Bladder augmentation





Definition

Bladder augmentation, also known as augmentation cystoplasty, is reconstructive surgery to increase the reservoir capacity of the bladder. The procedure is very common and involves tissue grafts (anastomosis) from a section of the small intestine (ileum), stomach, or other substitutes that are attached to the urinary bladder by sewing or stapling. Whether due to chronic obstructive bladder damage, birth defects that resulted in small reservoir capacity, or dysfunction due to nerve innervation of the bladder muscle (sphincter), surgery is chosen only after a thorough medical work-up that involves assessment of the lower urinary tract, functional physiological evaluation, and anatomic assessment. Some laparoscopic methods (surgery with a fiber-optic instrument inserted through the abdomen) of bladder augmentation have been tried, but reports indicate that these are technically arduous and may not have the long-lasting effects of open surgery.


Purpose

Bladder dysfunction and incontinence may be due to problems with the reservoir capacity of the bladder or with the "gatekeeping" muscle (the sphincter), which, instructed by the brain, allows urine to build up or to be released. Bladder augmentation is used to treat serious and irreversible forms of incontinence and to protect the upper urinary tract (kidney function) from reflexia (urine back up to the kidneys). Many candidates for the surgery are highly compromised individuals with other serious conditions like spinal cord injuries and multiple sclerosis, as well as patients likely to undergo kidney transplantation . Patients who undergo bladder augmentation must be free of bowel and urethral disease and be able to perform self-catheterization (able to place a urinary tube into their urethra).


Description

Standard augmentation involves segments of the bowel used to create a pouch or wider wall for the bladder in order to enhance its reservoir capacity. Often this reconstruction surgery is accompanied by procedures that tighten the neck of the bladder, as well. Milkulicz performed the first clinical augmentation cystoplasty using abdominal tissue in 1898. Couvelaire, in the 1950s, popularized bladder augmentation for the treatment of the contracted bladder due to tuberculosis. Until the 1970s it was thought that those with bladder dysfunction could be treated with bladder diversion, and that this procedure offered a simple and safe means of emptying the bladder. However, it was soon discovered that pressure from the bladder caused irreparable damage to the kidneys, with 50% of patients exhibiting such deterioration. The new diagnostic assessment of the bladder as well as the need for a new medical intervention for patients with severe bladder dysfunction opened the way for urinary tract reconstruction. Today, many techniques are available, along with new types of grafting substitutions.

The basic procedure involves open abdominal surgery with resection of a 10–20 in (25–30-cm) segment of ileum, cecum (first part of the large intestine), or the ileocecum (the junction of small and large intestines) cut down the middle (detubularized), and shaped into a U-configuration with a pouch at the bottom. This opening or pouch will be the "patch" for the bladder. During surgery, the bladder itself is also opened at the dome and cut at right angles to

During a bladder augmentation procedure, an incision is made in the abdomen to expose the intestines and bladder (A). A section of ileum (small intestine) is removed and opened (B). After being sterilized, it is grafted onto the bladder to increase its capacity (C). The appendix and cecum (large intestine) may also be used (D). (Illustration by GGS Inc.)
During a bladder augmentation procedure, an incision is made in the abdomen to expose the intestines and bladder (A). A section of ileum (small intestine) is removed and opened (B). After being sterilized, it is grafted onto the bladder to increase its capacity (C). The appendix and cecum (large intestine) may also be used (D). (
Illustration by GGS Inc.
)
create a clam-like shape. The open bowel "patch" is then attached to the bladder with sutures or stapling.


Diagnosis/Preparation

Patients selected for bladder augmentation are chosen after they undergo a thorough physical exam, x-ray tests, and bladder physiology tests, as well as a renal and bladder ultrasound for any dilation of the kidneys or ureters or kidney obstruction. A VCUG (holding and voiding urine) test is performed to assess the contour of the bladder and to assess for ureteral reflux (back up of urine to the kidneys). Finally, a CMG (cystometrogram) is performed in the physician's office to judge the pressure and volume levels at which the urine leakage occurs. Once the tests, as well as the history and physical exam are completed, treatment plans commence.

The patient should plan for up to two weeks in the hospital. The patient will have been on a low-residue diet for a few days before admission. Surgery will take place two to three days after hospital admittance. In the hospital, a general examination will be performed and blood taken. The bowel will need to be cleaned in preparation. Clear fluids will be given, as well as a strong laxative prior to surgery.


Aftercare

Early complications of surgery include cardiovascular, thrombo-embolic (blood clot), gastrointestinal, and respiratory complications associated with major abdominal surgery. Many patients require three months after surgery to allow their augmented bladder to establish itself. This involves a special diet for a few months as well as patient familiarity with the fact that the augmented bladder empties after the native bladder. Two weeks after surgery tests are performed to ensure that the patch is leak proof. Once a watertight reservoir is demonstrated, the catheters and drains that were introduced for surgery are removed.


Risks

Long term risks of the procedure include peptic ulceration of the bladder and perforation of the gastric segment. Spontaneous perforation is rare but it is life threatening and has a 25% mortality rate. Other risks include bacterial infections, metabolic changes, urinary tract infections, and urinary tract stones. Nocturnal incontinence is sometimes a problem after the surgery.

Normal results

Although some patients recover spontaneous voiding function, this does not occur with reliable predictability. Preoperatively, patients should be prepared for the likelihood that they will have to perform lifelong intermittent catherization and irrigation of the augmented bladder. Other effects are a special diet for up to three months and pain after surgery.


Morbidity and mortality rates

Reported surgical risks include 3–5.7% rate of adhesive small bowel obstruction requiring operative intervention, 5–6% incidence of wound infection, 0–3% reoperation rate for bleeding. Long term complications include a 50% unchanged bladder compliance and renal deterioration. No reduction in growth in children has been reported, but the procedure is not recommended for children who have not reached puberty, unless there is the threat of kidney damage.


Alternatives

Bladder augmentation is a medical treatment of last resort for those patients unable to avoid incontinence through medical alternatives. Other surgeries may be indicated if the individual is not a candidate for self-catherization or has other medical or psychological conditions that would rule out bladder augmentation.


Resources

BOOKS

Dewan, P., and M. E. Mitchell, eds. Bladder Augmentation. Oxford Press, 2000.

PERIODICALS

Abrams, P., S.K. Lowry, et al. "Assessment and Treatment of Urinary Incontinence." Lancet 355 (June 2000): 2153–58

Fantl, J. A., D. K. Newman, J. Colling, et al. "Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline, Number 2, 1996." Agency for Health Policy and Research Publications (March 1996).

Greenwell, T. J., S. N. Venn, and A. R. Mundy. "Augmentation Cystoplasty." British Journal of Urology International 88, no. 6 (October 2001): 511–534.

Qucek, M. I., and D. A. Ginsberg. "Long-term Urodynamics Follow-up of Bladder Augmentation for Neurogenic Bladder." Urology 169 (January 2003): 195–198.

Rackley, R. R., and J. B. Abdelmalak. "Radical Prostatectomy: Laparoscopic Augmentation Cystoplasty." Urological Clinics of America 28 (August 2001).

ORGANIZATIONS

National Association for Continence. P.O. Box 8310 Spartanburg, SC 29305. (800) BLADDER, (252-3337). http://www.nafc.org .

National Kidney and Urologic Diseases Information Clearing-house. 3 Information Way, Bethesda, MD 20892-3580. (301) 654-4415. http://www.niddk.nih.gov .

The Simon Foundation for Continence. P.O. Box 835 Wilmette, IL 60091. (800) 23SIMON (237-4666). http://www.simonfoundation.org .


OTHER

"Bladder Augmentation." Dr. Rajhttp. [cited April 2003]. http://www.drrajmd.com/treatments/treatments.htm .

Carr, Michael, and M. E. Mitchell. "Bladder Augmentation." Digital Urological Journal. [cited April 2003]. http://www.duj.com/Article/Carr/Carr.html .

"Neurogenic Bladder." [cited April 2003]. <http://www.med.wayne.edu/urology/DISEASES/neurogenicbladder.html #x003E; .


Nancy McKenzie, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


A urological surgeon who is an MD with advanced training in urology and special surgical training for this type of surgery. Surgery takes place in a general hospital.

QUESTIONS TO ASK THE DOCTOR


  • How many bladder augmentation surgeries do you perform a year?
  • What complications of this surgery do you think are the most likely and/or worrisome?
  • Are there other patients with my underlying medical conditions who have had this surgery that I could contact?
  • Is there a pre-op patient group with this hospital that could help me understand my rehabilitation and help with the compliance with the diet and self-catherization?

User Contributions:

dr naresh valecha
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Feb 18, 2007 @ 2:02 am
its very good brief description,I would happy and thankful to u
if u send me more details(comprehensive)
thanks
Patricia
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Aug 22, 2007 @ 4:16 pm
My son is just about 11years old and his urologist wants this procedure done. He also mentioned about bladder augmentation by growing his own bladder and attaching it to his bladder. Can you tell me what you know about this and how safe both procedures are if you can. Thanks for your help in advance.
rachi
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Apr 17, 2008 @ 11:11 am
My son is just about 11years old and his urologist wants this procedure done. Can you tell me what you know about this and how safe both procedures are if you can. Thanks for your help in advance
mark
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May 5, 2008 @ 11:11 am
im 29 had this op done and i would not look back thanks to my doctor
tamyka smith
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Dec 18, 2008 @ 11:23 pm
The doctor of my 5 year old son wants to do this surgery on him. Are there any alternatives? What about just having a Mitrofonoff for awhile and not having the surgery unless things get worse?
carr
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Dec 26, 2008 @ 10:10 am
this is where my nauseauses is coming from,and frequent urination....
punjani
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Jan 5, 2009 @ 11:11 am
Reconstructive surgery for the bladder called bladder augmentation.
michelle hong
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Jan 31, 2009 @ 8:20 pm
my brother is a paraplegic and its been ten yrs since he had a bladder augmentation he seems to have frequent bladder infections and im very concerned. my ? is how long does the bladder augmentation last. And are there any new procedures that can be performed on a bladder thats already been augmented?
patricia
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Jun 16, 2009 @ 6:18 pm
Mark, how long ago did you have this surgery done?
t roche
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Jul 5, 2009 @ 1:13 pm
i am a 61 male after a lifetime of incontinanc and embarassment at th e age of 49yrs i was diognesd with primary detrusur instability
i had a clam bladder type operation. at surgery bladder was found tb unusealy small so a bigger strip of bowel was used.i have self catheriesd ever since, full glories control iam only now having problems with insertion of catheter now talkis of supra pubic device.ialso now have spinal damage with server ballance and mobility problems it has beem worth it to strees free control over my bladder.
rohayu
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Jul 31, 2009 @ 3:03 am
l have juz gone 4 tis surgery on june 3rd im juz 14 n it is much better to me but recently l had urine infection 4 two times n my surgeon decided to change the catheter but it is good to go 4 the opt.
Debra
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Aug 6, 2009 @ 8:08 am
My son had this procedure when he was two. We have to catheter his bladder through his side. We have always had trouble getting the tube into his bladder. Sometimes it goes right in,but most of the time it doesn't. We have expressed our concerns to his doctor but he doesn't seem concerned.
barbara clark
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Oct 22, 2009 @ 4:16 pm
i had this bladder augmentation when i was about 13 yrs. old. i had gone my whole childhood wetting the bed and wetting on myself during the day. i was unable to control my bladder. for me they tried a few different things before they went with the augmentation, but nothing worked. so they did this operation. now the recovery was a little difficult for me because i was a teenager and i had to go home with these tubes coming out of my stomach and a catheter in me. but now i am 29 and i am so glad i had the operation because now i dont have accidents. now i have to use a catheter anytime i need to go, but that is a small price to pay for having no more wetting on myself.
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Apr 29, 2010 @ 3:15 pm
what will we do to the inestine after removal part from it?
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Apr 29, 2010 @ 3:15 pm
what will we do to the inestine after removal part from it?
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May 6, 2010 @ 9:09 am
Who can tell me more about the complications after surgery and the recovery time?
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Jun 8, 2010 @ 3:03 am
I have a 5yr old son and our consultant has advised us the only way to go now is Bladder augentation with a mitrofanoff, He has already had a vesicostomy and the changed to a superpubic cathertar, he had regular botox into the bladder, he has very high bladder pressures and has to have bladder wahes every day! is there any alternatives? what are the major complications we need to know about?
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Jun 26, 2010 @ 3:03 am
Hi I am at th last resort and told I need a bladder augmitation, I am a 50 year old man and have a legion on my spine (cervical myopathy) other than that I am healthy,,
If I don't have this bladder surgery my kidneys will be damaged, I am scared to death I am going to die, is there anyone out thre that can help me that has had this surgery, is it life threatning,, painful, will I need a caheria 24 hours aday,what is recovery like.. please somone help,, I ned to raise my young son I don't want to die..thanks for your help...Lou
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Jul 16, 2010 @ 2:14 pm
I am 77. My bladder tumor has been internal. I have had surgery five times, with BCG therapy on three occasions. The third run of BCG (completed April 20, 2009) caused damage to the bladder lining that continues to this day. The pain continued until June 8, 2010 and could be subdued by consuming PHENOZOPYRIDINE like candy. On June 8 a surgical biopsy was performed and through that process the pain was 95% eliminated. The tumor had not returned. The problem is with the shrinkage of the bladder which requires 12 to 15 trips to the bathroom every night and many trips during the day. Based on my own internet research, Bladder Augmentation surgery appears to be the only remedy to this problem. My primary care doctor says no, but I have yet to discuss it with my urologist. If he too is ambivolent about it, I intend to find a urologist who will take this seriously. A catheter is not a solution as my eurethra is too tender and the discomfort would be intolerable as a permanent answer. Am most interested in hearing from you. Thank you.
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Dec 27, 2010 @ 10:22 pm
My son was born with bladder exstrophy and had bladder augmentation surgery a few months ago at the age of ten. My son uses a catheter through a metrophanoff(sp). He seemed to be doing well and staying dry but he just started leaking just a tiny bit a few days ago and I was just wondering what could have caused this? Could this be caused from a uti? Is there anything that he could do to prevent leakage?
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Jan 18, 2011 @ 3:15 pm
I am 46 years old and a Paraplegic in a wheelchair. My Doctor has suggested this surgery due to my bladder will no longer hold urine. Is there anyone out there that has had this operation? If so did you have any complications after and or any problems in the years after. I hope alot of you will respond to this because I have a big decission to make in a few weeks.
Thanks
Chuck
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Feb 7, 2011 @ 7:19 pm
I am a 23 year old women. I had this surgery done when I was seven that was back in 1994. The surgery worked, my kidneys are back from 50% to about 90%. I am to be cath 4 times a day. I do have two children. I had the surgery in Iowa city Iowa. If they did not due this surgery I would have died and I am thankful for the surgery
MSH
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Feb 11, 2011 @ 6:18 pm
I had bladder augmentation surgery when I was 17 (due to spina bifida). I am now 40. Several years ago I began having incontinence issues again. I have been to my family doctor AND a urologist who both say they know nothing about it and have never heard of the piece of intestine deteriorating after so long. I don't know what to do or where to go. I have also been told that there are no doctors for adults with spina bifida in my state which is ironic since Riley Hospital for children is in my state. Anyone have anything they can tell me or specifically a doctor/clinic to call based in Indiana? Would be much appreciated. Thanks.
DET
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May 25, 2011 @ 2:14 pm
I had a Clam Cystoplasty nearly 21 years ago, and have had problems since,i.e urine infections bladder spasms, I have to use a catherter every time I go to the toilet. I cannot bend without my bladder going into spasm.The pain is so severe when I have aninfection that it doubles me up in pain.My G.P doesn't seem to believe the problems that I am having almost burying his head in the sand,as if I am telling lies. As I said I had the op 21 years ago (I wish I had have been better informed,bacause no way would I have had it done!)
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Jul 21, 2011 @ 4:04 am
i had a clamsystoplasty when i was about 11years old, i am now 34 years old and the procedure worked for me, i have to say i have had some problems over the years such as really bad water infections and kidney pains, i also have bad mucus in my urine and a very strong smell in my urine. i get really bad spasms and stomach pains all the time and i also suspect that i have irratable bowel syndrome, i dont know wether theses problems are caused by having the procedure done, but i have always wondered. but on the plus side the operation worked straight away and the incontinence i suffered at night stopped immediately.which was very important for me as i was becoming a teenager and was very embarrassed about my problem.i did not have to take the horrible medicine desmopressin any more each night before bed which consisted of blowing the medicine up my nose through a tube and having to have pads on my bed and an alarm to wake me in the night if i wet the bed.so yes my quality of life was significlantly improved by having the operation.and after all these years i have suffered no incontinence at all.
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Aug 16, 2011 @ 7:07 am
THANK YOU FOR YOUR ILLUSTRATION
CAN I ASK ABOUT THE SECREATIONS FROM THE AUGMENTATION PART (ILEUM), FOR HOW LONG IT REMAINS(LIFE LONG??)
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Sep 30, 2011 @ 6:18 pm
Can someone please help me i had this op done two years ago and have never been right from it. I keep taking really bad infections to the point were I have to call 999 as the pain is unreally and I can't breath. But I have this pain in my left side that just want go away and the more I'm on my feet the worst it get, the pain goes up into my chest and into my arm, it's also making my legs sore. I'm just in pain all the time. My doctor makes me feel like I'm mad, and is so unhelpful and just keeps giving me pain killers. I was taken into hospital last week and they looked into the bladder but said it was fine. So why am I in so much pain. Please help
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Nov 4, 2011 @ 7:19 pm
My son is getting ready to have a vesicostomy, bladder neck swing ,and bladder augmentation. He is 13 and has Spina Bifida. He has been through lots of surgery's in his lifetime. He is very nervous about this one. Any feedback would be greatly appreciated. His dr told me the surgery will take 15 hrs, he will be in the hospital for at least a month, and full recovery is approximatly 3-4 months.
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Nov 10, 2011 @ 3:03 am
I have had bladder problems for years now & after numerous tablets tests etc,it was decided that i was to have BOTOX injections into the bladder.
The first time it worked but i was still running to to loo very often i have had to s.i.c since the op. I had it repeated over a week ago & am worse off now than i have ever been (back to square one)I am now being considered for the bladder augmentation & have been told i will have to go to England to have it performed. The thought of this scares me. Does any one or Dr know if it can be done here in Belfast? Your help is much appreciated. Any other info would gladly be also welcomed.
Thanks in advance
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Nov 16, 2011 @ 12:12 pm
Hi I am a 54 year old woman and I have been told by my consultant that I need full bladder reconstruction as I have severe refulf which is damaging my kidneys after the op I will need to self catheratise. I am really worried and wonder if you can send me some more information Thank you
dan
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Mar 15, 2012 @ 7:19 pm
Cincinnati Children's hospital is an excellent centre for urinary and colorectal problems in kids.

Using drugs like ditropan with intermittent catheterization can be an alternative to augmentation, but does not work for everyone. Obviously, the risk is kidney damage if the bladder pressure is high, so you need good diagnostics. Constipation and UTIs makes things worse, so make sure you are on top of that.
dawn
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May 26, 2012 @ 8:20 pm
is there any chance of reversing augmentation cystoplasty?
MARION
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Jun 21, 2012 @ 5:05 am
My Doctor has suggested this is the way forward for me i am quite dubious anout the results.As i have recently been widow the after care worrys me as i live on my own . i want to know is it the right thing for me i have twice had Botox and Bladder stretched and and tot fitterd.
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Jul 3, 2012 @ 7:07 am
my master research is about bladder augmentation i will be greatly thankful to u if send me more details
thanks
satish patel
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Jul 19, 2012 @ 4:04 am
myself satish patel36yr old,i had paralegia(acute transeverse myeilitis)when i was 19yr old,i also had a neuroganic bladder small cpcity blader urine incontinence reflux urine,i was advised for augmentain blader and i was operated by dr sabnis at nadiyad kidney hsptl,since last 17yr i do self catheterisation and no any problem,thanks to great dr sabnis saheb,my life settled after opratin i got married and 1male child.so its a great procedure for such type of urinry problm.
FRED LADNER
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Aug 13, 2012 @ 9:21 pm
my son(sean)is 43year old quad c-7. sean had bowel augmentation over two years ago. after his first surgury they found a leak and had to cut him open to redo the surgury. they punctured his lung and the doctor called me and said to get to the hospital because sean might die. sean recovered but was at deaths door. sean also had every infection a person could get including staff. since the operation sean has unbearable pain in his stomach and has lost about 40 pounds seans bowel is full of nasty, smelly, urine. if there is any way sean could get rid of the pain he can deal with the rest of his problems. he only weighs about 95 pounds and i(father) am extremely worried. sean was 21 when he had his accident. please help
Robin
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Jan 6, 2013 @ 9:21 pm
can anyone tell me about after the surgery, what do you eat, how long did recovery take,
the truth how bad is it. I have interstituial cystitis, and my bladder is shrinking, it only holds
2-4 onces with severe pain, they tell me the surgery might not help the pain . just help me hold more,
if it holds over 4 oz now it is like passing kidney stones ever day over and over. and it bleeds at time.
and I usually go pee about 30-50 times in 24 hours. does anybody else have anything simmilar to this.
I also have a bad back, shoulders, well my body is shot, with constant pain. I am real nervious about this
surgery, I did real well with 3 back surgeries, shoulder surgery, and knee surgery. but my belly is differant.
moves more and softer than my back. seeking answers Thanks Robin
savvy
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Jan 30, 2013 @ 3:03 am
is there any way nerves that are damaged can be repaired to function as normal or close.
Yvonne
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Mar 15, 2013 @ 5:17 pm
Robin:I'm 58, female, and have severe IC as well. Have endured well over 50 bladder distentions, had clorpactin (bleach), BCG (aka tuberculosis virus), & capsaicin (aka cayenne pepper)instilled (all of which about killed me from the pain). Had the neuro interstim implanted 3 times before having it removed finally (over 4 yr time). VA botoxed my bladder in 2008 & since, I have to self-cath, up to 50 X daily. NO ONE can know the pain you endure unless they also have IC. The burning pain from my bladder is never ending and mind-boggling. I have fibromyaglia and IBS associated with the interstitial cystitis, Miniere's Disease, Ranaud's Syndrome, and numerous radiculopathies and neuropathies, require cryotherapy every 4 wks for the bladder pain.I finally saw a urologist outside the VA (bladder was punctured when I was in the Navy, causing my disability)and he said there are 6 steps of treatment for IC. I've had the first 5 repeatedly to no avail, and only worsened as a result. Step 6 is either complete removal of the bladder or bladder augmentation. Probably won't kill the pain, but likely to deccrease the frequency. For me, there is no worse feeling than the IC urgency/pain. You can only ease the pain by voiding. If there's even 1/2 of 1% chance to decrease the frequency, I am going for it. If u can figure how to contact me or me contact u w/o this 'forum,' we could talk more. The docs wanted to do this to me in 87 but I was afraid of the self-cath bit. Sometimes I void 45 x in 1 hr just to ease the pain. 1 drop of urine feels like a gallon & I have to go. No choice. Do u have fibro and/or IBS? I also have a bad back, pinched nerves and chronic pain that no painkiller will stop.
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May 25, 2013 @ 11:11 am
I had a Bladder Augmentation about 11 years ago, I had problems before with pain, from when my first child was born 48 years
ago, and was told around about 11years ago that I had a diseased bladder, and only an augmentation would help, well for one
thing I was never told that I would have to use a catheter, or have a blocked urethra from the mucus which is the part of the intestine they use to make a larger bladder, and produce's this mucus, now every second week I'm on antibiotic's, and now they don't work any more, and the Urologist that did the procedure has retired, and the one I see now, tells me there's
only an infection, but the pain is so bad I feel like screaming, and live on pain killers, so sorry I had the operation, that's for sure!!!
angel vines
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Aug 7, 2013 @ 9:21 pm
I'm a 35 yrd old female I've had overactive bladder for 4 years now I'VE had every done under the sun my Doctor wishes to do the Bladder Augmentation can any one tale me is this surgery worth the rest of your life is it worth the pain I want to be human again can anyone give advice on this surgery.
Toni
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Oct 31, 2013 @ 5:17 pm
I had my bladder op 27 years ago . I wet the bed every night of my life until then .At 13 I don't remember much of what the doctor said . But I have lead a normal life since , I have never looked back . Until now. I have had Severe IBS for years which I didn't think had anything to do with my op but I am now having blood problems and they need to rule out that my op isn't causing problems for me all these years later. What I am asking is does anyone suffer from IBS symptoms mine are very bad
I just need to rule this out . Thank you
James
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Nov 15, 2013 @ 6:06 am
Im a quadriplegic and Its been three weeks since i have had this operation.
Im still needing to urinate on low volumes and voiding also, is this common at this stage post the surgery?
Your views would be appreciated

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