UROGYNECOLOGICAL SURGERY CURRENT APPROACHES AND TREATMENTS FOR INCONTINENCE

Urogynecological_Surgery_Kapak

SURGICAL TREATMENT OF OVERACTIVE BLADDER

Pınar Yıldız1 Bahadır Alper Sargın2

1Ümraniye Training and Research Hospital, Department of Gynecology and Obstetrics, İstanbul, Türkiye
2Kartal Dr. Lütfi Kırdar City Hospital, Department of Gynecology and Obstetrics, İstanbul, Türkiye

Yıldız P, Sargın BA. Surgical Treatment of Overactive Bladder. In: Balsak D, Çim N, Ege S editors. Urogynecological Surgery Current Approaches and Treatments for Incontinence. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.139-148.

ABSTRACT

Overactive bladder (OAB) that remains refractory to conservative, pharmacological, and minimally invasive therapies may require invasive surgical management. The key surgical options are augmentation cystoplasty (AC), urinary diversion (UD), and detrusor myectomy (DM). AC is a reconstructive procedure using an intestinal segment (often ileum) to enlarge the bladder and reduce intravesical pressure. It is indicated as a last resort for severe OAB unresponsive to other treatments. AC can increase bladder capacity 3-4-fold and achieve continence improvements above 90%. However, it necessitates careful patient selection and counseling, as many patients require lifelong intermittent catheterization and ongoing surveillance. AC carries significant risks, including early complications such as urinary leakage and fistula formation. Long-term issues include recurrent urinary tract infections and bladder stone formation, metabolic acidosis and vitamin B12 deficiency, and a small risk of malignancy in the augmented bladder.

UD involves rerouting urine to an external ostomy (ileal conduit) or an internal reservoir, bypassing the native bladder. It is an effective definitive solution for refractory OAB. Incontinent and continent diversion techniques exist, including orthotopic neobladder reconstruction. UD’s complications include major surgical risks and long-term anatomical issues such as strictures at uretero-intestinal anastomoses causing hydronephrosis, parastomal hernias, and stomal stenosis requiring revision. Patients also face chronic infection and stone formation, as well as metabolic acidosis, vitamin B12 deficiency, and progressive renal function decline. Patients with continent diversions report better body image and overall high satisfaction despite the significant lifestyle alterations.

DM (autoaugmentation) entails excising a portion of the detrusor muscle to create a low-pressure pseudodiverticulum, thus increasing capacity without using bowel. Although DM offers short-term symptom relief, fibrosis often causes the benefits to diminish over time. Most patients require subsequent interventions and intermittent catheterization, and current guidelines do not recommend DM due to poor long-term efficacy.

Keywords: Overactive bladder; Refractory overactive bladder; Augmentasyon cystoplasty; Urinary diversion; Detrusor myectomy

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