The preoperative surgical evaluation should include a thorough history and physical examination to determine the underlying etiology of the bladder dysfunction, as well as laboratory, radiographic, endoscopic, and urodynamic studies. It is largely upon these results that the surgeon will decide whether the patient requires augmentation or substitution cystoplasty and what appropriate management of the ureters and outlet should be.
The preoperative laboratory evaluation is necessary to assess renal function and acid-base status. Serum creatinine, a blood urea nitrogen (BUN), and 24-h creatinine clearance are helpful measures to assess renal status, particularly in those individuals who may have renal insufficiency or chronic renal failure. Urinalysis and culture should be performed to identify urinary infection, which should be eradicated prior to reconstruction. Urinary cytology may be helpful in those patients with sensory urgency in order to exclude carcinoma in situ.
The entire urinary tract needs to be imaged prior to reconstruction. Upper tract evaluation will initially begin with intravenous urogram to assess the upper tracts, particularly if ureteral reconstruction is necessary. Voiding cystography will identify bladder abnormalities that may influence a decision regarding bladder substitution rather than simple augmentation and will identify the presence and severity of vesicoure-teric reflux. A cystogram may help to characterize the competence of the sphincter mechanisms and lower urinary tract patency.
Urodynamic studies should evaluate bladder and outlet function during filling, storage, and voiding. This is best accomplished by using multichannel fluorourodynamics, which combine electronic urodynamic data collection and simultaneous cystourothrography. Filling cystometrogram will assess compliance, stability, storage, sensation, and capacity. Storage after filling will further define stability and competence of the outlet. Pressure flow studies will document voiding dysfunction and the Valsalva leak-point pressure can be used to evaluate the bladder outlet for intrinsic sphincter deficiency (10). Other urodynamic tools such as the urethral pressure profile, electromyography, and fluoroscopy may further enhance information regarding the continence mechanisms.
Endoscopic evaluation should precede all urinary tract reconstructive procedures to identify any structural bladder or urethral problems that may alter the choice of the proposed reconstructive procedure. Significant outlet findings, urethral stricture disease, or trauma may help predict continence or catheterization difficulties, particularly in those individuals who have had prior outlet procedures performed. Finally, cystourethroscopy will identify any concomitant bladder pathology such as tumors, stones, or diverticuli that need to be identified prior to the reconstruction.
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