










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

SIUJ.ORG SIUJ  •  Volume 4, Number 3  •  May 2023

Key Words Competing Interests Article Information

Clavien-Dindo classification system, 
augmentation cystoplasty, ileocystoplasty

None declared. Received on August 24, 2022 
Accepted on October 16, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2022;4(3):195–202

DOI: 10.48083/HCFX2060

195

ORIGINAL RESEARCH

Augmentation Cystoplasty:  
Experience in the Developing World

Naveed Ahmed Mahar,1 Mohsin Mustafa Memon,1 Farag Mohsen Saleh AboAli,1 Shireen Piyarali,1 
Harris Hassan Qureshi,1 Sara Rasheed Kalwar,1 Murli lal1

1 Department of Urology, Sindh Institute of Urology and Transplantation, Pakistan

Abstract

Objective To assess functional outcomes and classify postoperative complications of augmentation cystoplasty by 
the Clavien-Dindo classification system.

Methods A total of 197 adult patients undergoing augmentation cystoplasty between January 2016 and December 
2020 at the Department of Urology, Sindh Institute of Urology and Transplantation (SIUT), were included in the 
study after obtaining approval from the ethics review committee. Patients’ records were reviewed for assessment of 
complications up to 3 months of follow-up. Functional outcomes were assessed by comparing preoperative video 
urodynamics study (VUDS) findings with follow-up VUDS findings at 1 year. IBM SPSS v23 was used to record and 
analyze all the complications, treatments, and pre- and postoperative VUDS data.

Results Of the 197 patients included in this study, 127 (64.5%) were male and 70 (35.5%) were female. The mean age 
of the patients was 38.4 ± 9.92 years. Eighty-seven patients (44.2%) remained complication-free, 64 patients (32.5%) had 
grade I-II complications, 44 patients (22.3%) had grade III and IV complications, and only 2 patients (1%) had grade V 
complications. Stomal stenosis was the most frequent complication, occurring in 14.7% of patients, followed by renal 
function deterioration and high-grade fever, each noted in 13.7% of patients. Mean preoperative bladder capacity was 
144.3 ± 63.09 mL, mean preoperative filling pressure was 43.34 ± 26.92 cm3 H2O, while mean postoperative bladder 
capacity was 460.83 ± 70.69 mL and mean postoperative filling pressure was 7.47 ± 5.79 cm3 H2O.

Conclusion Augmentation cystoplasty can increase bladder capacity and improve bladder function. Because of the 
potential for complications, it is essential to carefully choose patients for surgery and provide proper preoperative 
counseling. Additionally, it is crucial to give proactive postoperative care.

Introduction

The bladder, aided by pelvic floor muscles, the external urethral sphincter, and the bladder neck, plays a crucial role in 
continence and releasing urine through the urethra[1,2]. On average, the bladder holds 400 mL of urine[3,4].

The best course of treatment for bladder dysfunction depends on the degree of discomfort and the risk for upper 
tract injury. The most common treatment for incomplete bladder emptying is intermittent self-catheterization, while 
antimuscarinic medications are used to treat storage dysfunction. Neuromodulation and intradetrusor injections of 
botulinum toxin are 2 intriguing alternatives[5].

Augmentation cystoplasty (AC) is a complex and uncommon urological procedure used to treat refractory bladder 
dysfunction. The goal of AC is to provide adequate urine storage and continence, to prevent upper tract injury from 

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high pressure, and to improve bladder compliance in 
patients with low-capacity, high-pressure, or poorly 
compliant bladder[6].

Tizzoni and von Mikulicz were the first to describe 
augmentation cystoplasty in dogs and humans, respec-
tively[7,8]. But the procedure wasn’t used very often until 
the 1950s, when Couvelaire popularized its use for treat-
ment of the tiny, contracted bladder from genitourinary 
tuberculous (TB)[9].

Patients undergoing AC may encounter one or more 
complications, like with any other surgical procedure. 
Fever, pain, sepsis, wound infection, anastomotic leak, 
and a decline in electrolytes and renal function are some 
of the short-term complications linked to AC. Stomal 
stenosis, the necessity for further surgery, metabolic 
consequences, stone formation, declining renal func-
tion, and recurring infections are examples of long-term 
consequences. The majority of these complications are 
attributed to the complexity of surgery and the absorp-
tive nature of the bowel mucosa[10,11].

Outcomes are measured using 2 main parameters: 
complication rate and improvement in overall func-
tional capacity and compliance with follow-up video 
urodynamic study (VUDS).

Benefits and complications associated with augmen-
tation cystoplasty are well documented, but data from 
our region is scarce. A systematic method was previously 
lacking for evaluating morbidity and mortality in the 
immediate postoperative period. The Clavien-Dindo 
classification system is now used around the world as a 
standard tool to classify and calculate the rates of 
complications after surgery[12].

In this study, we examine early (within 3 months) 
postoperative complications using the Clavien-Dindo 
classification system and functional outcomes in terms 
of improvement in VUDS after ileocystoplasty with or 
without a catheterizable channel.

Methods
This obser vationa l study was conducted at t he 
Department of Urology, Sindh Institute of Urology and 
Transplantation (SIUT), following permission of the 
institutional ethics review committee (ERC reference 
number: SIUT-ERC-2021/A-344). The medical records 

Abbreviations 
AC augmentation cystoplasty
CIC clean intermittent catheterization
CISC clean intermittent self-catheterization
VUDS video urodynamics study

of all 197 adult patients undergoing augmentation 
cystoplasty between January 2016 and December 2020 
were evaluated. In contrast to the 181 (91.9%) patients 
who received concurrent Mitrofanoff procedure, only 16 
(8.1%) patients (who did not consent to Mitrofanoff and 
agreed to clean intermittent self-catheterization [CISC] 
per urethra) underwent augmentation cystoplasty 
alone. Before surgery, extensive preoperative diagnostic 
workup was carried out. Initial workup included 
detailed history, physical examination, bladder diary, 
ultrasound kidney ureter and bladder pre- and post-
void, blood urea and nitrogen, uroflowmetry (UFM), 
and voiding cystourethrogram (VCUG). Acid fast 
bacillus urine smear and GeneXpert were performed 
in patients suspected of having genitourinary (GU) 
tuberculosis (TB). VUDS was performed in all patients 
with bladder dysfunction, except for thimble bladder 
on VCUG or genitourinary fistulae. Augmentation 
cystoplasty was performed in patients with refractory 
bladder dysfunction who had either small capacity, high 
pressure (posing risk for upper tract), and/or reduced 
compliance on VUDS. Patients with GU tuberculosis 
and extremely small capacity (thimble bladder) were also 
subjected to augmentation cystoplasty after completion 
of anti-tuberculosis treatment. Patients with deranged 
renal function were first kept on continuous drainage 
with either suprapubic catheterization or urethral 
drainage. If renal function improved to within normal 
range, then augmentation cystoplasty was performed 
straightaway. A ll those patients with refractor y 
bladder dysfunction in whom renal function did not 
improve below 2.5 mg/dL on continuous drainage 
were counseled to increase awareness of potential 
postoperative risk for rapid renal function deterioration 
and renal insufficiency subsequently requiring renal 
replacement therapy or transplant. Patients who did not 
wish for future renal transplant and serum creatinine 
was more than 2.5 mg/dL were kept on conservative 
therapy with anticholinergics and CISC every 2 to 3 
hours or suprapubic catheterization. A multidisciplinary 
approach was adopted involv ing a neurologist, 
psychologist, and nephrologist (where required). Each 
patient received thorough counseling regarding the 
entire procedure with the help of audiovisuals. Patients 
were admitted the day before surgery, and a prophylaxis 
regimen of broad-spectrum antibiotics was started at 
admission. No patient received vigorous preoperative 
bowel preparation. Patients were advised to consume 
clear liquids for 24 hours with overnight fasting prior to 
surgery. All patients underwent ileocystoplasty. An ileal 
segment of 25 to 60 cm depending upon the preoperative 
bladder capacity assessed by cystometry and video 
urodynamics was harvested with intact blood supply 20 
cm proximal to the ileocecal junction (Figure 1). The ileal 
segment was then detubularized over the anti-mesenteric 
border to create an ileal plate (Figure 2). The plate was 

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then configured into either a “U” or “W” configuration 
to anastomose with the already opened (bivalve) bladder 
with polydioxanone suture 3/0 (Figures 3 and 4). For the 
Mitrofanoff procedure, we utilized the patient’s appendix 
(appendicovesicostomy) (Figure 5). The Monti procedure 
(Figure 6) was performed if the appendix was not healthy, 
short in length, or had a narrow lumen preventing the 
14-French catheter to be negotiated. All Mitrofanoff 
procedures were done by creating a submucosal tunnel 

FIGURE 1. 

Selected part of the ileum being harvested along with 
the mesentery

FIGURE 2. 

Ileal plate after detubularization

into the bladder wall (Figure  7) according to Paquin’s 
law and exteriorized at McBurney’s point by VQZ plasty 
(Figure 8). Following surgery, each patient remained in 
hospital for at least 5 days. The drain was removed on the 
third postoperative day (POD) once the drain output was 
down to 0 to 50 mL per 24 hours. The patient was followed 

FIGURE 3. 

“U” configuration of the ileal plate

FIGURE 4. 

Anastomosis of the ileal plate with the bivalved  
urinary bladder

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up for 3 months with regular physical examination, 
serum electrolytes, serum creatinine, and urine analysis 
where indicated. On the 7th POD, the Foley catheter was 
removed and on the 14th POD, the Mitrofanoff tube was 
removed, and the patient was trained for CISC. On day 
21, the suprapubic catheter was removed after clamping 
for a few days until the patient was fully trained for CISC, 

FIGURE 5. 

Healthy appendix with good length and adequate blood 
supply for appendicovesicostomy 

FIGURE 8. 

VQZ plasty final result 

FIGURE 7. 

Appendicovesicostomy by creating a submucosal 
tunnel in the bladder wall

FIGURE 6. 

The Monti procedure. (A) Both ileal plates are 
anastomosed at the short limb to form a long plate;  
(B) the ileal plate is tabularized over a 16-French 
catheter to form a tube for the Mitrofanoff procedure

A

B

which was performed every 3 hours in daytime with 
nighttime continuous drainage for next 3 months. After 
3 months, the patient then followed every 6 months with 
advice to perform regular CIC every 3 to 4 hours and a 
bladder wash once a week. Repeat follow-up VUDS 
of each patient was performed at 1 year to compare 
functional outcomes. A predesigned proforma was used 

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to record patient information such as age, sex, diagnosis, 
preoperative VUDS findings, procedure performed, 
and postoperative VUDS findings. The number and 
frequency of complications encountered within the 
first 3 months as well as the treatment provided were 
recorded in the proforma. For data analysis, IBM SPSS 
v23.0 was used. For categorical variables, frequencies 
were computed, but for continuous variables, the mean 
and standard deviation were calculated. The chi-square 
test was used to stratify effects modifiers. P-values below 
0.05 were considered significant.

Results
Of the 197 patients included in this study, 127 (64.5%) 
were male and 70 (35.5%) were female. The mean age 
of the patients was 38.4 ± 9.92 years (Table 1). Of the 
197 patients, 128 (65%) had a diagnosis of neurogenic 
bladder, mostly secondary to spinal pathology. In 
45 patients (22.8%), the definitive cause of bladder 
dysfunction could not be established (Table 2). A 
total of 181 patients (91.9%)underwent Mitrofanoff 
formation along with ileocystoplasty, and 16 (8.1%) had 
ileocystoplasty alone. No patient with augmentation 
cystoplasty without Mitrofanoff experienced bladder 
rupture.

Of the 197 patients, 87 (44.2%) remained complica-
tion-free; the majority, 64 (32.5%), had complications of 

grade I-II requiring observation and pharmacological 
management. Grade III complications were observed 
in 38 (19.3%) patients requiring intervention, 24 (12.2%) 
without general anesthesia and 14 (7.1%) under general 
anesthesia. Of the 8 patients who suffered more severe 
complications, 6 (3%) had grade IV complications, and  
2 (1%) had grade V complications and succumbed to 
death due to multiorgan failure secondary to sepsis and 
peritonitis (Tables 3 and 4).

Stomal stenosis (14.7%) was the most frequent compli-
cation, followed by renal function deterioration 

and high-grade fever (13.7% each) (Table 4). Most of 
the decline in renal function was seen in patients who 
had a low glomerular filtration rate before surgery.

Preoperative VUDS was performed in 196 patients 
and 1 patient had genitourinary fistulae and urodynamic 
study was not possible. Mean preoperative bladder 
capacity was 144.3 ± 63.09 mL and mean preoperative 
filling pressure was 43.34 ± 26.92 cm3 H2O, while mean 
postoperative bladder capacity was 460.83 ± 70.69 mL 
with mean postoperative filling pressure of 7.47 ± 5.79 
cm3 H2O (Table 1). Of the 197 patients, 185 (94.4%) 
patients had reduced compliance preoperatively, while 
11 (5.6%) patients had normal compliance. Postopera-
tively, normal compliance was observed in 195 (99%) 
patients.

TABLE 1. 

Descriptive statistics of age, preoperative and postoperative creatinine (mg/dL), and pre- and  
postoperative VUDS findings 

n Minimum Maximum Mean SD

Age 197 18 60 38.40 9.927

Preoperative serum creatinine 197 0.30 6.00 1.4620 0.73751

Postoperative serum creatinine 197 0.10 7.00 1.3930 0.93390

Preoperative filling pressure 196 6 185 43.51 26.883

Preoperative capacity 196 25 400 144.44 63.231

Preoperative Pdet at Qmax 196 0 100 20.74 18.057

Preoperative flow rate 196 0 23 5.50 4.303

Postoperative filling pressure 197 0 54 7.47 5.795

Postoperative capacity 197 283 690 460.83 70.609

Postoperative Pdet at Qmax 197 0 61 7.07 6.745

Postoperative flow rate 197 0 19 3.17 3.028

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Complication rate stratified by age and sex yielded 
no statistically significant association (P  =  1.00 and 
P = 0.393, respectively).

Discussion
Augmentation cystoplasty is a surgical procedure 
intended to increase bladder capacity and retention of 
larger volumes of urine without a significant increase in 
intravesical pressure or urinary leakage[13]. The goal of 
these procedures is to improve the patient’s long-term 
health and quality of life. Before the advent of clean 
intermittent catheterization (CIC), which subsequently 
decreased morbidit y, especia lly when used with 
anticholinergic drugs, quality of life was low.

Due to lack of detrusor contractility, augmented 
bladders cannot empty on their own, hence nearly 
every patient needs CIC through a newly formed Mitro-
fanoff or the urethra. It is crucial to conduct a multi-
disciplinary preoperative examination to ascertain the 
patient’s motivation and capability for clean intermittent 
self-catheterization, as doing so helps to avoid serious 
problems, especially in the early postoperative period. 
The majority of patients are hesitant to perform CIC 
through the urethra, so with AC they also need a Mitro-
fanoff procedure[14].

Following surgery, most patients need basic care. 
Third space loss emphasizes the significance of f luid 
electrolyte control. Between 10 mL and 30 mL of saline 
is used to irrigate the bladder a minimum of 3 times 
daily in order to flush out mucus and maintain tube 

TABLE 3. 

Frequency of complications based on the Clavien-Dindo 
classification 

Complication grade Frequency, n Percentage

None 87 44.2

Grade I 42 21.3

Grade II 22 11.2

Grade IIIa 24 12.2

Grade IIIb 14 7.1

Grade Iva 4 2.0

Grade IVb 2 1.0

Grade V 2 1.0

Total 197 100.0

TABLE 4. 

Frequency of postoperative complications 

Complication Frequency, n  Percentage 

Fever 27 13.7

Urinary leak/Bladder perforation 7 3.6

Bowel anastomotic leak 1 0.5

Ileus 16 8.1

Drain dislodgement 2 1.0

Sepsis 9 4.6

Intra-abdominal bleeding 1 0.5

Wound site bleeding 0 0

Deterioration of renal functions 27 13.7

Electrolyte imbalance 13 6.6

Dislodgement of splints/catheters 9 4.6

Surgical site infection (SSI) 21 10.7

Wound dehiscence 3 1.5

Urinary tract infection 25 12.7

Stomal stenosis 29 14.7

Incisional hernia 2 1.0

Per urethral incontinence 4 2.0

Stomal incontinence 2 1.0

Death 2 1.0

patency. After 2 to 3 weeks, if no extravasation is seen on 
a cystogram, the Foley catheter can be removed. Until 
the patient is comfortable with the technique of CIC, the 
suprapubic tube remains in place. Particularly in the first 
few months, daily irrigation to remove mucus is crucial. 
Studies of electrolytes, creatinine, and blood urea and 
nitrogen should be conducted at regular intervals[15].

The incidence of postoperative complications is 
used as a measure of surgical quality, but there is no 
consensus on what constitutes a complication and how 
severe it is, making it difficult to compare outcomes[16]. 
The majority of reports have evaluated postoperative 
complications using a non-standardized system and 
have not accounted for the severity of complications. 

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There have been uses of terms like “minor,” “moder-
ate,” and “severe,” but they are arbitrary, unreliable, and 
frequently defined differently by each author[17].

The Clavien-Dindo classification (CDC) is a stan-
dardized system for the registration of surgical compli-
cations that has received international validation and 
acceptance. The CDC system’s key feature is that the 
degree of a complication’s severity is determined by the 
kind of therapy needed to manage the complication[18].

In some studies, the number of complications after 
augmentation enterocystoplasty was as high as 20% to 
22%, and the number of deaths was between 0% and 
3.2%[19]. The complication rate in our study was 35%, 
with the majority of complications being self-limiting 
and requiring no to minimal intervention. More severe 
complications were observed in patients who had low 
glomerular filtration rate before surgery.

The most common early effects[19,20] are prolonged 
postoperative ileus, temporary urinary fistula (0.4% 
to 4%), wound infection (5% to 6.4%), bleeding that 
requires further intervention (0% to 3%), and throm-
bo-embolic problems (1% to 3%).

In our study, stomal stenosis (14.7%) requiring endo-
scopic dilatation or surgical revision remained the most 
frequently observed complications, followed by fever 
(13.7%) and a rise in serum creatinine (13.7%). Dete-
rioration of renal function and electrolyte imbalance 
were usually transient and managed pharmacologically.  
A few patients required hemodialysis.

In a study conducted at SIUT, the infection at the 
surgical site was reported as the most frequent complica-
tion of a catheterizable channel[14].

Patients with neurogenic bladder are more likely to 
experience perforation, and it is generally believed that 
the perforation location is at the anastomotic suture line 
between the bowel segment and native bladder[21,22].

In a study in 2016, investigators retrospectively eval-
uated postoperative complications according to the 
Clavien-Dindo classification and found wound infec-
tion in 42% of patients, wound dehiscence in 28%, and 
urinary leakage in 14%. All were grade I-III according 
to Clavien-Dindo classification. No major grade IV or V 
complications were observed[23].

In another study, the mortality rate from AC was 
reported to be 0% to 3.2%[24]. The mortality rate in our 
study was 1% (2 patients).

The main limitations of our study are lack of knowl-
edge about the patient’s quality of life after augmentation 
cystoplasty and the long-term risk for complications. 
This study opens the door for more research into these 
areas in the future.

Conclusion
Augmentation cystoplasty has proved to be quite 
versat i le for i ncrea si ng bladder c apacit y a nd 
enhancing bladder function in patients. Unfortunately, 
augmentation enterocystoplasty is associated with 
various complications. Hence, selecting patients for 
the procedure and providing them with adequate 
preoperative counseling are crucial, as is provisioning of 
proactive postoperative care following surgery.

Acknowledgements
The authors thank Dr Syed Arslan Shah and Dr 
Muhammad Nasurullah for help with data acquisition.

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