Poor baseline renal function may potentially expose patients to severe electrolyte abnormalities and worsening renal function and is a relative contraindication. However, in patients with renal dysfunction that is a direct result of bladder dysfunction with elevated storage pressure, AC may be appropriate and help stabilize renal function [19]. Other relative contraindications include inflammatory bowel disease (Crohn’s disease), irradiated bowel, short gut syndrome, bladder tumors, and liver failure [20].

Extensive history and physical exam, serum chemistries (complete blood count, electrolyte and creatinine levels, coagulation factors), urine cytology, urinalysis, and cultures are required. All patients should also undergo anatomic and functional assessment of the urinary tract with cystoscopy (to exclude intravesical abnormalities such as tumors), urodynamics (to characterize bladder capacity, compliance, or uninhibited detrusor contractions, to assess detrusor and Valsalva leak point pressures, and to rule out infravesical obstruction), cystography (to rule out vesicoureteral reflux), and upper tract imaging (ultrasound or computerized tomography; to document the presence of hydronephrosis or stone disease). A history of bowel disease may require preoperative bowel imaging studies or colonoscopy. A voiding diary can help in planning for the final reservoir size by assessing 24-h urine volume [21], although the augmentation usually enlarges with time. The need for latex precautions for at-risk patients with spinal dysraphism should also be kept in mind. Planning for other concomitant procedures such as a continent catheterizable stoma (using the Mitrofanoff or Monti principles), ureteral reimplantation, or bladder neck management is an essential prerequisite before considering the intervention [22]. Finally, since CIC is frequently a necessary adjunct, adequate manual dexterity and cognitive abilities are prerequisites to be considered an adequate surgical candidate and it is crucial, in the preoperative visits, to reinforce the importance of compliance with CIC postoperatively [23].

With the ultimate goals of lowering urinary storage pressures, preserving renal function, maximizing continence, and hopefully maintaining volitional voiding, the clam ileocystoplasty is the most commonly reported technique.

With the patient supine or in the low lithotomy position, a midline infraumbilical incision is usually adequate to gain intraperitoneal access, but a short Pfannenstiel incision has also been described [50]. With a Foley catheter in the surgical field, the native bladder is distended. The loose areolar tissue is bluntly dissected to expose the anterior and perivesical spaces [51]. With stay sutures on either side, the bladder is bivalved in the coronal or sagittal plane [11]. A “smile” incision has also been described [52]. The bladder incision should be a broad opening to create a large anastomosis and prevent an hourglass deformity [35]. Occasionally, supratrigonal cystectomy can be done for conditions such as severe interstitial cystitis [53].

A 15–40 cm segment of ileum is then harvested approximately 20 cm proximal to the ileocecal valve on a broad well-vascularized pedicle that may be identified by transillumination. A side-to-side stapled or hand-sewn ileoileostomy reestablishes bowel continuity cephalad to the isolated segment and the mesenteric defect may be closed to prevent internal hernias, or alternatively left open if judged to be wide enough. The isolated segment is irrigated thoroughly until return is clear to prevent intraperitoneal soiling as much as possible. It is then detubularized on its antimesenteric side to prevent intraluminal pressure rises from peristaltic contractions. The segment is reconfigured into a U, S, or W shape [36, 54] (Figs. 12.1 and 12.2). The surgeon should make sure that the segment reach down into the pelvis without tension or twist on the mesentery. The ileal patch can then be reapproximated to the edges of the cystotomy, starting posteriorly, with one to two layers of 2-0 continuous absorbable sutures. The vesico-intestinal anastomosis is tested for watertightness and drains are inserted prior to closing the abdominal wall in a standard fashion. The goal is to create a new reservoir in as spherical a configuration as possible to maximize the surface area as per Laplace’s law.

More recently, minimally invasive (laparoscopic and robot-assisted) approaches have become more frequently reported from a number of institutions. Depending on the surgeon’s experience and expertise, most of the suturing can be performed intra- or extracorporeally [55]. More technically demanding, these minimally invasive techniques have the advantages of reduced perioperative pain and morbidity, shorter hospital stay, and cosmetic superiority, with outcomes similar to the open surgery [20, 56–58].

As for any major abdominal surgery, intravenous fluids and bowel rest are maintained for several days with close monitoring of inputs and outputs. Routine nasogastric tube drainage is not required as it has not been shown to lead to faster bowel function recovery [59]. Antibiotic prophylaxis for 24 h [60], thromboprophylaxis, and early ambulation are also recommended. A closed-suction pelvic drain is kept until output tapers off or once peritoneal fluid is confirmed with fluid chemistries [21].

Proper drainage and irrigation of the augment, initially several times a day with 50–100 mL of sterile saline and then gradually reduced to an as-needed basis, are necessary to prevent mucus from accumulating, plugging the catheters and disrupting the fresh anastomosis. We usually favor a Foley urethral catheter (16–18 Fr) and a suprapubic (SP) Malecot catheter (20–22 Fr). Both tubes are kept for approximately 4 weeks, after which a cystogram is performed. The Foley is then removed if there is no extravasation and patients resume spontaneous voiding. Post-void residuals are closely monitored initially as well as on a long-term basis, and CIC is initiated when needed. The SP tube may be kept for 1–2 more weeks longer and used for daily bladder irrigation. Although there is no evidence to support it, antimicrobial prophylaxis can be administered at the time of catheter removal since bacterial colonization has likely occurred [33].

Flood and colleagues reported an overall 28 % early and 44 % late complication rate in this difficult group of patients, with a chance of requiring a reintervention ranging from 15 % to 40 % [61–63]. Table 12.3 lists the possible consequences of such procedure.