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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, aiming to create an epithelial diverticulum with improved storage capacity and compliance — 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]

EAU 2026 includes detrusor myectomy as an option in selected neuro-urological patients, while recommending intestinal augmentation for refractory low compliance and/or neurogenic detrusor overactivity. Autoaugmentation has inconsistent long-term results; persistent unsafe pressures require timely reassessment rather than waiting for an assumed delayed benefit.[20]

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]
  • No reliable emptying plan — catheterization may still be required. A simultaneous catheterizable channel is not itself a contraindication; combined operations have been reported.[18]
  • Severely small bladder capacity where the achievable degree of augmentation is insufficient.

Surgical Techniques​

1. Detrusorectomy (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.
  • Storage improvement is variable and must be confirmed; myotomy incises muscle, whereas myectomy/detrusorectomy removes it.

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 intestinal patch (Lima nonsecretory cystoplasty): in 129 augmentations in 123 patients (104 sigmoid, 25 ileal), capacity ↑ 329%; compliance ↑ 7-fold; no mucus, no perforation, no neoplasia; failure 10.1%.[10]
  • Mucosal-regrowth evidence: in an animal study, regrowth occurred in 4/5 sheep when muscularis mucosae and submucosa were preserved, versus none after deeper removal. A related 10-child clinical series reported no detected regrowth. This is not an 80% human risk estimate or proof that regrowth cannot occur.[11]
  • A silicone balloon conformer in place 2 weeks postop may prevent mucosal shrinkage (8/10 continent with a conformer versus 1/12 without in a small comparative series; not established routine care).[12]

4. Seromuscular enterocystoplasty (SE)[13]​

Detrusorectomy combined with a seromuscular bowel patch (preserving submucosa). In a 10-child series after spinal trauma, mean capacity increased 83 → 320 mL and end-filling intravesical pressure fell 48 → 21 cm H₂O at three months; 9/10 used Valsalva voiding and none were incontinent. This historical observation is not a recommendation to use abdominal straining: emptying pressures and upper-tract safety require assessment.

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]
  • These very small reports establish feasibility, not comparative recovery or durability benefits.

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]23Median 134 moMedian 419 mL14/23 voiding without residual; 9 used CICCapacity improved in all; no comparative failure estimate
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 bowel)[10]123 patients / 129 augmentationsMedian 51 mo↑ 329%Mixed outlet procedures; no stand-alone continence rate given13/129 (10.1%) augmentations
Nguyen (demucosalized gastric)[9]1123 mo109 → 236 mL10/11 (91%)Low
Stöhrer (adult autoaugmentation)[2]50Seven-year recruitment experience, not uniform follow-upIncreased; timing variableMost needed CICOne enterocystoplasty and one deafferentation; two additional failures attributed to psychological factors

Possible temporal pattern (not guaranteed): 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]

Tradeoffs Compared with Enterocystoplasty​

FeatureAutoaugmentationEnterocystoplasty
Bowel-mediated metabolic complicationsAvoided when no bowel mucosa is incorporated; unrelated metabolic disease remains possibleHyperchloremic acidosis, B₁₂ deficiency
Mucus productionNoneSignificant
Malignancy riskAvoids an entero-urinary junction; does not eliminate baseline bladder-cancer riskLong-latency risk reported; estimates vary by population
Bowel morbidityAvoids bowel resection in pure autoaugmentation; risk depends on access and concomitant surgeryResection and adhesions introduce bowel morbidity
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). A reliable comparative perforation rate is not established.[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 and secondary surgery — clinical failure, urodynamic failure, and conversion to enterocystoplasty are different outcomes. For example, MacNeily reported 12/17 clinical failures, but only four subsequent enterocystoplasties. The heterogeneous series do not establish a reliable ranking of techniques.[3][10][17][18]

Controversial Durability​

  • Negative long-term data: MacNeily reported 71% of 17 myelomeningocele patients were clinical failures at median 75 mo; 14/15 (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); capacity improvement in all, with nine still using CIC; this uncontrolled series does not prove zero long-term failure risk.[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 procedure that avoids bowel incorporation that preserves the option for future enterocystoplasty.

Technique Selection​

  • Simple detrusor myotomy / myectomy: less extensive than bowel augmentation, but durability is variable; selection should account for current pressures, upper-tract risk, and the consequences of waiting for a response.
  • Detrusorectomy with rectus muscle backing: favorable long-term results in a selected 23-patient series; superiority over other techniques is unproven. The earlier 7- and 19-patient publications overlap with this cohort and should not be added as independent evidence.[3]
  • Autoaugmentation with demucosalized bowel overlay: combines the metabolic advantages of autoaugmentation with the structural support of a bowel patch; the cited Lima series comprises 129 augmentations in 123 patients using both sigmoid and ileum.[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

20. European Association of Urology. EAU Guidelines on Neuro-urology. 2026. Bladder augmentation and follow-up. Official guideline.