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Bladder Autoaugmentation (Detrusorectomy / Detrusor Myotomy)

Bladder autoaugmentation (also called detrusor myotomy or detrusorectomy) increases bladder capacity and compliance by excising or incising the detrusor muscle over the dome while leaving the underlying urothelium intact, creating a large epithelial diverticulum that functions as a low-pressure reservoir — all without incorporating bowel into the urinary tract.[1][2] First described by Cartwright and Snow in 1989, it was developed to avoid the metabolic, mucus-related, and malignancy complications inherent to enterocystoplasty.[1]

Indications​

Refractory low-capacity, poorly compliant, or hyperreflexic bladder (CIC + anticholinergics failed). Common conditions: neurogenic bladder (myelomeningocele, SCI, tethered cord, sacral agenesis), posterior urethral valves, bladder exstrophy.[2][3][4]

Particularly considered when:[1][2][5]

  • The patient or family wishes to avoid bowel interposition and its metabolic/mucosal complications.
  • The patient has renal insufficiency (where enterocystoplasty acidosis would be poorly tolerated).
  • A simpler, extraperitoneal procedure that preserves the option for future enterocystoplasty is desired.
  • The patient has no anterior abdominal-wall anomalies (important for the rectus muscle backing technique).[3]

Contraindications​

  • Severely fibrotic or thickened bladder — urothelium may not prolapse adequately.
  • Anterior abdominal-wall anomalies (omphalocele, gastroschisis) — preclude rectus-muscle backing.[3]
  • Need for simultaneous continent catheterizable channel — autoaugmentation alone does not provide a stoma; outcomes may be compromised when combined.
  • Severely small bladder capacity where the achievable degree of augmentation is insufficient.

Surgical Techniques​

1. Standard detrusor myotomy (Cartwright–Snow)[1]​

  • Extraperitoneal or transperitoneal approach.
  • Detrusor muscle over the entire dome is excised; bladder epithelium is preserved.
  • Urothelium prolapses through the defect → large epithelial bulge / diverticulum.
  • Functions as a low-pressure reservoir.

2. Detrusorectomy with rectus muscle backing (Perovic)[3][6][7]​

Addresses the key problem of urothelial retraction and shrinkage after simple myotomy.

  • Completely extraperitoneal approach (inferior midline or transverse incision).
  • Detrusorectomy involves the entire upper half of the bladder.
  • Both rectus abdominis muscles dissected from their anterior and posterior sheaths.
  • Prolapsed urothelium sutured to the rectus muscles at multiple points to prevent retraction.
  • Rectus muscles provide structural backing; may facilitate voluntary emptying.
  • Long-term results (median follow-up 134 mo): median bladder capacity 419 mL (range 296–552); 14/23 patients voluntary voiding without PVR.[3]

3. Autoaugmentation with demucosalized bowel overlay (composite cystoplasty)[8][9][10]​

Hybrid combining autoaugmentation with a demucosalized seromuscular bowel patch placed over the exposed urothelium.

  • Demucosalized gastric patch (Nguyen–Mitchell): in 11 pediatric patients, capacity 109 → 236 mL; compliance 3 → 9 mL/cmH₂O; no metabolic complications; mucus-free urine.[9]
  • Demucosalized sigmoid patch (Lima nonsecretory cystoplasty): in 129 augmentations, capacity ↑ 329%; compliance ↑ 7-fold; no mucus, no perforation, no neoplasia; failure 10.1%.[10]
  • Critical technical point: complete removal of the muscularis mucosae and inner submucosa is essential — when preserved, mucosal regrowth occurs in 80%; when completely removed, regrowth does not occur.[11]
  • A silicone balloon conformer in place 2 weeks postop may prevent mucosal shrinkage (continence 80% with vs 8% without).[12]

4. Seromuscular enterocystoplasty (SE)[13]​

Detrusorectomy combined with a seromuscular bowel patch (preserving submucosa). In 10 children with spastic neurogenic bladder, mean capacity 83 → 320 mL; end-filling pressure 48 → 21 cm H₂O; 9/10 voided successfully via Valsalva; none incontinent.

5. Laparoscopic autoaugmentation[14][15][16]​

  • Extraperitoneal retropubic approach is technically feasible.[15]
  • KTP-laser-assisted laparoscopic detrusorotomy showed poor durability — both patients ultimately required enterocystoplasty.[14]
  • A single laparoscopic case for traumatic SCI showed excellent results at 6 mo (capacity 510 mL, continent).[16]
  • Overall: shorter hospital stay and less postop discomfort, but long-term durability uncertain.

Outcomes​

SeriesnFollow-upCapacityContinenceFailure
Cartwright & Snow[1]7ShortImproved 3/55/7 excellent1/7 (14%)
MacNeily[17]1775 moMinimal5/13 (38%)12/17 (71%)
Hansen (myotomy)[4]256.8 yr103 → 176 mL (5 mo)18/25 (72%)Low
Djordjevic (rectus backing)[3]23134 moMedian 419 mL14/23 voluntary voiding0%
Dik (detrusorectomy)[18]354.9 yrImproved 37%19/25 (76%) with sling3/35 (9%)
Rocha (myotomy + balloon)[12]10Long-term140 → 240 mL8/10 (80%)2/10 (20%)
Lima (demucosalized sigmoid)[10]12951 mo↑ 329%High10.1%
Nguyen (demucosalized gastric)[9]1123 mo109 → 236 mL10/11 (91%)Low
Stöhrer (adult myotomy)[2]507 yrSubstantial increaseMost on CIC2/50 (4%)

Temporal pattern: transient decrease or no change in bladder capacity during the first 3 months, followed by significant and sustained increase beginning ~5 months postoperatively; compliance continues to improve for up to 5 years. Low-dose anticholinergics may accelerate the therapeutic effect.[2][4]

Advantages Over Enterocystoplasty​

FeatureAutoaugmentationEnterocystoplasty
Metabolic complicationsNoneHyperchloremic acidosis, B₁₂ deficiency
Mucus productionNoneSignificant
Malignancy riskNone0–5.5% (latency ~20 yr)
Bowel obstruction riskNone (simple myotomy)4.5%
Surgical complexitySimple, extraperitonealMajor intraperitoneal
Operative timeShorterLonger
Preserves future optionsDoes not preclude enterocystoplasty—
Degree of augmentationLess predictable, smaller increaseGreater, more reliable
DurabilityVariable; may deteriorateMore durable

Complications​

  • Urothelial retraction and fibrosis — primary cause of failure; rationale for rectus-muscle backing and demucosalized bowel overlay modifications.[5][6][19]
  • Bladder perforation — rare; reported particularly when combined with AUS (1 case in Stöhrer's series of 50). Lower than with enterocystoplasty.[2]
  • Increased post-void residual — most patients require CIC; the diverticulum does not contract effectively.[2]
  • Delayed functional improvement — 1–6 months (occasionally >1 year); requires patient motivation and patience.[2][4]
  • Failure requiring secondary enterocystoplasty — 9–71% depending on technique; highest with simple myotomy without backing or overlay; lowest with rectus backing (0% in Djordjevic's series) and demucosalized bowel overlay (10.1% in Lima's).[3][10][17][18]

Controversial Durability​

  • Negative long-term data: MacNeily reported 71% of 17 myelomeningocele patients were clinical failures at median 75 mo; 93% considered urodynamic failures; progressive hydronephrosis in 5; enterocystoplasty in 4. Concluded that autoaugmentation "cannot be endorsed for the management of congenital neuropathic bladder."[17]
  • Positive long-term data: Hansen (n=25, 6.8 yr): sustained significant increases in capacity and compliance; normal renal function in all but 1; continence 72%.[4] Djordjevic (n=23, 134 mo): continued significant capacity increase (median 419 mL); no failures with rectus backing.[3]
  • Critical review by Gurocak: the clinical outcome of autoaugmentation "does not appear to be durable" vs enterocystoplasty, but acknowledges definite advantages of low morbidity and absence of bowel-related side effects. Patient selection is the most crucial factor for success.[5]

Patient Selection — Keys to Success​

Best candidates for autoaugmentation:[2][3][5][12]

  • Detrusor hyperreflexia (overactivity) rather than pure fibrotic low compliance.
  • Adequate baseline bladder capacity (the procedure improves compliance more reliably than capacity).
  • No anterior abdominal-wall anomalies (for rectus backing).
  • Motivated to wait for potentially delayed functional improvement.
  • Willing to perform CIC postoperatively.
  • Renal insufficiency that makes enterocystoplasty metabolically risky.
  • Prefers a less-invasive, reversible procedure that preserves the option for future enterocystoplasty.

Technique Selection​

  • Simple detrusor myotomy / myectomy: simplest but highest failure rate; reserve for mild disease or as a temporizing measure.
  • Detrusorectomy with rectus muscle backing: best long-term results among pure autoaugmentation techniques; prevents urothelial retraction; allows voluntary voiding in some patients.[3]
  • Autoaugmentation with demucosalized bowel overlay: combines the metabolic advantages of autoaugmentation with the structural support of a bowel patch; the Lima nonsecretory sigmoid technique has the largest experience (129 patients).[10]
  • Silicone balloon conformer: may improve outcomes of simple autoaugmentation by preventing early mucosal shrinkage.[12]

References​

1. Cartwright PC, Snow BW. "Bladder Autoaugmentation: Early Clinical Experience." The Journal of Urology. 1989;142(2 Pt 2):505-8. doi:10.1016/s0022-5347(17)38798-0

2. Stöhrer M, Kramer G, Goepel M, et al. "Bladder Autoaugmentation in Adult Patients With Neurogenic Voiding Dysfunction." Spinal Cord. 1997;35(7):456-62. doi:10.1038/sj.sc.3100441

3. Djordjevic ML, Vukadinovic V, Stojanovic B, et al. "Objective Long-Term Evaluation After Bladder Autoaugmentation With Rectus Muscle Backing." The Journal of Urology. 2015;193(5 Suppl):1824-9. doi:10.1016/j.juro.2014.11.081

4. Hansen EL, Hvistendahl GM, Rawashdeh YF, Olsen LH. "Promising Long-Term Outcome of Bladder Autoaugmentation in Children With Neurogenic Bladder Dysfunction." The Journal of Urology. 2013;190(5):1869-75. doi:10.1016/j.juro.2013.05.035

5. Gurocak S, De Gier RP, Feitz W. "Bladder Augmentation Without Integration of Intact Bowel Segments: Critical Review and Future Perspectives." The Journal of Urology. 2007;177(3):839-44. doi:10.1016/j.juro.2006.10.064

6. Perovic SV, Djordjevic ML, Kekic ZK, Vukadinovic VM. "Bladder Autoaugmentation With Rectus Muscle Backing." The Journal of Urology. 2002;168(4 Pt 2):1877-80. doi:10.1097/01.ju.0000030041.09225.41

7. Perovic SV, Djordjevic ML, Kekic ZK, Vukadinovic VM. "Detrusorectomy With Rectus Muscle Hitch and Backing." Journal of Pediatric Surgery. 2003;38(11):1637-41. doi:10.1016/s0022-3468(03)00579-7

8. Dewan PA. "Autoaugmentation Demucosalized Enterocystoplasty." World Journal of Urology. 1998;16(4):255-61. doi:10.1007/s003450050063

9. Nguyen DH, Mitchell ME, Horowitz M, Bagli DJ, Carr MC. "Demucosalized Augmentation Gastrocystoplasty With Bladder Autoaugmentation in Pediatric Patients." The Journal of Urology. 1996;156(1):206-9.

10. Lima SV, Araújo LA, Vilar FO. "Nonsecretory Intestinocystoplasty: A 10-Year Experience." The Journal of Urology. 2004;171(6 Pt 2):2636-39. doi:10.1097/01.ju.0000112782.00417.5e

11. Dewan PA, Close CE, Byard RW, Ashwood PJ, Mitchell ME. "Enteric Mucosal Regrowth After Bladder Augmentation Using Demucosalized Gut Segments." The Journal of Urology. 1997;158(3 Pt 2):1141-6. doi:10.1097/00005392-199709000-00114

12. Rocha FT, Bruschini H, Figueiredo JA, et al. "Use of an Inflatable Silicone Balloon Improves the Success Rate of Bladder Autoaugmentation at Long-Term Followup." The Journal of Urology. 2011;185(6 Suppl):2576-81. doi:10.1016/j.juro.2011.01.029

13. Dayanç M, Kilciler M, Tan O, et al. "A New Approach to Bladder Augmentation in Children: Seromuscular Enterocystoplasty." BJU International. 1999;84(1):103-7. doi:10.1046/j.1464-410x.1999.00144.x

14. Poppas DP, Uzzo RG, Britanisky RG, Mininberg DT. "Laparoscopic Laser Assisted Auto-Augmentation of the Pediatric Neurogenic Bladder: Early Experience With Urodynamic Followup." The Journal of Urology. 1996;155(3):1057-60.

15. McDougall EM, Clayman RV, Figenshau RS, Pearle MS. "Laparoscopic Retropubic Auto-Augmentation of the Bladder." The Journal of Urology. 1995;153(1):123-6. doi:10.1097/00005392-199501000-00044

16. Siracusano S, Trombetta C, Liguori G, et al. "Laparoscopic Bladder Auto-Augmentation in an Incomplete Traumatic Spinal Cord Injury." Spinal Cord. 2000;38(1):59-61. doi:10.1038/sj.sc.3100939

17. MacNeily AE, Afshar K, Coleman GU, Johnson HW. "Autoaugmentation by Detrusor Myotomy: Its Lack of Effectiveness in the Management of Congenital Neuropathic Bladder." The Journal of Urology. 2003;170(4 Pt 2):1643-6. doi:10.1097/01.ju.0000083800.25112.22

18. Dik P, Tsachouridis GD, Klijn AJ, Uiterwaal CS, de Jong TP. "Detrusorectomy for Neuropathic Bladder in Patients With Spinal Dysraphism." The Journal of Urology. 2003;170(4 Pt 1):1351-4. doi:10.1097/01.ju.0000081954.96670.0a

19. Manzoni C, Grottesi A, D'Urzo C, et al. "An Original Technique for Bladder Autoaugmentation With Protective Abdominal Rectus Muscle Flaps: An Experimental Study in Rats." The Journal of Surgical Research. 2001;99(2):169-74. doi:10.1006/jsre.2001.6098