title: Ureteral tissue balloon expansion for laparoscopic bladder augmentation: survival study.
abstract: OBJECTIVE
  The search for the perfect urinary bladder substitute continues. Despite their inherent limitations, intestinal segments remain the commonest material for bladder reconstruction. The ureter, with its transitional epithelium, may be the ideal tissue to augment the bladder. Ikeguchi et al reported the feasibility of chronic ureteral balloon expansion by open surgery (J Urol 1998;159:1665). Herein, we propose a completely minimally invasive approach to balloon overdilate a segment of juxtavesical ureter incrementally and to use this in-line tissue-expanded ureteral patch to augment the bladder laparoscopically.
  
  
  METHODS
  In five female pigs, a novel ureteral expansion balloon device (Microvasive, MA) was inserted percutaneously and advanced antegrade into the juxtavesical ureter. The device has two channels: one for balloon inflation and the other for draining the kidney. After progressive ureteral expansion over a 3- to 4-week period, laparoscopic augmentation ureterocystoplasty was performed. Animals were euthanized at 15 days (N = 1), 1 month (N = 1), 2 months (N = 1), and 3 months (N = 2).
  
  
  RESULTS
  Percutaneous balloon device placement was technically successful in all five cases (mean operating room time 52 minutes). The mean volume of the tissue-expanded ureter at 1, 2, and 3 weeks was 12.9 cc, 60.3 cc, and 171.8 cc, respectively. Laparoscopic augmentation ureterocystoplasty with (N = 3) or without (N = 2) concomitant subtotal cystectomy was technically successful in all five cases without any open conversion. The mean operative time was 126.5 minutes, and the mean blood loss was 29 mL. Postoperative complications consisted of one case each of pyelonephritis and ureteral stricture. At autopsy, the mean capacity of the bladder was 574 mL, and the P(ves) at maximum capacity was 14 cm H(2)O. Histologic examination of the tissue-expanded ureter revealed regenerated transitional epithelium and muscle hypertrophy.
  
  
  CONCLUSIONS
  Chronic ureteral tissue expansion can be carried out safely and efficaciously. The expanded tissue is thick, healthy, and vascular, with histologic features of normal transitional epithelium and muscle hypertrophy and hyperplasia. This expanded ureteral tissue can be used to augment the bladder with laparoscopic techniques. Such augmented bladders do not show significant shrinkage and possess urodynamic characteristic of normal capacity and normal compliance over a follow-up of 3 months.
authors.affiliation: Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
authors.forename: Mihir M
authors.initials: MM
authors.lastname: Desai
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
authors.forename: Mahesh
authors.initials: M
authors.lastname: Goel
authors.forename: Sidney C
authors.initials: SC
authors.lastname: Abreu
authors.forename: Anup P
authors.initials: AP
authors.lastname: Ramani
authors.forename: Mohamed A
authors.initials: MA
authors.lastname: Bedaiwy
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
authors.forename: Surena F
authors.initials: SF
authors.lastname: Matin
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Steinberg
authors.forename: Jennifer
authors.initials: J
authors.lastname: Brainard
authors.forename: David
authors.initials: D
authors.lastname: Robertson
authors.forename: Gyung Tak
authors.initials: GT
authors.lastname: Sung
mesh_terms: D000714:Anastomosis, Surgical; D000818:Animals; D001707:Biopsy, Needle; D002404:Catheterization / Q000379:methods*; D004195:Disease Models, Animal; D005260:Female; D007150:Immunohistochemistry; D010535:Laparoscopy / Q000379:methods*; D020127:Recovery of Function; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D013552:Swine; D013997:Time Factors; D015626:Tissue Expansion; D014513:Ureter / Q000473:pathology / Q000601:surgery*; D001743:Urinary Bladder / Q000473:pathology / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods