Pregnancy and delivery after augmentation cystoplasty:A case report and review of literature

lNTRODUCTlON

Augmentation cystoplasty was first described by Mikulicz in 1899[1],and involves segments of bowel,stomach or mega-ureter to increase bladder capacity in those with inadequate bladder function or lack of detrusor compliance.The procedure became widespread in the 1970s after the invention of clean intermittent self-catheterization.The most widely used bowel segment for augmentation cystoplasty is a detubularised patch of ileum or ileocecum while sigmoid colon is the less common alternative.

Pregnancy following augmentation cystoplasty is relatively rare.Clinicians may be uncertain about the effects of augmentation cystoplasty on reproductive health and pregnancy.Here we describe successful pregnancy outcomes in a woman with a history of myelomeningocele and sigmoidocolocystoplasty.As we know,this is the first detailed case report of pregnancy after sigmoidocystoplasty.We also place this case in the context of 24 related studies and 106 reports of 120 pregnancies by women with augmentation cystoplasty.

CASE PRESENTATlON

Chief complaints

A 30-year-old pregnant woman with a history of augmentation cystoplasty.

History of present illness

A 30-year-old woman(G2P0A1,one spontaneous miscarriage in first trimester)came to us at gestational week 32+3 for obstetric care.She had a history of congenital myelomeningocele,which was repaired at a local hospital as an infant.At age 13,she underwent nephrectomy of the left kidney at a local hospital to treat severe hydronephrosis.Until 18-years-old,she suffered from urinary incontinence and nocturnal enuresis which gradually resolved after age 18.However,she continued to experience mental distress due to dysuria as well as high urinary frequency and urgency.At age 21,these symptoms worsened and she visited the urology department of our hospital.Color Doppler ultrasonography revealed hydronephrosis of the right kidney as well as stones in the bilateral lower ureter and trabecular bladder.Urodynamics testing indicated low bladder compliance leading to a diagnosis of neurogenic bladder.The patient underwent augmentation sigmoidocolocystoplasty,during which the bladder was observed to have a pear shape with thick walls.A sigmoid colon segment 15 cm long was selected and clamanastomosed to the bi-valved bladder,while taking care to preserve the mesentery vascular supply.A suprapubic tube was secured in the bladder and the patient self-catheterized until regaining continence at 4 mo after surgery.

At the age of 22,the woman came to the gynecology department of our hospital with a complaint of excessive menses volume.Examinations indicated large intramural myoma and severe anemia.She was given a transfusion of 3 units of erythrocyte suspension,after which abdominal myomectomy was performed.During the procedure,the intestine,left side of the uterus,left adnexa,omentum and mesentery were discovered to be extensively adhered to one another.A myoma of diameter 6 cm with a clear border was observed on the right side of the uterus deep inside the uterine cavity.

We spent some time exploring small shops and lesser-known museums and churches. We walked along canals and down narrow lanes, seeing a different Paris, but still not making any real contact with the people of this magnificent city.

The prince drained off the wine and answered: O king of the world! learn and know that I have only one aim in life, and this is to know what the rose did to the cypress

The patient had no family history of similar illnesses.

The King mourned, but he did not think that the Queen had done the wicked deed, and as he was afraid the maiden would also be taken from him, he wanted to take her with him

Personal and family history

When the woman returned to us at the age of 30-years-old and in gestational week 32+3 she reported becoming incontinent starting in the second trimester and experiencing urinary incontinence when standing,dysuria when squatting and incomplete bladder emptying.Previous prenatal examinations and obstetric assessments at a local hospital revealed no fetal congenital anomalies.At 26 wk of gestation,she developed acute pyelonephritis in the right kidney and progressive hydronephrosis;the renal pelvis dilated to a thickness of 4.6 cm with parenchymal thickness 2.0 cm and the diameter of the upper right ureter increased to 1 cm.Because bladder deformity and the trabecula made it difficult to find the ureteric orifice,we failed to place a double pigtail ureteral stent under cystoscopy and instead performed percutaneous nephrostomy drainage.There was no change in creatinine clearance in the serial examinations and serial urine dipsticks for protein and occult blood were negative.In the third trimester,the patient showed elevated liver enzymes and itching over the entire body.After testing negative for hepatitis virus infection,she was given oral transmetil and liver function gradually returned to normal.During the entire pregnancy,she suffered two urinary tract infections which were treated promptly with cefoxitin and ceftriaxone.

Physical examination

Abdominal enlargement,other signs were negative.

THERE was once upon a time a king who was so much beloved by his subjects that he thought himself the happiest monarch1 in the whole world, and he had everything his heart could desire. His palace was filled with the rarest of curiosities, and his gardens with the sweetest flowers, while in the marble stalls of his stables stood a row of milk-white Arabs, with big brown eyes.

Laboratory examinations

There was no change in creatinine clearance in the serial examinations and serial urine dipsticks for protein and occult blood were negative.

Imaging examinations

The patient provided written informed consent to participate in this study.Written informed consent was obtained for the publication of any potentially identifiable images or data included in this article.

FlNAL DlAGNOSlS

Pregnant woman with a history of augmentation cystoplasty and isolated kidney.

TREATMENT

Given the patient’s history of myomectomy deep inside the uterine cavity,we performed a cesarian section under general anesthesia in the presence of an experienced obstetrician and reconstructive urological surgeon at gestational week 40+2.During the procedure,which took 167 min,dense adhesions between the omentum and the parietal peritoneum were observed.The bowel loop,which was used for augmentation,was draped over the entire anterior surface of the uterus.The mesentery of the neobladder went across the uterus from the left side.Saline solution was injected to expand the bladder and neobladder until their interface with surrounding structures was obvious.The adhesion between the uterus and neobladder was dissected with an ultrasonic scalpel.Left lateral traction was applied to the neobladder and finally a right lateral longitudinal incision was made(Figures 2 and 3).A live female newborn weighing 2790 g was delivered.Apgar scores were 9.9 at 1.5 min and 10 at 10 min.No sign of injury to the vascular pedicle of the neobladder was found.Mother and child recovered normally and were discharged 1 wk after delivery.

OUTCOME AND FOLLOW-UP

Our review of the literature indicates no consensus on a particular mode of delivery as the best for women with augmentation cystoplasty.Of 101 pregnancies for which the mode of delivery was described(including the present case),72 were vaginal deliveries,with or without instrumental extraction,while the remaining 29 were by cesarean section,13 of which were conducted because of obstetric indications.

58. They lived happily ever afterward: The Grimms changed the story considerably138 to try to justify139 the father s redemption and ability to live happily ever after. However, many critics, such as Hans Dieckmann, find the ending disturbing and even unethical. The father, who was too weak to resist the evil suggestion of his wife and with her abandoned the children in the forest, is not only not punished for his highly immoral140 way of acting141 but even gets to enjoy the treasures the children bring back (Dieckmann 1986). Also note that part of their happiness centers on their acquisition of material wealth.Return to place in story.

DlSCUSSlON

As augmentation cystoplasty becomes more common,clinicians and patients may wish to understand in detail whether it influences pregnancy outcomes.The present case highlights that the procedure need not have negative impacts on such outcomes,even when the patient has a history of myelomeningocele surgical repair,left nephrectomy and repeated urinary tract infections.

To put the present case in perspective with other clinical experiences,we reviewed the literature on outcomes of pregnancies involving women with augmentation cystoplasty(Table 1)[2-25].The main indication for reconstruction in published cases is myelodysplasia which is also normally an indication for invasive prenatal diagnosis using,for example,amniocentesis.However,amniocentesis may not be appropriate if the patient shows adhesions due to previous extensive abdominopelvic surgeries and if the mesenteric blood supply may be damaged by the procedure.While one report of patients with ileocecal cystoplasty indicated that amniocentesis was not performed because of the risk of injury to the bladder vasculature[3],other reports of patients with augmentation cystoplasty showed that it can be performed without complications[4,5].We recommend adequate doctor-patient communication of the potential risks of different methods of prenatal screening.Our patient refused amniocentesis after prolonged consideration so instead we performed color Doppler ultrasonography.

Our patient suffered repeated urinary tract infections and had a history of pyelonephritis and hydronephrosis.These features appear to affect 60%-100% of pregnant women with a history of augmentation cystoplasty[4-6].Most studies recommend monthly culture tests of midstream urine to detect and treat infections early and completely.Recurrent urinary tract infections have been associated with premature labor[4,5,7,9,17,26],but our review of 104 pregnancies involving women with a history of augmentation cystoplasty,including the present case,showed that only 11(10.6%)ended in preterm births.Our analysis of the literature suggests that most reports of premature labor in women with augmentation cystoplasty and recurrent urinary tract infections were published before 2002.Thissuggests that clinical management of such women has improved.

Our patient had a history of hydronephrosis during pregnancy,and we identified nine patients who had suffered this condition[4,7-9,11,15,17].Seven of those cases were treated with ureteral stent or,as in the present case,nephrostomy.Both procedures can relieve obstructions and thereby protect renal function[27].One study recommended assaying serum creatine monthly and if it increases,performing renal ultrasonography of the upper tract to detect progressive hydronephrosis[4].Although our patient had only one functioning kidney and experienced two urinary tract infections,pyelonephritis and progressive hydronephrosis during pregnancy,her renal function remained normal.This was likely because she was treated promptly with antibiotics and nephrostomy.Similarly,renal function remained stable throughout pregnancy in all but two of the pregnancies involving women with an augmentation cystoplasty that we identified in the literature.Those two patients suffered complications of hyperchloremic acidosis and hypokalemia[2],or anemia and anuria secondary to bilateral ureteral obstruction[4].

Telephone follow-up with the patient at 42 d after delivery revealed that she had suffered another urinary tract infection which was treated with ceftazidime.The nephrostomy tube was removed at 5 wk after delivery,after which the patient intermittently self-catheterized to maintain urinary continence.No significant problems were observed in the newborn.

On the other hand,Cesarean section can damage the neobladder and vascular pedicle[6]leading some to suggest that it should be avoided unless there is a positive obstetric indication[28].Most reports of cesarean sections performed on pregnant women with a history of augmentation cystoplasty have involved a classical incision rather than a low-segment uterine incision.In fact,some advocate making the incision in an upper rather than lower segment in order to avoid adhesions between the neobladder and surrounding tissues[4,15].In our case,we made a right lateral longitudinal incision of the corpus uteri,based on the position of the mesentery.Injury of mesentery to the neobladder can occur whether the incision is made higher or lower since the augmentation cystoplasty may be draped over the uterus[12,14].We suggest that the choice of uterine incision should be individualized.We also recommend two measures that may have contributed to the good outcomes of cesarean section for our patient:(1)Preoperative imaging,especially magnetic resonance imaging,should be performed to gain thorough insight into the patient`s anatomy;and(2)The cesarean section should be performed in the presence of a urologist with knowledge of the cystoplasty,as emphasized in several previous studies[7,10,28,29].Vesical injection of saline or methylene blue solution may facilitate dissection in patients with marked adhesion,as in the present case.If perforation of the neobladder is suspected,the potential leak should be inspected[4].

She reminded her how she had not followed her instructions, but had eaten the first onion with all its skins, on which account her first-born had been a lindorm

It is recommended that all patients who have undergone augmentation cystoplasty alone can deliver vaginally in the absence of any obstetric indications[4,5].For women with a history of enterocystoplasty who had undergone insertion of an artificial urinary sphincter(AUS)together,vaginal delivery may not be indicated because pressure on the AUS may cause ischemic damage to the urinary continence mechanism.Indeed,some studies have suggested that vaginal delivery may increase risk of postpartum incontinence in women who have undergone augmentation cystoplasty combined with bladder neck reconstruction[5].Other studies,however,have shown that the presence of a reconstructed lower urinary tract,with or without an artificial urinary sphincter,does not preclude normal pregnancy and vaginal delivery[6]and need not affect postpartum continence[10].

Ensuring good pain control during delivery can be challenging in patients with myelodysplasia,such as the present case.Epidural anesthesia is generally not possible in these patients so general anesthesia may be required during cesarean section[11],as we performed in our patient.It may be possible to achieve painless vaginal delivery by inducing extradural anesthesia above the point of myelomeningocele repair[16].

CONCLUSlON

The present case,together with a relatively small amount of literature,suggests that women who undergo augmentation cystoplasty can have a healthy reproductive life.The most common complications are urinary tract infections and hydronephrosis.During pregnancy,clinicians should closely monitor urine and renal function.Ureteral stent or nephrostomy may be necessary to relieve obstructions and preserve renal function.Augmentation cystoplasty by itself is not a contraindication for vaginal delivery,though it may not be optimal for women who undergo bladder neck surgery.Research is needed to identify the optimal delivery method for such women.When performing cesarean sections on such women,attention should be paid to exploratory preoperative imaging and to consultation with the urologist familiar with the patient`s cystoplasty.

It s the most amazing thing that will ever happen in my life. This was Roger s first National League home run, and I caught the ball. Tears rolled down my face. Roger came running out at the end of the inning and said, I can t believe it. I said, You can t? I can t!

FOOTNOTES

Ruan J contributed to the data acquisition and analysis,preparation and writing of the manuscript;Duan MF contributed to the collection of history and patient follow-up;Luo DY study coordination,drafting and revision of the manuscript.

The patient was admitted at gestational week 39+3 to the obstetrics department.Ultrasonography and magnetic resonance imaging showed that the bladder was vertically stretched by the pregnant uterus to a level approximately 3.1 cm above the umbilical level and 2.9 cm below the fundus(Figure 1).This implied a severe adhesion between her uterus and the neobladder.

The authors declare that they have no conflicts of interest to disclose.

The authors have read the CARE Checklist(2016),and the manuscript was prepared and revised according to the CARE Checklist(2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial(CC BYNC 4.0)license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Jie Ruan 0000-0001-5104-4343;Li Zhang 0000-0003-2859-8254;Mei-Fan Duan 0000-0002-7871-7365;De-Yi Luo 0000-0002-7282-1006.

Chinese Society of Perinatal Medicine.

The King45 himself, old as he was, could not help watching her, and telling the Queen softly that it was a long time since he had seen so beautiful and lovely a creature.

Ma YJ

Filipodia

When she had lived there some time, it happened that the King of the country was hunting in the forest, and his hunters came to the tree on which the maiden sat

Ma YJ

1 Vordermark JS,Deshon GE,Agee RE.Management of pregnancy after major urinary reconstruction.

1990;75: 564-567[PMID: 2406671]

2 Smith AM.Enterocystoplasty and pregnancy.

1973;117: 527-529[PMID: 4582708 DOI:10.1016/0002-9378(73)90115-4]

3 Doyle BA,Smith SP,Stempel LE.Urinary undiversion and pregnancy.

1988;158: 1131-1132[PMID: 3369496 DOI: 10.1016/0002-9378(88)90238-4]

4 Hill DE,Kramer SA.Management of pregnancy after augmentation cystoplasty.

1990;144: 457-9;discussion 460[PMID: 2374220 DOI: 10.1016/s0022-5347(17)39488-0]

5 Fenn N,Barrington JW,Stephenson TP.Clam enterocystoplasty and pregnancy.

1995;75: 85-86[PMID:7850305 DOI: 10.1111/j.1464-410x.1995.tb07240.x]

6 Creagh TA,McInerney PD,Thomas PJ,Mundy AR.Pregnancy after lower urinary tract reconstruction in women.

1995;154: 1323-1324[PMID: 7658529 DOI: 10.1016/S0022-5347(01)66848-4]

7 Yamazaki Y,Yago R,Toma H,Onodera J,Nakabayashi M.[Pregnancy after augmentation cystoplasty.A case report].

1997;88: 632-635[PMID: 9234621 DOI: 10.5980/jpnjurol1989.88.632]

8 Yamamoto M,Yamada K,Hirata N,Kawata Y,Hirayama A,Kashiwai H,Momose H,Shiomi T,Suemori T,Natsume O,Hirao Y.[Pregnancy and delivery in the patients with spina bifida--report of 5 cases].

1997;88: 1005-1012[PMID: 9465600 DOI: 10.5980/jpnjurol1989.88.1005]

9 Taniguchi A,Kakizaki H,Murakumo M,Nonomura K,Koyanagi T.[Management of pregnancy and delivery after augmentation cystoplasty].

2002;93: 39-43[PMID: 11842538 DOI:10.5980/jpnjurol1989.93.39]

10 Quenneville V,Beurton D,Thomas L,Fontaine E.Pregnancy and vaginal delivery after augmentation cystoplasty.

2003;91: 893-894[PMID: 12780859 DOI: 10.1046/j.1464-410x.2003.04260.x]

11 Greenwell TJ,Venn SN,Creighton S,Leaver RB,Woodhouse CR.Pregnancy after lower urinary tract reconstruction for congenital abnormalities.

2003;92: 773-777[PMID: 14616465 DOI: 10.1046/j.1464-410x.2003.04465.x]

12 Shaikh A,Ahsan S,Zaidi Z.Pregnancy after augmentation cystoplasty.

2006;56: 465-467[PMID:17144396]

13 Sagili H,Singh P,Manikandan K,Dasari P.Vaginal delivery after augmentation cystoplasty and Mitrofanoff's procedure for incontinence following traumatic bladder neck transection.

2013;33: 740-741[PMID: 24127970 DOI: 10.3109/01443615.2013.817385]

14 Kapoor D,Chipde SS,Agrawal S,Chipde S,Kapoor R.Delivery after augmentation cystoplasty: Implications and precautions.

2014;5: 206-209[PMID: 24678231 DOI: 10.4103/0976-9668.127334]

15 Correia C,Pardal C,Igreja J.Management of pregnancy after augmentation cystoplasty.

2015;2015[PMID: 25994430 DOI: 10.1136/bcr-2015-209304]

16 Kameda M,Takahara E,Kobayashi M,Sasaki K,Morihara R,Date I.Pregnancy and delivery after myelomeningocele repair,ventriculoperitoneal shunt implantation,and augmentation cystoplasty.

2017;33: 1015-1017[PMID: 28247115 DOI: 10.1007/s00381-017-3364-7]

17 Dap M,Larmure O,Morel O,Lemelle JL.Pregnancy outcomes among patients with prior bladder exstrophy.

2017;139: 368-369[PMID: 28833084 DOI: 10.1002/ijgo.12307]

18 Hayashi Y,Nishimura E,Shimizu S,Miyano G,Okawada M,Nagae I,Lane GJ,Katsumata K,Yamataka A,Tsuchida A.Sigmoidocolocystoplasty for neurogenic bladder reviewed after 20 years.

2017;52: 2070-2073[PMID:29223546 DOI: 10.1016/j.jpedsurg.2017.08.029]

19 GOODWIN WE,BETENBAUGH HS,HAYNES VE,ROSS SC.Full-term pregnancy and spontaneous delivery after ileocystoplasty.

1962;181: 906-908[PMID: 13900347 DOI: 10.1001/jama.1962.03050360092019d]

20 Kirkeby LT,Beier-Holgersen R,Nordling J.Successful pregnancy after ileocystoplasty.Case report.

1992;26: 195[PMID: 1626210 DOI: 10.1080/00365599.1992.11690455]

21 Muthulakshmi B,Allahdin S.Pregnancy with clam ileocystoplasty and appendix Mitrofanoff procedure: vaginal delivery can be considered.

2010;21: 893-894[PMID: 20401467 DOI: 10.1007/s00192-009-1073-9]

22 Henry L,Cormier L,Fontaine B,Mangin P.[Vaginal delivery in a patient with an artificial urinary sphincter and augmentation enterocystoplasty].

2002;12: 303-305[PMID: 12108348]

23 Natarajan V,Kapur D,Sharma S,Singh G.Pregnancy in patients with spina bifida and urinary diversion.

2002;13: 383-385[PMID: 12466911 DOI: 10.1007/s001920200085]

24 Le Liepvre H,Dinh A,Idiard-Chamois B,Chartier-Kastler E,Phé V,Even A,Robain G,Denys P.Pregnancy in spinal cord-injured women,a cohort study of 37 pregnancies in 25 women.

2017;55: 167-171[PMID: 27670808 DOI: 10.1038/sc.2016.138]

25 Hensle TW,Bingham JB,Reiley EA,Cleary-Goldman JE,Malone FD,Robinson JN.The urological care and outcome of pregnancy after urinary tract reconstruction.

2004;93: 588-590[PMID: 15008736 DOI:10.1111/j.1464-410x.2003.04665.x]

26 Bey E,Perrouin-Verbe B,Reiss B,Lefort M,Le Normand L,Perrouin-Verbe MA.Outcomes of pregnancy and delivery in women with continent lower urinary tract reconstruction: systematic review of the literature.

2021;32:1707-1717[PMID: 34125241 DOI: 10.1007/s00192-021-04856-1]

27 Voges GE,Orestano L,Schumacher S,Hohenfellner R.[Continent urinary diversion and pregnancy].

1995;55: 711-715[PMID: 8582593 DOI: 10.1055/s-2007-1022320]

28 Greenwell TJ,Venn SN,Mundy AR.Augmentation cystoplasty.

2001;88: 511-525[PMID: 11678743 DOI:10.1046/j.1464-4096.2001.001206]

29 Niknejad KG,Atala A.Bladder augmentation techniques in women.

2000;11:156-169[PMID: 11484743 DOI: 10.1007/s001920070043]