What is bladder augmentation?

Bladder augmentation is for children with bladders that are too small or have pressure that's too high to store urine normally, causing incontinence. This can result from several different conditions, including spina bifida, bladder obstruction and an inside-out bladder, or exstrophy. The surgery increases bladder size and capacity and lowers pressure within the bladder.

There are two types of bladder augmentation. In ileal augmentation, a segment of the child's intestine is removed and attached to the bladder to make the bladder larger. In gastric augmentation, also known as a gastrocystoplasty, a segment of the child's stomach is removed and attached to the bladder.

There are many factors considered in the decision whether to use a segment of the stomach or intestine. Your surgeon or nurse practitioner will discuss his or her recommendation with you before the operation. However, even if your surgeon would prefer to do a gastric augmentation, he or she may realize during the procedure that this isn't the best option and part of the intestine will be used instead. For this reason, the intestine is always cleared out before the surgery.

Are any artificial parts added to the bladder?

No. The surgeon will use a segment of your child's own intestine or stomach to augment the bladder.

What should we expect before the surgery?

Your child will be admitted the day before the scheduled surgery. He or she will be limited to clear, liquid foods such as Jell-o, Popsicles, apple juice and soup broth. Your child will be given a medicine called GoLYTELY, which causes many bowel movements, as well as antibiotics given intravenously and by mouth. The IV will also be used to give your child fluids to prevent dehydration.

How long does the surgery take?

It varies, but the surgery generally takes anywhere from four to eight hours. If your child's surgery is a bit shorter or longer, don't be alarmed. The operating room nurse, who you'll the meet the day of surgery, will give you periodic updates on the status of the surgery.

Where is the incision?

The incision will be on the abdomen, in most cases down the middle. The length of the incision will depend on your child's particular case.

What tubes are left in place after the surgery?

Bladder catheters, made of a special, soft plastic, are left in to ensure that urine drains well while your child is healing. Another catheter, called the suprapubic catheter, is inserted in the lower abdomen. The suprapubic catheter will be left in place for about three weeks. Some children will have a catheter in the belly button or through another surgical opening. If so, it will be removed at the same time as the suprapubic tube.

It's normal to see reddening of the skin and a small amount of reddish-brown drainage and pus-like secretions around the catheter site. This is a natural reaction and nothing to be alarmed about. Before you take your child home, we will provide instructions for taking care of the tubes and catheters.

What should we expect after the operation?

Many children will be given a caudal or epidural nerve block at the end of the procedure to minimize pain after surgery. The catheter for the epidural usually remains in place for about two days.

While in the hospital, your child will receive medication as needed for pain. Younger children will be given pain medication — usually morphine — intravenously before the nerve block wears off. Most older children, and those with any spinal anomalies, may receive patient controlled analgesia, or PCA pumps, which allow the patient to self-administer pain medication through the IV. You can discuss the best form of pain control for your child with the anesthesiologist, who you'll meet the day of the surgery.

For several days after the surgery, your child will have a tube in his or her nose called a nasogastric or NG tube that will drain secretions from the stomach. The NG tube is necessary because after the surgery, the bowels temporarily "go to sleep" and don't function normally. Without the NG tube, your child would suffer nausea and vomiting. This tube allows the bowels and stomach to recuperate and heal properly.

During this period, your child can't eat food but will receive IV fluids to prevent dehydration. Once the NG tube is removed and the bowels start to work, your child will consume a liquid diet. If that's tolerated, your child can resume a regular diet.

Children who've had a gastric augmentation should be given smaller-portioned meals for three to four weeks following surgery, until the stomach has stretched to its new size.

Children are usually discharged from the hospital and sent home on the sixth or seventh day after surgery.

Will my child have bladder spasms after surgery?

It's common after surgery of this type for children to experience bladder spasms and perhaps even episodes of urinary incontinence, losing small amounts of blood-tinged urine or urine with mucus. If the symptoms become a problem, a medication called Ditropan (oxybutynin) may be prescribed. Ditropan won't eliminate all of the spasms but should decrease the discomfort. Placing a damp, warm washcloth on the perineum — the skin between the anus and the genitals — may also make your child more comfortable.

Your child may want to wear light mini-pads in his or her underwear until this problem resolves. In some children the spasms and bloody urine may continue for two to three weeks. After the catheters are removed, your child should no longer need Ditropan.

Are there any problems I should watch for after the surgery?

Please contact Pediatric Urology at (415) 353-2200 if you're concerned about your child's progress after surgery or if your child shows any of the following symptoms:

  • Continuous vomiting
  • Excessive bleeding from the incision (some spotting or blood stains on the dressing is normal)
  • Inability to tolerate liquids
  • Temperature greater than 101° F

Contact Pediatric Urology if you're unable to catheterize your child, if the catheters aren't draining or if you can't irrigate them.

Will my child's medications cause side effects?

Ditropan (oxybutynin) may cause:

  • Decreased appetite
  • Dry mouth
  • Flushed cheeks
  • Skin that feels warm — this doesn't mean the child has a fever

After surgery, poor appetite isn't a concern; many children aren't interested in food after surgery. However, we ask that you offer your child fluids frequently to maintain an adequate urine output. Your child doesn't have to drink a large amount at a time — just a few sips every 15 minutes or so. You can be creative with the liquids, and may offer Popsicles, Jell-o and soup, if your child enjoys them. Smoothies are a terrific source of vitamins and are usually well tolerated. Getting your child to consume enough liquids may require patience and persistence on your part.

Morphine, Droperidol or Demerol are among the pain medications your child may receive while in the hospital. These medications may make your child drowsy. Some children become overexcited, nervous or develop a rash; if this happens, simply inform your child's nurse, and the medication will be changed to something your child better tolerates.

Before your child is discharged, he or she will be switched to an oral pain reliever, usually Tylenol with codeine, or Tyco. Tyco requires a prescription and comes in both tablet and liquid form. The codeine can make some children constipated, so it's particularly important to encourage your child to be as active as he or she can tolerate comfortably, and to provide plenty of liquids, fruits and vegetables. Gradually, you can start to manage your child's discomfort with regular Tylenol as needed. Within a week or two after discharge you should begin to notice your child is feeling more like normal.

What is the follow-up after surgery?

You will need to make an appointment for three weeks after surgery to have your child's catheters removed. When the catheters are removed, it may feel strange or mildly painful.

At the follow-up visit, your child will also have a cystogram — an imaging test of the bladder — to be sure healing is complete. The cystogram also shows us the shape and size of your child's new bladder. We will review catheterization technique with you so you feel comfortable with this new way of emptying the bladder.

Three months after the surgery your child should have urodynamic testing and an ultrasound of the kidneys and bladder.

As my child grows, will the bladder increase in size?

Yes. As your child grows, his or her bladder should expand appropriately.

What are the long-term effects of gastric augmentation?

The stomach secretes acid regardless of where it's placed in the body — even when it's attached to the bladder. For this reason, your child will need to take a medication called Tagamet (cimetidine) or Zantac (ranitidine) for several months following the operation. These medications are long-acting antacids. Some children feel discomfort around the bladder every now and then, and these medications may provide relief.

Over the long term, the acid usually causes no problems — in fact, it may reduce the rate of urinary tract infections — but in a few children, too much acid can alter their blood chemical balance. If your child gets the flu, he or she will be particularly susceptible to dehydration.

What are the long-term effects of ileal augmentation?

The intestines secrete mucous regardless of where they're placed in the body — even when attached to the bladder. This is not a problem, but the mucous can block the catheters and lead to blocked urine flow, especially soon after the operation. It's important to irrigate your child's bladder frequently. The nurses and doctors will review bladder irrigation with you several times while your child is in the hospital. The irrigation is simple and just takes practice.

Your child will always have mucous in the urine after this type of operation. Again, this is not a problem so long as the bladder is regularly and consistently emptied. If there's increased mucous one day, simply increase the frequency of clean, intermittent catheterization to every two hours and perhaps irrigate the bladder a few times during the day.

Will my child have urinary tract infections after the surgery?

For unknown reasons, some children are particularly prone to urinary tract infections after bladder augmentation.

It's important to differentiate between bacteria in the urine and an infection. Children who catheterize normally have some bacteria in their urine because they're constantly introducing a foreign object — the catheter — into their bladder. This is not a problem so long as the urine is emptied out of the bladder every three to four hours. If the urine looks cloudy or dark, simply increase the frequency of the catheterizations to every two hours for a few days and try to increase intake of fluids. Usually, the urine will clear.

However, if your child develops a fever, lack of appetite, stomach cramping, back pain and is generally not feeling well, there may be more bacteria than normal. In this case, your child may need to have a urine test and possibly a course of antibiotics. If you notice these symptoms, your primary care doctor or a doctor from Pediatric Urology should evaluate your child immediately.