • Vesicoureteral reflux: the most common complication in early series, particularly when the segment was not detubularized (cecal contractions caused reflux at capacity in ~30%).[8][14]
  • Persistent cecal contractions: with non-detubularized segments, volume-dependent contractions persist in 100% even with anticholinergics, vs 10–12% with a detubularized patch.[9][10]
  • Urinary tract stones: ~5.6–10.8%, higher with intussuscepted ileal nipple (10.8%) than appendix stoma (5.6%).[15]
  • Stomal stenosis: 15.3–23.5%, depending on continence mechanism.[15]
  • Metabolic disturbances: hyperchloremic metabolic acidosis can occur, possibly less frequent than with ileal neobladder (arterial pH 7.41 vs 7.39 in one trial).[17] Clinically significant acidosis primarily seen with pre-existing renal insufficiency.[14]
  • Bowel-related complications from ileocecal segment harvest:
    • Diarrhea: loss of ileocecal valve shortens transit time and impairs bile-salt reabsorption → mixed secretory-osmotic diarrhea, fat malabsorption, steatorrhea. Functional reconstruction of the ileocecal valve has been described to mitigate.[18][19]
    • Vitamin B₁₂ deficiency: terminal ileum is the exclusive site of active B₁₂ absorption; resection of >30 cm increases risk; annual B₁₂ monitoring recommended.[18][21]
    • Cholelithiasis: bile-salt derangements increase pigment-stone propensity.[18]
    • Hyperoxaluria and urolithiasis: fat malabsorption → free oxalate absorption → calcium-oxalate stones.[18]
  • Hernia: open CCIC requires a long midline laparotomy → high rates of ventral and parastomal hernias; the hand-assisted laparoscopic approach was specifically designed to address this.[7]

Malignancy Risk​

Comparable to other enterocystoplasties. Adenocarcinoma (often signet-ring) is the most common histologic type, predominantly arising at the entero-vesical anastomosis with mean latency ~19–20 yr.[22][23] Whether augmentation itself is an independent risk factor remains debated; one matched cohort study found no significant difference (4.6% vs 2.6%, p=0.54).[24]

Long-Term Follow-Up​

  • CIC compliance (most patients require CIC).
  • Annual metabolic panel (electrolytes, bicarbonate, renal function).
  • Renal ultrasound for hydronephrosis and stones.
  • Periodic vitamin B₁₂ levels.
  • Cystoscopy as clinically indicated.
  • Channel assessment for stenosis or continence issues.[3][20]

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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