Informed consent is a process of communication between the health care provider and the patient that ultimately culminates in the authorization or refusal of a specific intervention.¹ The process involves multiple elements, including disclosure, comprehension, voluntary choice, and authorization. Physicians disclose understandable information to patients to facilitate informed choice. In the pediatric population, such decisions regarding interventions are made by the parent/guardian on behalf of their child due to young age.

Bladder augmentation (BA) is a major intra-abdominal procedure that is accompanied by risks and benefits which must be discussed prior to its performance. In pediatrics BA is most frequently employed in the neurogenic bladder population, although it has been performed in pediatric patients with bladder/cloacal exstrophy and/or posterior urethral valves.² The benefits of BA in a patient with upper tract injury from medically refractory impaired bladder compliance could be viewed from the perspective of avoidance of renal replacement therapy if the hostile bladder continues unimpeded. In contrast, urinary incontinence from abnormal bladder capacity or storage characteristics is another clinical scenario where BA may be considered as part of the surgical treatment plan. The benefits of achieving urinary continence by means of surgical reconstructive procedures such as BA when medical management fails have been well documented.^3,4

However, these benefits of BA are inextricably linked to its postoperative risks with extended follow-up. Multiple prior single-institution studies have described a high percentage of patients who underwent BA undergoing future surgeries for a litany of augmentation-associated complications such as bladder calculi, bladder perforation, bowel obstruction, repeat BA, and even bladder cancer.^2,5-10 Clinical studies that quantify risk of complications over specific a time frame following BA, while accounting for patients having multiple complications and differential follow-up, are useful when counseling families prior to performing BA. Szymanski et al in a single-institution cohort of 400 patients with spina bifida reported the risk of any subsequent surgery within the first 5 years after BA occurred in 1 in 4 of their patients; however, complications continued to accumulate throughout follow-up.⁵ The risk increased to nearly 1 in 2 patients (43.9%) at 10 years and over half (57.4%) at 20 years. Schlomer and Copp using a national pediatric database described 10-year cumulative incidence ranges for the following outcomes after BA: bladder stones (13.3%-36.0%), bladder perforation (2.9%-6.4%), small-bowel obstruction (5.2%-10.3%), and reaugmentation (5.2%-13.4%).²

Bladder calculi are the most frequently reported additional surgery after BA. The mucus that is produced by the intestinal segment used in BA is theorized to be the nidus for stone formation, and daily bladder irrigations to remove the mucus have been shown to reduce the risk of bladder stone formation.^8,9 Endoscopic procedures can be safely and effective performed to remove the bladder stone as an alternative to open cystolithotomy, similar to non-BA patients.¹¹

Bladder perforation is a potentially lethal complication of BA and fortunately not as commonly observed as bladder calculi. Avoidance of prolonged intervals of noncatheterization can minimize the risk of bladder rupture.^8,9 BA surgical technique can also reduce risk of bladder perforation. Utilization of a detubularized and reconfigured intestinal segment had a lower risk of bladder perforation or reaugmentation compared to nondetubularized and reconfigured segments.⁵ Bladder perforation risk was 9.6% for patients undergoing vs 23.7% for those not undergoing detubularized reconfigured ileocystoplasty. Similarly reaugmentation rate was 5.3% for patients undergoing vs 15.2% for those not undergoing detubularized reconfigured ileocystoplasty.

The most concerning long-term reported complication of BA is carcinogenesis, and its causality has not been proven to place a moratorium on the procedure. Too few long-term data are available, probably because of the too low incidence and the long latency between surgery and cancer occurrence. Higuchi et al reported on 153 patients treated with BA matched 1:1 to a control group treated with intermittent catheterization based on etiology of bladder dysfunction, gender, and age.¹⁰ There was no difference in the incidence of bladder cancer in patients with BA (7 patients, 4.6%) vs controls (4 patients, 2.6%). In addition, there was no difference between the 2 groups regarding age at diagnosis, stage at diagnosis, mortality rate, or median survival.¹⁰

Lastly, in the scope of lower urinary tract reconstructive surgery performed in pediatric patients who undergo BA, a significant percentage undergo the Mitrofanoff procedure.² Creation of a continent catehetrizable channel such as the Mitrofanoff procedure carries additional risks for needing revisionary procedures for the channels.¹² These additional channel procedures only “augment” the reported risks of additional surgery compared to BA alone.

At the current time, BA despite its risks will continue to play a specific role in the surgical care of pediatric patients with complex abnormal lower urinary tract. BA is not unlike other surgical procedures with increasing complications with continuous follow-up.^2,5 This facts makes the transition from pediatric to adult urology critical for ongoing identification of such issues after BA and mitigation of them when possible. Therefore, parents of children undergoing BA should be told by their surgeon that the future holds a lifetime need for close urological surveillance.