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Bladder and Ureter

Insertion of Suprapubic Catheter

Retropubic Urethropexy:
and Burch Operations


and Ureteroneocystostomy
With Bladder Flap

End-to-Side Anastomosis

Intestinal Loop
Urinary Diversion



Clam Gastrocystoplasty

"Clam" Gastrocystoplasty

Pelvic radiation is frequently necessary for the treatment of gynecologic cancer. Normally, the bladder tolerates irradiation therapy up to 7000 cGy without significant sequela. In some patients, however, radiation fibrosis develops, creating a small stiff bladder with low capacity and high pressure resulting in total incontinence of urine. Frequently, these patients have a low urethral pressure but an extremely high vesical pressure. The usual urogynecologic pin-up surgical procedures, e.g., the Marshall-Marchetti-Krantz or Burch operations will not alter the physiologic changes that created the problem, i.e., radiation fibrosis of the bladder.

A source of nonirradiated highly vascular tissue placed in the wall of the bladder for augmentation can relieve this disabling and incapacitating situation.

There are cases in which the patient has received no radiation but has a severe detrusor instability of the bladder with total incontinence. Transecting the bladder in the longitudinal plane produces some denervation of the bladder and reduction of detrusor instability. The augmentation of stomach to the transected bladder is referred to as a "clam" procedure and can relieve the incontinence.

Physiologic Changes. The physiologic sequela of removing a small gastric flap from the grater curvature of the stomach has few if any consequences. The augmentation of an opened bladder with this gastric flap has significant physiologic changes. The bladder capacity increases significantly. The usual bladder capacity of a radiation-fibrosed bladder is less than 100 mL. The gastric flap increases the bladder capacity from 300 to 500 mL.

The gastric flap secretes acid. This gives the patient an acid urine that creates an unfavorable environment for bacterial growth.

The gastric flap is quite distensible. Because of this distensibility the bladder, when full of urine, will have a low pressure, usually in the range of 30-40 cm of water. If the urethral pressure has a natural pressure of 70-80 cm of water, continence will be restored. If the urethral pressure is low, continence will be improved if a Goebell-Stoeckel fascia lata sling operation in addition to the clam gastrocystoplasty is performed (see Vagina and Urethra), for discussion of the Goebell-Stoeckel fascia lata sling.


Figure 1 shows the esophagus, stomach, spleen, and omentum. The left gastroepiploic artery for this flap is shown, although the right gastroepiploic artery works equally well. The defects in the mesentery between the short gastric arteries are made, and each short gastric artery is cut and tied. The right gastroepiploic artery is transected at the junction of the duodenum and each of the branches of the right gastroepiploic artery and transected and tied. The GIA (gastrointestinal anastomosis) stapler is placed across the stomach for approximately 6 cm. The base of this triangular flap will be approximately 6 cm.

The right gastroepiploic artery has been transected (bottom). The right side of the wedge of stomach has been cut and stapled. The left portion of the wedge flap is shown with the GIA stapler dividing both the anterior and the posterior gastric wall.

The defect in the stomach is shown, and small incisions are made for a gastrotomy in the proximal and the distal stomach.

A GIA stapler is placed in the small gastrotomy incisions on the greater curvature. The GIA stapler reapproximates the stomach and then cuts between the edges to reestablish continuity.

The remaining defects created by the small stab wound gastrotomies are picked up with Babcock clamps and cross-clamped and stapled with a TA-55 4.8 stapler. The TA-55 stapler closes the two gastrostomy defects. Excessive tissue is cut away.

A feeding tube gastrostomy is placed in the stomach for decompression and possible total enteral nutrition if needed. The procedure is initiated by placing the automatic pursestring suture device across the stomach wall 8-10 cm proximal to the resected and reconstituted gastric flap.

A small gastrotomy is made in the center of the pursestring suture. A stab wound is made in the left upper quadrant of the abdomen, and a No. 22 French Malecot catheter is brought through the abdominal wall to be inserted into the lumen of the stomach.

Figure 8 shows the stomach lumen, the abdominal wall, and the feeding tube gastrostomy catheter (Malecot) in place. The visceral peritoneum of the stomach is sutured to the parietal peritoneum to prevent leakage of gastric juice until mesothelialization has sealed the wound.

The right gastroepiploic artery on the greater curvature of the stomach, a branch of the celiac artery, is shown transected and tied. The remaining short gastric branches of the left gastroepiploic artery are seen transected and tied. The omentum with its attached gastric flap is shown lateral to the left colon. It is placed in the left descending colonic gutter along the line of Toldt. The wedge of stomach with omentum attached is brought down into the lower pelvis. In the bottom portion of this figure, the incision line into the bladder is shown, thus creating an opening shaped like a sea clam. This linear incision (broken line) in the bladder offers a wide defect. Those patients with severe detrusor instability have reduced, uncontrolled contractions of their bladder.

Figure 10 shows the left gastoepiploic artery with its short gastric branches feeding the wedge of the gastric flap. All staples must be completely removed. The presence of staples will create stones in the bladder. The triangle gastric flap is open and now forms the shape of a diamond.

The longitudinally opened bladder is shown-thus its description as a clam. The gastric diamond-shaped flap is sutured into the bladder defect. The suture material should be synthetic absorbable.




At the bottom, the diamond-shaped wedge of stomach is seen sutured in place to the clam gastrocystoplasty-opened bladder, while the reconstituted stomach with its staple line is shown at the top.

We frequently place two Foley catheters in the reconstructed bladder. A transurethral No. 16 French Foley catheter with a 5-mL bag is placed through the urethra into the reconstructed bladder. We frequently perform a small cystotomy 3 cm away from the gastric wedge suture line to insert a second Foley catheter as a suprapubic cystotomy. This double drainage guards against the possibility of mucus produced by the gastric artery plugging up one of the Foley catheters, thus allowing the possibility of a disrupted suture line through elevated hydraulic pressure. A Jackson-Pratt suction drain is brought through the anterior abdominal wall and placed near the bladder suture line. The Foley catheter is left in the bladder for approximately 2 weeks. When drainage has ceased, the Jackson-Pratt suction drain is removed. The patient initiates timed voiding by bearing down. The patient should void every 4-6 hours. Patients are discouraged from getting up at night to void; they are encouraged to void immediate upon arising.

All feedings are initiated when there are excellent bowel sounds and a bowel movement. At this time it will be safe to remove the tube gastrostomy.

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