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Sigmoid Cystoplasty (Sigmoidocystoplasty)

Sigmoid cystoplasty is a form of augmentation cystoplasty that uses a detubularized segment of sigmoid colon to enlarge the bladder. It is considered equally effective to ileocystoplasty in increasing capacity and compliance, with practical advantages including anatomic proximity to the bladder, a thick colonic wall facilitating ureteral reimplantation, and a lower rate of small-bowel obstruction (SBO).[1][2] Some centers advocate sigmoid as the preferred bowel segment for augmentation cystoplasty.[1]

Indications​

Same as for other forms of augmentation cystoplasty — refractory low-compliance or overactive bladder. Common underlying conditions: neurogenic bladder, exstrophy, posterior urethral valves, refractory IC/BPS.[1][3][4]

Sigmoid is particularly favored when:

  • Ureteral reimplantation is needed — thick sigmoid wall provides an excellent submucosal tunnel.[3][5]
  • Concurrent constipation is present — sigmoid resection may improve bowel function.[4]
  • Minimizing SBO risk is desired (avoids small-bowel manipulation).[1]
  • A Mitrofanoff channel is planned — the sigmoid "tail" modification can stabilize the catheterizable stoma.[5]

Surgical Technique (Goodwin cup-patch)​

  1. Segment isolation: ~15–25 cm of sigmoid on its mesentery, preserving the marginal artery.
  2. Bowel continuity restoration: end-to-end or side-to-side colocolonic anastomosis.
  3. Detubularization: opened along the antimesenteric border. Critical — tubular sigmoid retains coordinated peristalsis in 94%, vs only 12% with the detubularized cup-patch.[6][2]
  4. Reconfiguration: folded into a U-shaped or cup-patch configuration (Laplace's law).
  5. Cystotomy: native bladder bivalved.
  6. Anastomosis: sigmoid patch sutured to the opened bladder watertight.[6][7]

Sigmoid "tail" modification: A 3–5 cm segment of non-detubularized colon is left intact and fixed to the posterior abdominal wall to stabilize a catheterizable stoma (appendix or tapered ileum).[5]

Concomitant procedures often performed: ureteral reimplantation (36–92% of patients), bladder-neck procedures for continence, and continent catheterizable channel.[1][3][5][9][10]

Outcomes​

ParameterPre-opPost-op
Bladder capacity114–161 mL373–469 mL
Bladder compliance2.96 mL/cmH₂O14.07 mL/cmH₂O
Maximum detrusor pressure31 cmH₂O10.9 cmH₂O
Continence23%82–95%
Renal function (CrCl normal)—93% (80/86 pts)

References: [1][2][3][4][9]

In the largest long-term series (Hayashi 2006, n=86, mean follow-up 13.1 yr), CrCl was normal in 93% and continence improved in 71%; bladder stones occurred in 21% but were absent at final review.[9] Zhang 2014 (n=52, mean 49 mo) reported significant improvements in capacity, compliance, and renal function with 100% patient satisfaction; all patients reported improvement in constipation; no obvious metabolic acidosis or perforation.[4]

Sigmoid vs. Ileum​

FeatureSigmoidIleum
Small-bowel obstructionLower (avoids SB manipulation)Higher
Anatomic proximity to bladderCloserRequires mobilization
Ureteral reimplantationThick wall — reliable submucosal tunnelThinner wall
Ileocecal valvePreservedPreserved
ConstipationMay improve with sigmoid resectionNo effect
Pathologic contractions (long-term)43%26%
Mucus productionModerateModerate–high

The key disadvantage: a higher rate of persistent pathologic contractions — 43% with colocystoplasty vs 26% with ileocystoplasty in a long-term urodynamic study of 84 patients. From a pure-urodynamic standpoint, ileum remains the most favorable segment.[11]

Complications​

  • Persistent peristaltic contractions — the most important complication unique to sigmoid: 94–100% with native tubular configuration; reduced to 12% (cup-patch) to 43% (detubularized patch), but still higher than ileum (26%). Anticholinergics needed in ~11.5%.[2][4][6][11]
  • Urinary tract stones: ~21% (18/86) in the largest long-term series; risk factors include continent stomas and exstrophy.[1][9]
  • Recurrent febrile UTIs: ~21%.[4]
  • Bowel dysfunction: ~10.6%; sigmoid resection may paradoxically improve constipation in neurogenic bowel.[3][4]
  • Adhesive intestinal obstruction: ~8.5%; overall SBO rate trends lower than with ileocystoplasty.[1][3]
  • Bladder perforation: comparable to ileocystoplasty; highest risk in neurogenic bladder.[1]
  • Vesicoureteral reflux: with reimplantation, low-grade reflux recurrence (I–II) in ~8.6% of renal units; without reimplantation, de novo low-grade reflux in ~4.5%.[9]
  • Deteriorating renal function: 5.2–6.4%.[3][10]

Metabolic Disturbances​

  • Animal-model data: no metabolic advantage of ileum over colon — both cause comparable acidosis.[13]
  • Pediatric series: significant hyperchloremic acidosis in 10%, borderline acidosis in 27% after sigmoidocystoplasty.[14]
  • Calcium / phosphorus abnormalities in 16.5% / 43%, more frequent in acidotic patients — likely reflecting bony buffer activation; may delay growth in children.[14]
  • Clinically significant acidosis primarily in patients with pre-existing renal insufficiency.[2]
  • Zhang 2014 reported no obvious metabolic acidosis at mean 49 mo.[4]

Manage with oral alkali (sodium bicarbonate or potassium citrate) and regular CIC to minimize urine contact time.

Histopathology and Malignancy Risk​

Long-term histopathology of sigmoidocystoplasty:[9][15]

  • Inflammation in all cases at >10-yr follow-up.
  • Hyperplasia ~10%; metaplasia ~5%.
  • No dysplasia or malignancy identified in the largest series (n=86, mean 13.1 yr; and 100 SCP patients).
  • PCNA staining was significantly more intense in patients who stopped regular bladder irrigations and in those with bladder stones, suggesting these factors may promote mucosal proliferation.

Overall malignancy risk after augmentation:[16][17][18]

  • Urothelial cell carcinoma is the most common histologic type after colocystoplasty (vs adenocarcinoma after gastrocystoplasty).
  • Cystoplasty tumor risk (1.58%) is significantly higher than ileal neobladder (0.05%) or ileal conduit (0.02%); orthotopic ileo-colonic neobladder ~1.29%.
  • Mean latency ~19–20 yr; tumors frequently advanced at diagnosis with poor prognosis (1-yr survival ~56%).
  • Endoscopic surveillance recommended beginning ≥ 5 yr postoperatively.[17][19]

Seromuscular Colocystoplasty Lined With Urothelium (SCLU)​

A notable variant designed to avoid incorporating intestinal mucosa into the urinary tract:[20][21]

  1. A de-epithelialized (mucosa-stripped) sigmoid seromuscular patch is prepared, preserving the submucosa (critical to prevent patch contraction and fibrosis).[21]
  2. Native bladder urothelium is exposed by detrusorectomy at the dome.
  3. The seromuscular patch is placed over the exposed urothelium, which then lines the augmented segment.

SCLU outcomes[22][23][24]​

  • Capacity ↑ 1.8–2.96-fold.
  • No bladder perforations, bowel obstructions, or metabolic abnormalities reported.
  • Mucus production not clinically significant.
  • Continence achieved in 71–81% after initial/secondary procedures.
  • Hourglass deformity in 22%; augmentation failure in 12.5%.
  • Biopsy shows colonic mucosal regrowth in some patients (5/7 interpretable biopsies in one series).
  • Not recommended when a continent catheterizable channel is constructed simultaneously (3/5 required re-augmentation).[24]
  • Best results when combined with an AUS and when no concomitant bladder procedure is performed.

Long-Term Follow-Up​

Per the AUA/SUFU NLUTD guideline, annual lifelong surveillance:[25]

  • Focused history, exam, symptoms.
  • Basic metabolic panel (electrolytes, bicarbonate, renal function).
  • Renal ultrasound for hydronephrosis and stones.
  • Regular bladder irrigations to reduce mucus accumulation and stone formation.[15]
  • Cystoscopy as clinically indicated; routine endoscopic evaluation considered ≥ 5 yr postoperatively.[17][19]
  • Monitoring for calcium / phosphorus abnormalities and bone health, particularly in children.[14]

Sigmoid vs. Ileum — When to Choose Sigmoid​

Sigmoid cystoplasty is particularly well suited when:[1][4][5][6]

  • Ureteral reimplantation is needed (thick wall for submucosal tunnel).
  • The patient has concurrent constipation.
  • Minimizing SBO risk is a priority.
  • The ileocecal valve and terminal ileum should be preserved (B₁₂ or bile-salt malabsorption risk).
  • SCLU is planned (sigmoid is the standard segment for this technique).

Primary disadvantage: higher rate of pathologic contractions vs ileum — making detubularization and cup-patch reconfiguration essential.[6][11]

References​

1. 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

2. 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

3. Zhang F, Liao L. "Sigmoidocolocystoplasty With Ureteral Reimplantation for Treatment of Neurogenic Bladder." Urology. 2012;80(2):440-5. doi:10.1016/j.urology.2012.05.010

4. Zhang P, Yang Y, Wu ZJ, et al. "Long-Term Follow-Up of Sigmoid Bladder Augmentation for Low-Compliance Neurogenic Bladder." Urology. 2014;84(3):697-701. doi:10.1016/j.urology.2014.05.025

5. Mathews R, Docimo S, Gearhart JP. "Sigmoid 'Tail' Modification for Bladder Augmentation." Urology. 1997;49(4):609-11. doi:10.1016/s0090-4295(97)00006-x

6. 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

7. Reddy PK, Lange PH, Fraley EE. "Total Bladder Replacement Using Detubularized Sigmoid Colon: Technique and Results." The Journal of Urology. 1991;145(1):51-5. doi:10.1016/s0022-5347(17)38245-9

9. Hayashi Y, Yamataka A, Kaneyama K, et al. "Review of 86 Patients With Myelodysplasia and Neurogenic Bladder Who Underwent Sigmoidocolocystoplasty and Were Followed More Than 10 Years." The Journal of Urology. 2006;176(4 Pt 2):1806-9. doi:10.1016/j.juro.2006.03.123

10. Wang Z, Liao L. "Effectiveness and Complications of Augmentation Cystoplasty With or Without Nonrefluxing Ureteral Reimplantation in Patients With Bladder Dysfunction: A Single Center 11-Year Experience." The Journal of Urology. 2018;199(1):200-205. doi:10.1016/j.juro.2017.07.073

11. 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. Mohler JL. "Metabolic Acidosis After Bladder Replacement: Comparison of Severity and Reversibility in Ileal and Colonic Reservoirs." The Journal of Urology. 1988;139(3):628-33. doi:10.1016/s0022-5347(17)42547-x

14. Beseghi U, Guys JM, Dibenedetto V, et al. "Metabolic Consequences of Sigmoidocystoplasty in Children." Pediatric Surgery International. 1996;11(2-3):150-2. doi:10.1007/BF00183750

15. Miyano T, Yamataka A, Iwashita K, et al. "Histology of the Neobladder Mucosa After Sigmoidocolocystoplasty." Journal of Pediatric Surgery. 2000;35(1):104-8. doi:10.1016/s0022-3468(00)80024-x

16. 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

17. 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

18. 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

19. Austen M, Kälble T. "Secondary Malignancies in Different Forms of Urinary Diversion Using Isolated Gut." The Journal of Urology. 2004;172(3):831-8. doi:10.1097/01.ju.0000134890.07434.8e

20. Gonzalez R, Buson H, Reid C, Reinberg Y. "Seromuscular Colocystoplasty Lined With Urothelium: Experience With 16 Patients." Urology. 1995;45(1):124-9. doi:10.1016/s0090-4295(95)97364-8

21. Buson H, Manivel JC, Dayanç M, Long R, Gonzalez R. "Seromuscular Colocystoplasty Lined With Urothelium: Experimental Study." Urology. 1994;44(5):743-8. doi:10.1016/s0090-4295(94)80220-3

22. Jung HJ, Lee H, Im YJ, et al. "Prerequisite for Successful Surgical Outcome in Urothelium Lined Seromuscular Colocystoplasty." The Journal of Urology. 2012;187(4):1416-21. doi:10.1016/j.juro.2011.12.009

23. Jednak R, Schimke CM, Barroso U Jr, Barthold JS, González R. "Further Experience With Seromuscular Colocystoplasty Lined With Urothelium." The Journal of Urology. 2000;164(6):2045-9.

24. González R, Ludwikowski B, Horst M. "Determinants of Success and Failure of Seromuscular Colocystoplasty Lined With Urothelium." The Journal of Urology. 2009;182(4 Suppl):1781-4. doi:10.1016/j.juro.2009.02.062

25. 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