Please note: This page is intended for healthcare professionals only. It is designed as a general educational guide and does not replace local guidance, senior clinical advice, or individual clinical judgement. Patients should not use this page as medical advice and should seek advice from an appropriate healthcare professional.
Functional, Continence & Reconstruction
This is a very brief introduction into most common urological operations. The list below is not exhaustive of all urological operations, but the procedures an SHO will more commonly encounter.
⚠️ Postoperative care is procedure and patient-specific. Always read the operation note before taking any action. Instructions regarding catheters, drains, stents, antibiotics, anticoagulation, imaging, and follow-up may differ between patients.
Functional urology deals with problems of bladder storage, bladder emptying, urinary incontinence, and urethral/bladder reconstruction. These operations are often not cancer operations; they are done to improve symptoms, protect the upper tracts, preserve continence, or create a safe way for the patient to empty their bladder.
Patient information leaflets
- Bladder procedures – HERE
- Urethral procedures – HERE
Bladder Procedures
Intradetrusor Botox (Botulinum Toxin A)
- Cystoscopic Botox injections for OAB / detrusor overactivity (idiopathic or neurogenic)
- Can be done under LA with flexible scope, or GA
- Doesn't work immediately onset 1–2 weeks; duration 6–9 months
- Counsel about possible urinary retention → may require ISC
Hydrodistension (Cystodistension)
- Bladder is filled and stretched beyond its usual capacity under GA
- Used to improve symptoms of painful bladder and occasionally refractory OAB
- Therapeutic role: can improve pain temporarily (weeks–months)
- Risks: temporary flare in symptoms, haematuria, rarely perforation
Augmentation Cystoplasty (enterocystoplasty including Clam)
- Bladder enlargement using a detubularised bowel patch (usually ileum) to increase capacity and improve compliance in low-capacity or neurogenic bladders
- Clam cystoplasty refers to the classic technique where the bladder is bivalved front-to-back ("clam shell") and the bowel patch is sewn into the opened bladder — a specific style within augmentation surgery
- Many patients require long-term ISC
- Mucus production is expected because bowel continues to produce mucus
- Specific risks: mucus (can block catheters!), urine and bowel leak, ileus, stones, infections, metabolic acidosis, B12 deficiency
Suprapubic Catheter (SPC) Insertion
- Insertion options:
- Radiological (USS/CT-guided)
- Cystoscopic – under direct vision; done in theatre
- Open surgical – for hostile abdomen or non-distended bladder
- Bedside Seldinger SPC (Emergency) – for acute retention when urethral catheterisation fails
- Risks: bowel injury (↑ with blind insertion), infection, associated catheter issue (blockage, leaking, misplacement)
- Changed every 10–12 weeks. Often 1st change is done by Urology nurse in hospital (but depends on local policy)
Female Continence Procedures
Urethral slings
These are used for stress urinary incontinence (SUI) to support the urethra
Mid-urethral slings
- Synthetic mesh placed TVT (retropubic) or TOT (transobturator)
! Synthetic mesh slings in the UK are tightly regulated and used only in specialist centres with strict governance and informed consent
Autologous Fascial Sling
- Sling from rectus fascia or tensor fascia lata
- For intrinsic sphincter deficiency or when mesh avoided
- Specific risks: retention → may need ISC, groin pain, wound complications, worsening of bladder overactivity, mesh erosion if synthetic mesh used
Colposuspension (Burch)
- Vaginal wall sutured to Cooper's ligament to lift bladder neck
- For stress urinary incontinence (SUI) with urethral hypermobility
- Specific risks: retention, bladder overactivity, vaginal prolapse, bladder injury, chronic pain
Bulking Agents
- Periurethral injections to improve urethral coaptation
- Used mild SUI or high-risk surgical patients
- Common bulking agents include Bulkamid® (most used), Macroplastique®, Coaptite®, and Urolastic®; older agents like collagen and Durasphere are largely obsolete
- Can require repeat treatments
Artificial Urinary Sphincter (AUS) – Female
- AUS in women is uncommon and usually reserved for severe intrinsic sphincter deficiency after other surgery has failed.
- Cuff around bladder neck/proximal urethra; pump in labia majora
- Specific risks: erosion, infection, device failure
Male Continence Procedures
AUS – Artificial Urinary Sphincter
- Gold standard for severe male SUI (typically post-prostatectomy)
- It consists of:
- Cuff - around the bulbar urethra
- Abdominal pressure balloon/reservoir – contains water that is used to inflate the cuff
- Scrotal pump – a switch that cycles water between cuff and reservoir
- Specific risks: erosion, infection, mechanical failure, de novo urgency
Please read this section about catheterisation safety in AUS - HERE
Male Sling
- Placed around bulbar urethra to support it
- They can be fixed (eg. AdVance) or adjustable (eg. ATOMS)
- For mild–moderate male SUI
- Specific risks: perineal pain and scrotal, retention, persistent leakage, erosion
Neuromodulation
It is used for refractory OAB, non-obstructive retention, voiding dysfunction and faecal incontinence. It works by modulating sacral nerve pathways rather than directly operating on the bladder (S3-4).
This is a staged procedure:
Percutaneous Nerve Evaluation (PNE)
- Temporary test lead + external stimulator (2-3 weeks)
- ≥50% improvement → proceed to permanent implant
- Patient may report tingling, pulling or stimulation in the pelvic/perineal/leg area
Sacral Neuromodulation (SNM) – staged procedure
- Stage 1: Trial phase – only tined leads are inserted + connected to external stimulator
- Stage 2: Permanent generator implanted if Stage 1 successful
Urethral Reconstruction Procedures
Urethroplasty +/- buccal mucosal graft (BMG)
- Extent:
- Short stricture excision + primary anastomosis
- Long or penile strictures urethroplasty with BMG or staged procedure
- Staged repairs: for lichen sclerosis, hypospadias failure, complex strictures
- Best long-term cure rates
- Specific risks: recurrence, erectile dysfunction, graft issues, urine leak and fistula, injury to Stensen's duct
Optical Urethrotomy
- Endoscopic incision of short, primary bulbar strictures
- Sometimes called Direct Vision Internal Urethrotomy (DVIU)
- High recurrence for long/recurrent strictures
Meatotomy / Meatoplasty
- Widening of stenotic urethral meatus
- Effective for distal lichen sclerosis-related narrowing
Optilume
- Drug-coated balloon used for selected anterior urethral strictures
- The balloon widens the stricture and delivers paclitaxel to reduce recurrence. No permanent implant is left behind.
- Minimally invasive, day-case procedure, can be done under LA
Major Reconstruction & Urinary Diversion
This is major surgery involving the bowel. Common risks are: urinary and bowel leak, ileus, bowel obstruction, stomal complications (retraction, stenosis), hernias, recurrent UTIs, uretero-ileal anastomotic stricture, mucus production, stone formation, metabolic abnormalities (esp. hyperchloraemic metabolic acidosis), B12 deficiency (if terminal ileum used), long-term renal deterioration
Ileal Conduit (Urostomy)
- Non-continent diversion; ureters anastomosed to ileal segment → stoma
- Most common urinary diversion
Orthotopic Neobladder (Studer / Hautmann)
- Detubularised ileal reservoir attached to native urethra → void per urethra
- Often requires abdominal straining and sometimes ISC
- Specific risk - nocturnal incontinence, rarely pouch perforation
Continent Cutaneous Diversion (Indiana / Mainz Pouch)
- Bowel reservoir with continent catheterisable stoma, emptied by CISC
- Specific risk: rarely pouch perforation
Mitrofanoff (Appendicovesicostomy)
- Appendix used as continent catheterisable channel to bladder
- Stoma usually at umbilicus or lower abdomen
Monti / Yang–Monti Channel
- Bowel segment reconfigured into catheterisable tube when appendix unavailable
- Functions similar to Mitrofanoff