Ileocystoplasty
Ileocystoplasty is the most commonly performed type of augmentation cystoplasty, using a detubularized segment of ileum anastomosed to the native bladder to increase bladder capacity and improve compliance.[1][2] Cheng and Myers describe enterocystoplasty as the gold standard for augmentation when conservative therapies have failed.[1]
Indications
For NLUTD, augmentation may be considered when detrusor overactivity or poor compliance is refractory to, or the patient cannot tolerate, appropriate less invasive therapy, including antimuscarinics and intradetrusor botulinum toxin where suitable.[1][27] β3 agonists may relieve neurogenic OAB symptoms, but EAU 2026 strongly advises against using them to reduce urodynamically proven neurogenic detrusor overactivity.[32] For severely impacted idiopathic OAB, AUA/SUFU 2024 permits augmentation only after all other therapeutic options have failed .[33] For selected adults with neurogenic lower urinary tract dysfunction, AUA/SUFU says clinicians may offer augmentation cystoplasty for refractory detrusor overactivity or poor compliance .[27] Common underlying conditions:
- Neurogenic bladder (myelodysplasia / spina bifida, spinal cord injury, tethered cord, sacral agenesis)
- Bladder exstrophy / cloacal exstrophy
- Posterior urethral valves
- Idiopathic detrusor overactivity[1][2][3]
The primary goals are upper-tract protection, continence, and quality of life.
Contraindications
Contraindications and practical barriers to consider include the following.
- Significant renal insufficiency increases the consequences of metabolic acidosis. Smith's 1977 review listed azotemia (creatinine clearance below 40 mL/min) as a contraindication, together with vesical malignancy, a neurogenic bladder with a spastic pelvic floor that cannot be modified, and young boys (mucus problems).[4] A single contemporary creatinine-clearance cutoff has not been validated; renal reserve, baseline acidosis, and alternatives are assessed individually.
- Inability or unwillingness to perform clean intermittent catheterization (CIC) when CIC is anticipated postoperatively.
- Active inflammatory bowel disease, prior pelvic radiation precluding healthy bowel use, or prior extensive ileal resection resulting in short bowel.[35]
- Patient or caregiver unable to commit to lifelong follow-up.
Surgical Technique
The standard open technique:[1][5][6]
- Bowel-segment selection. Approximately 15–40 cm of ileum, selected to preserve as much terminal ileum and the ileocecal valve as feasible. Some chapter authors recommend preserving the final 20 cm of terminal ileum specifically to protect bile-salt and vitamin B₁₂ absorption.[28] Record the actual segment and length used.
- Bowel continuity restoration: Side-to-side ileoileal anastomosis (stapled or hand-sewn).
- Detubularization. The isolated ileal segment is opened along the antimesenteric border, disrupting coordinated peristaltic contractions and converting the segment into a low-pressure reservoir.[6]
- Reconfiguration. The opened segment is folded into a U- or S-shaped patch to maximize volume and minimize pressure.
- Cystotomy. Bivalve the native bladder sagittally or coronally down to the ureteric orifices. Inadequate opening can leave the ileal patch as a diverticulum; for a very thick, fibrotic bladder, consider supratrigonal cystectomy to avoid patch exclusion.[35]
- Anastomosis: Reconfigured ileal patch is sutured to the opened bladder in a watertight fashion. Taking slightly more serosa and muscularis than mucosa with each running bite, rolling the mucosa inward, and inspecting the full suture line for protruding mucosa has been described; after closure, the augment can be filled modestly through the suprapubic tube and any leak repaired with interrupted sutures.[28]
Concomitant procedures
Frequently performed at the time of ileocystoplasty:[1][7]
- Catheterizable channel (Mitrofanoff appendicovesicostomy or Monti channel) for patients who cannot catheterize per urethra.
- Ureteral reimplantation for selected anatomic indications; high-pressure reflux can improve with augmentation alone, so reimplantation is not automatic.
- Bladder-neck procedures for incontinence (sling, bladder-neck closure).
Minimally invasive approaches
Laparoscopic and robot-assisted ileocystoplasty are technically feasible. Procedural complexity remains substantial.[3][5][8][9]
Outcomes
- Bladder capacity: increased from mean 111 to 788 mL at 12 months in a 23-patient laparoscopic series.[8]
- Maximum detrusor pressure: significant decrease from mean 92 to 15 cm H₂O at 12 months in the 23-patient laparoscopic series.[8]
- Continence: older mixed-segment cohorts reported 82–95%, often after additional outlet procedures.[6][7]
- Upper-tract outcomes: In a historical mixed-reconstruction cohort of 129 children and young adults, renal function was maintained or improved in 91% with CIC at mean 44-month follow-up.[6] A separate 22-child mixed-augmentation cohort reported increased estimated GFR and resolution of hydronephrosis in 17/19 affected patients at mean 13.4-year follow-up.[10] In a selected series of 80 patients with spina bifida who had ileocystoplasty plus a bladder-outlet procedure, 32/80 developed new renal scars and 12/80 developed stage 3 or worse CKD during median 14-year follow-up; 22/32 with new scars had been nonadherent to CIC.[31]
- Patient satisfaction: in a long-term SCI cohort (mean 14.7 yr), 13/14 questionnaire respondents (of 19 patients) would consider the operation again or recommend it to a friend.[11]
In a retrospective 84-patient mixed-segment study, postoperative pathologic contractions occurred in 26% of 31 ileal, 43% of 35 colonic, and 50% of 18 gastric reconstructions. Within this series, ileal reconstructions had the lowest contraction frequency, with residual contractions.[12]
Complications
Significant long-term morbidity requiring lifelong surveillance.[1][13][14]
- Urinary tract stones. In Szymanski's 413-patient spina bifida augmentation cohort (80.9% ileocystoplasty), the 10-year bladder-stone risk was 28.2%, with recurrence in 52.4% of stone formers.[14] In Chang's 22-child cohort (19 ileal and 3 sigmoid augmentations), urinary stones were the most frequent late complication, occurring in 8/22 at mean 13.4 years.[10] Continent catheterizable stomas and bladder or cloacal exstrophy are reported risk factors; mucus and urinary stasis may contribute.[7][10]
- Urinary tract infections. Distinguish asymptomatic bacteriuria from symptomatic infection. Balanca's 77-patient SCI cohort was assessed at a median 13 years after augmentation ileocystoplasty with supra-trigonal cystectomy; 55.8% had at least one febrile UTI, mostly within the first two postoperative years.[15] Taghavi reported symptomatic UTI in 36/71 (51%) children with mixed augmentation types over median 4.5 years.[15][16]
- Bladder perforation. Szymanski estimated 10-year risk of 9.6% with detubularized reconfigured ileocystoplasty versus 23.7% without it in a spina bifida cohort.[14] Overdistension and unreliable emptying are important preventable risks, but perforation may have other causes.[8][14] New abdominal or shoulder pain after augmentation warrants urgent evaluation for perforation; in a nine-case series, six were initially misdiagnosed as UTI or bowel obstruction, and the one undiagnosed patient died.[34]
- Hyperchloremic metabolic acidosis. Most common metabolic abnormality, from chloride and ammonium reabsorption by ileal mucosa. Severity depends on segment length, contact time with urine, and baseline renal function. Treat documented acidosis with an individualized alkali regimen; potassium-containing therapy requires particular caution with renal impairment or hyperkalemia.[13][17][18]
- Vitamin B₁₂ deficiency. Monitor according to ileal use and nutritional risk.[17]
- Bowel dysfunction. Ileal resection can cause diarrhea or altered bowel habits through bile-acid dysfunction even when the ileocecal valve is preserved.[29] Loss of the ileocecal valve and right colon increases diarrhea after comparable ileal resection; it is a separate risk of ileocecal harvest.[30] Bowel obstruction requiring laparotomy had an estimated 10-year risk of 4.5% in Szymanski’s mixed spina bifida augmentation cohort.[7][14]
- Reoperation. Szymanski estimated a 43.9% 10-year risk in a mixed-era spina bifida augmentation cohort. A separate 114-adult continent cutaneous ileocecocystoplasty cohort had 42.1% additional surgery over median 40 months and 20.2% channel revision.[14][19]
Malignancy Risk
Malignancy after intestinal augmentation is uncommon. A systematic review across augmentation types reported probabilities of 0–5.5% and mean latency 19 years.[20][21]
- Adenocarcinoma was the most common histologic type (51.6% of post-augmentation malignancies in a systematic review); signet-ring features appeared in 9/10 selected post-augmentation carcinomas (two after ileocystoplasty) in a multi-institutional pathology series.[20][22]
- About half of the tumors arise at the entero-vesical anastomosis.[20]
- Frequently diagnosed at advanced stage with poor prognosis (1-year survival approximately 56% in one series).[23]
- Whether augmentation itself is an independent risk factor (versus the underlying congenital bladder abnormality) remains debated; one matched cohort study found no significant difference in cancer incidence between augmented patients and controls (4.6% versus 2.6%, p=0.54).[24]
- In a selected ten-tumor post-augmentation series that excluded diagnosed urothelial carcinomas, nine tumors had gastrointestinal-type adenocarcinoma profiles and seven had potentially targetable alterations; TP53, KRAS, and MYC were among the most frequently altered genes.[25]
Older observational publications recommended scheduled endoscopy after five years.[26] AUA/SUFU states that clinicians should not perform screening or surveillance cystoscopy in NLUTD patients and should perform cystoscopy after reconstruction with bowel when gross hematuria or symptomatic recurrent UTI develops .[37][27] The statement text adds unexplained suprapubic pain to the signs that warrant full evaluation.[27] For women who undergo augmentation for non-neurogenic OAB or UUI, EAU 2026 weakly recommends offering cystoscopic surveillance from ten years after augmentation.[36] AUA/SUFU's Strong Recommendation against screening or surveillance cystoscopy applies to NLUTD, a different population.[37] Some surgical chapter authors recommend considering surveillance after ten years without citing an interval-comparison study.[28] The indication for surveillance is clearer after gastrocystoplasty.[2]
Long-Term Follow-Up
For NLUTD patients who have had reconstruction incorporating bowel, AUA/SUFU advises annual assessment :[27]
- Focused history, physical exam, and symptom assessment.
- Basic metabolic panel to monitor for acidosis and electrolyte disturbances.
- Urinary tract imaging (renal ultrasound for hydronephrosis and stones).
The statement text advises monitoring B₁₂ over time, with supplementation if appropriate, when terminal ileum is used.[27] Review catheterization and mucus-clearance practices at follow-up. In 75 patients with spina bifida, prior bladder stones, and abdominal-stoma catheterization (48 ileal and 27 colonic augments) who were stone-free three months after stone removal, random allocation to 240 mL daily saline washouts yielded fewer recurrent bladder stones and symptomatic UTI episodes over ten years than allocation to 60 or 120 mL.[31] Bone density assessment in at-risk patients and cystoscopy as clinically indicated are additional considerations.[17][18] AUA/SUFU recommends repeat urodynamics at an appropriate interval after treatment for NLUTD patients whose impaired storage or voiding places the upper tracts at risk .[27]
Alternatives
Other bowel segments (sigmoid, stomach) can be used for augmentation, each with distinct complication profiles. When regular catheterization cannot be arranged, evaluate an incontinent drainage or diversion option, including ileovesicostomy in selected patients with NLUTD; counsel about its high risk of further treatment or surgery.[27] Tissue-engineering approaches using biodegradable scaffolds seeded with urothelial and smooth muscle cells remain experimental.[1]
Videos
References
1. 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
2. Biers SM, Venn SN, Greenwell TJ. "The Past, Present and Future of Augmentation Cystoplasty." BJU International. 2012;109(9):1280-93. doi:10.1111/j.1464-410X.2011.10650.x
3. Barashi NS, Rodriguez MV, Packiam VT, Gundeti MS. "Bladder Reconstruction With Bowel: Robot-Assisted Laparoscopic Ileocystoplasty With Mitrofanoff Appendicovesicostomy in Pediatric Patients." Journal of Endourology. 2018;32(S1):S119-S126. doi:10.1089/end.2017.0720
4. Smith RB, van Cangh P, Skinner DG, Kaufman JJ, Goodwin WE. "Augmentation Enterocystoplasty: A Critical Review." The Journal of Urology. 1977;118(1 Pt 1):35-9. doi:10.1016/s0022-5347(17)57878-7
5. Elliott SP, Meng MV, Anwar HP, Stoller ML. "Complete Laparoscopic Ileal Cystoplasty." Urology. 2002;59(6):939-43. doi:10.1016/s0090-4295(02)01605-9
6. 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
7. Shekarriz B, Upadhyay J, Demirbilek S, Barthold JS, González R. "Surgical Complications of Bladder Augmentation: Comparison Between Various Enterocystoplasties in 133 Patients." Urology. 2000;55(1):123-8. doi:10.1016/s0090-4295(99)00443-4
8. el-Feel A, Abdel-Hakim MA, Abouel-Fettouh H, Abdel-Hakim AM. "Laparoscopic Augmentation Ileocystoplasty: Results and Outcome." European Urology. 2009;55(3):721-7. doi:10.1016/j.eururo.2008.03.102
9. Lorenzo AJ, Cerveira J, Farhat WA. "Pediatric Laparoscopic Ileal Cystoplasty: Complete Intracorporeal Surgical Technique." Urology. 2007;69(5):977-81. doi:10.1016/j.urology.2007.02.029
10. Chang JW, Kuo FC, Lin TC, et al. "Long-Term Complications and Outcomes of Augmentation Cystoplasty in Children With Neurogenic Bladder." Scientific Reports. 2024;14(1):4214. doi:10.1038/s41598-024-54431-z
11. Gurung PM, Attar KH, Abdul-Rahman A, et al. "Long-Term Outcomes of Augmentation Ileocystoplasty in Patients With Spinal Cord Injury: A Minimum of 10 Years of Follow-Up." BJU International. 2012;109(8):1236-42. doi:10.1111/j.1464-410X.2011.10509.x
12. Juhász ZS, Kispál Z, Kardos D, Vajda P. "Long-Term Urodynamic Findings Following Colo-, Gastro- And Ileocystoplasty." Pediatric Surgery International. 2024;40(1):131. doi:10.1007/s00383-024-05714-z
13. Gilbert SM, Hensle TW. "Metabolic Consequences and Long-Term Complications of Enterocystoplasty in Children: A Review." The Journal of Urology. 2005;173(4):1080-6. doi:10.1097/01.ju.0000155248.57049.4e
14. Szymanski KM, Misseri R, Whittam B, et al. "Additional Surgeries After Bladder Augmentation in Patients With Spina Bifida in the 21st Century." The Journal of Urology. 2020;203(6):1207-1213. doi:10.1097/JU.0000000000000751
15. Balanca A, Even A, Malot C, et al. "Long-Term Clinical and Urodynamic Effectiveness of Augmentation Ileocystoplasty With Supra-Trigonal Cystectomy in Individuals With Spinal Cord Injury." World Journal of Urology. 2022;40(8):2121-2127. doi:10.1007/s00345-022-04028-w
16. Taghavi K, O'Hagan LA, Bortagaray J, et al. "Complication Profile of Augmentation Cystoplasty in Contemporary Paediatric Urology: A 20-Year Review." ANZ Journal of Surgery. 2021;91(5):1005-1010. doi:10.1111/ans.16736
17. Pfitzenmaier J, Lotz J, Faldum A, et al. "Metabolic Evaluation of 94 Patients 5 to 16 Years After Ileocecal Pouch (Mainz Pouch 1) Continent Urinary Diversion." The Journal of Urology. 2003;170(5):1884-7. doi:10.1097/01.ju.0000091900.57347.ee
18. Cruz DN, Huot SJ. "Metabolic Complications of Urinary Diversions: An Overview." The American Journal of Medicine. 1997;102(5):477-84. doi:10.1016/S0002-9343(97)00020-X
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. 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
21. Ali-El-Dein B, El-Tabey N, Abdel-Latif M, Abdel-Rahim M, El-Bahnasawy MS. "Late Uro-Ileal Cancer After Incorporation of Ileum Into the Urinary Tract." The Journal of Urology. 2002;167(1):84-8. doi:10.1016/s0022-5347(05)65388-8
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. Garnier S, Vendrell J, Boillot B, et al. "Malignancy After Augmentation Enterocystoplasty: A Nationwide Study of Natural History, Prognosis and Oncogene Panel Analysis." The Journal of Urology. 2020;204(1):136-143. doi:10.1097/JU.0000000000000752
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
25. Stohr BA, Chan E, Anderson JA, et al. "Molecular Characterization of Adenocarcinomas Arising in the Urinary Bladder Following Augmentation Cystoplasty: A Multi-Institutional Study." Human Pathology. 2022;129:98-102. doi:10.1016/j.humpath.2022.09.003
26. Kälble T, Hofmann I, Riedmiller H, Vergho D. "Tumor Growth in Urinary Diversion: A Multicenter Analysis." European Urology. 2011;60(5):1081-6. doi:10.1016/j.eururo.2011.07.006
27. Ginsberg DA, Boone TB, Cameron AP, et al. "The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-Up." The Journal of Urology. 2021;206(5):1106-1113. doi:10.1097/JU.0000000000002239
28. Adams CM, Misseri R. Bladder Augmentation With Bowel. In: Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2025:432-435.
29. Barrington JW, Fern-Davies H, Adams RJ, Evans WD, Woodcock JP, Stephenson TP. "Bile acid dysfunction after clam enterocystoplasty." Br J Urol. 1995;76(2):169-171. doi:10.1111/j.1464-410x.1995.tb07667.x
30. Mitchell JE, Breuer RI, Zuckerman L, Berlin J, Schilli R, Dunn JK. "The colon influences ileal resection diarrhea." Dig Dis Sci. 1980;25(1):33-41. doi:10.1007/BF01312730
31. Husmann DA. "Long-term complications following bladder augmentations in patients with spina bifida: bladder calculi, perforation of the augmented bladder and upper tract deterioration." Transl Androl Urol. 2016;5(1):3-11. doi:10.3978/j.issn.2223-4683.2015.12.06
32. European Association of Urology. "EAU Guidelines on Neuro-urology." EAU Guidelines. 2026. Guideline
33. 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
34. Fontaine E, Leaver R, Woodhouse CRJ. "Diagnosis of perforated enterocystoplasty." J R Soc Med. 2003;96(8):393-394. doi:10.1177/014107680309600807
35. Çetinel B, Kocjancic E, Demirdağ Ç. "Augmentation cystoplasty in neurogenic bladder." Investig Clin Urol. 2016;57(5):316-323. doi:10.4111/icu.2016.57.5.316
36. European Association of Urology. "EAU Guidelines on Non-neurogenic Female LUTS." EAU Guidelines. 2026. Guideline
37. Ginsberg DA, Boone TB, Cameron AP, et al. "The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation." J Urol. 2021;206(5):1097-1105. doi:10.1097/JU.0000000000002235