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Characteristics of Neural Injury After Abdominoperineal Resection
0022-5347 /83/1291-0084$02.00/0
Vol. 129, January
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1983 by The Williams & Wilkins Co.
CHARACTERISTICS OF NEURAL INJURY AFTER ABDOMINOPERINEAL RESECTION J. G. BLAIVAS
AND
G. A. BARBALIAS
From the Departments of Urology, Columbia University College of Physicians and Surgeons, New York, New York, and Tufts-New England Medical Center Hospital, New Haven, Connecticut
ABSTRACT
A total of 13 men underwent synchronous video/pressure/flow electromyography studies after abdominoperineal resection of the rectum. All patients had diminished pressure in the proximal urethra and an incompetent vesical neck suggestive of sympathetic denervation. Five patients (38 per cent) had cystometric evidence of parasympathetic denervation and 7 (54 per cent) had electromyographic evidence of pudenda! denervation. These data suggest that denervation owing to surgical injury is an important cause of persistent symptoms after abdominoperineal resection of the rectum. bladder. The catheter was withdrawn slowly under fluoroscopic control and a urethral pressure profile was performed. The radiopaque marker at the site of the urethral pressure measurement served as a visual control. The catheter was held stationary for 5 seconds at 1 cm. intervals beginning at the bladder neck. The radiographic appearance of the bladder and urethra was observed carefully during the study and selected views were recorded on videotape. During bladder filling the patient was asked to cough and perform Valsalva's maneuver. If involuntary detrusor contractions occurred the patient was asked to try to inhibit them and the ability to do so was noted. The patient was instructed to void when a severe urge occurred or when he felt uncomfortably full.
Voiding dysfunction is common after abdominoperineal resection of the rectum, with a reported incidence of 7.5 to 69 per cent. 1- 6 The symptoms usually are transitory, subsiding within 3 to 6 months postoperatively. However, permanent treatment (surgery or an indwelling catheter) has been necessary in 3 to 33 per cent of the patients. 1• 3 ' 4 ' 7- 9 Urinary retention and obstructive urinary symptoms are most common but urinary incontinence and irritative symptoms may occur as well. The etiology of these symptoms has been attributed variously to exacerbation of pre-existing outlet obstruction, 2 - 4 , 9 •· 10 surgical denervation of the bladder and urethra,2· :i, 7 • 9 • 11 and disturbances of the anatomic relationship between the bladder and sphincters owing to loss of posterior support. 1' 12 Nevertheless, few scientific investigations have documented these contentions. We herein report our experience with complete neurourologic evaluation of 13 men with voiding dysfunction after abdominoperineal resection of the rectum.
RESULTS
The 13 men ranged from 31 to 77 years old, with an average age of 59 years. Abdominoperineal resection was performed in 8 patients (62 per cent) because of adenocarcinoma of the rectum and in 5 (38 per cent) because of ulcerative colitis. Two patients had undergone transurethral prostatectomy, 1 before and 1 after abdominoperineal resection. Seven patients had acute urinary retention after removal of the indwelling Foley catheter that had been inserted at the time of operation. Bladder symptoms that occurred after the removal of the catheter for the second time were obstructive in 5 patients (38 per cent), irritative in 2 (15 per cent), and obstructive and irritative in 6 (46 per cent). The interval between abdominoperineal resection and urodynamic evaluation varied from 11 days to 26 years (<3 months in 8 patients and 2, 5, 12, 25 and 26 years, respectively, in 5). The most striking finding in all patients was incompetence of the proximal (bladder neck) sphincteric mechanism, which was manifested by 2 occurrences. 1) During the urethral pressure profile the proximal 1 cm. of the urethra was isobaric with the bladder in all patients and the proximal 2 cm. were isobaric in 9 (fig. l, A). Figure 2 is a composite of the mean urethral closure pressure profiles of the patients after abdominoperineal resection compared to an equal number of randomly selected agematched controls. 2) The bladder neck was open radiographically in 9 patients: during bladder filling in 6 and during cough or Valsalva's maneuver in 3 (fig. 1, B). Cystometric and sphincter electromyography findings are given in the table. After the urodynamic study 5 patients (38 per cent) had clinical problems relating to incomplete bladder emptying, 3 (23 per cent) had urinary storage problems, 4 (31 per cent) had problems involving storage and emptying, and 1 (8 per cent) had normal findings. Incomplete bladder emptying was owing to an acontractile bladder in 1 patient and to pros-
MATERIALS AND METHODS
The 13 men were referred because of severe bladder symptoms after abdominoperineal resection of the rectum. Each patient underwent a detailed neurourologic history, physical examination and laboratory investigation. Simultaneous video/ pressure/flow electromyography studies were performed as described previously. J:J, 14 After preliminary uroflow determination a lOF triple lumen catheter was inserted into the bladder transurethrally and post-void residual urine was measured. One lumen was used for bladder filling. The second lumen located 1 cm. proximal to the catheter tip was used to record intravesical pressure. Its position was marked by a radiopaque marker. Urethral pressures were monitored via the third lumen through a 1 mm. side hole located 8 cm. proximal to the catheter tip. Normal saline was infused at a constant rate of 1.9 ml. per minute. Intra-abdominal pressures were monitored through the colostomy by a water-filled balloon catheter. All pressures were transduced electronically and recorded on a 6-channel strip chart recorder. Electromyography of the external urethral sphincter was performed by an experienced electromyographer using coaxial needle electrodes with oscilloscopic and audiographic observation. 13 Instantaneous urinary flow rate determinations were transduced electronically with a DISA uroflowmeter. With the patient in a supine, oblique position on the fluoroscopy table the catheters were inserted and manometers were zeroed at the level of the pubic symphysis. Bladder filling with room temperature meglumine diatrizoate was begun at a rate of approximately 50 ml. per minute with 50 to 100 ml. in the Accepted for publication March 12, 1982. 84
85
CI--IAR.ACTERJSTICS OF f\IETJB,AL I~'\!JUICY AFTER ABDO.MTNOPE,FGN'EAL 1lESECTI0l"i
with had small (<250 ml.) with tractions and an open bladder neck One had undergone uneventful osta1Ce(:to,n:1v 5 years before abdominoperineal resection. ""'"''"""~ were unresponsive to maximum doses of propantheline 45 and 60 mg. orally 4 times daily, respectively). Cystoscopic examination and random bladder biopsies failed to demonstrate evidence of bladder tumor but l patient died of recurrent adenocarcinoma of the colon involving the bladder 1 year postoperatively. The remaining 2 patients are being managed with condom catheter drainage. The 4 patients with storage and emptying problems had evidence of extensive neurologic damage characterized by detrusor areflexia (parasympathetic denervation), an open bladder neck at rest (sympathetic denervation), and clinical and electromyography evidence of lower motor neuron disease of the external urethral sphincter (pudendal denervation). Of these 4 patients 2 had return of voluntary bladder contractions 5 and 9 months postoperatively, respectively. Both patients then suffered prostatic obstruction: 1 underwent transurethral prostatectomy 2 years after abdominoperineal resection while 1 refused a further Two m,,.,...,,.,, had no recovery 2 and 11 years after abdominoperineal resection, reand they are being rnanaged with intermittent selfca1thEite1nz:1t1,:in. Of these 2 patients 1 50 mg. ephedrine pror;,rancllol 4 times to remain while l has and remains incontinent DISCUSSION
The routine use of an indwelling vesical catheter for 7 to 10 after =~·m0,v1,r,,,1>,<.,•\"a"pn;ao resection of the rectum is to the deleterious effect of this Even afte:r :removal of lower UPP (;J.>-c{!, CONTROLS @-/4) AP RESECT!ON
80 60
A, urethral closure presthat proxin1al urethra a:re isobaric vvith Vesical and urethral pressure channels are superin1p,JsE,d on each ancl as 1 line until increase in pressure occurs :3 cm. from neck Numbers indicate distance from bladder neck in centimeters at urethral is measured. B, incompetent sphincter mechanism month after abdominoperineal "'''"''hn,n Note of radiographic contrast material in posterior urethra maneuver ( U, urethral pressure measured at indicated by arrow. V, pressure. E, integrated sphincter ehictrrnm_','og;ram
tatic obstruction in 4. Despite prostatic obstruction the bladder neck was open radiographically in 3 of the 4 patients (figs. 3 and 4). Incontinence was prevented by the integrity of the distal sphincteric mechanism. Two of these patients had electromyographic evidence of an incomplete lower motor neuron lesion of the external urethral sphincter. The patient with an acontractile bladder was treated with intermittent self-catheterization and was voiding without residual urine after 5 months. Of the 4 patients with prostatic obstruction 2 underwent uneventful transurethral prostatectomy and were asymptomatic 9 months and l year later, respectively. The remaining 2 patients had
20
8 FIG. 2. Mean urethral closure pressure profiles after abdominoperineal resection compared to matched controls. Numbers indicate distance from centimeters at which urethral pressures were measured. B, bladder. BN, bladder neck.
Mos. After Abdominoperineal Resection (No. pts.)
<3
Cystometry findings Areflexia Hyperreflexia Normal
4
2 2
Electromyography findings Normal Complete or incomplete lower motor neuron lesion of external urethral sphincter
3 5
>3
86
BLAIVAS AND BARBALIAS
Fm. 3. Video/pressure study 6 weeks after abdominoperineal resection shows incompetence of proximal sphincteric mechanism and concomitant prostatic obstruction. A, urethral closure pressure profile shows that proximal 3 cm. of urethra are isobaric with bladder. B, there is minimal opening of bladder neck during cough (small arrows). C, obvious compression of prostatic urethra by obstructing prostate is noted during voiding. U, urethral pressure. V, vesical pressure. b, bladder. n, vesical neck.
urinary tract dysfunction (excluding surgical complications) has been reported in 62, 7 60, 1 55,3 23 2 and 22 per cent of the patients4 but the symptoms subsided spontaneously within 3 to 6 months in most instances. The pathophysiology of voiding symptoms after abdominoperineal resection has been attributed variously to malalignment of the bladder and urethra owing to loss of posterior supporting structures,1· 12 pre-existing bladder outlet obstruction2· 4' 9 • 10 and neurologic dysfunction.2· 3' 7• 9 ' 11 Marshall and associates reviewed a retrospective series of 600 consecutive patients who underwent large bowel surgery and found that the incidence of bladder symptoms was much higher in the patients who underwent abdominoperineal resection (60 per cent) than in those who underwent colostomy (8 per cent). 1 They offered several theories to explain these findings but concluded that malalignment of the bladder, posterior urethra and external sphincter was the main cause of incomplete bladder emptying and urinary incontinence after abdominoperineal resection. These investigators likened the external sphincter to an iris mechanism that lies within the triangular ligament. If 1 portion of the iris was pulled out of alignment (sagging of the prostate caused by loss of posterior support), it would no longer function as a sphincter and continence would be compromised. If, in addition, a cystocele occurred angulation could result in mechanical obstruction. To test this hypothesis 3 patients with persistent residual urine and severe incontinence after abdominoperineal resection were evaluated. These patients were able to contract the external urethral sphincter voluntarily and interrupt the stream but, nevertheless, still had dribbling incontinence. The incontinence and residual urine subsided when perineal pressure was applied during voiding, and 1 patient was improved markedly after an operation that suspended the prostate, bladder neck and anterior urethra from the symphysis pubis-the forerunner of the Marshall-Marchetti-Krantz procedure for stress urinary incontinence. However, most recent studies have suggested that voiding dysfunction after abdominoperineal resection usually is caused by intraoperative injury to pelvic and hypogastric nerves, often superimposed upon pre-existing bladder outlet obstruction.2-4· 7• 9• 11 In these series the incidence of neurogenic vesicourethral dysfunction after abdominoperineal resection varied from 7.5 to 72 per cent. Except for the study by Gerstenberg and associates2 all of these series evaluated patients with persistent, problematic symptoms and probably are not representative. However, Gerstenberg and associates studied 26 patients before and 6 to 12 months after abdominoperineal resection, and found that 2 (7.5 per cent) had clear-cut evidence of persistent neurogenic vesicourethral dysfunction. Although urodynamic studies also were done 3 months postoperatively these data were not included in the results. Accordingly, the over-all incidence of neural injury, including those that healed during the first 6 months, was not recorded and probably is higher than the 7.5 per cent. The neuroanatomical relationships underlying the mechanism of neural injury after abdominoperineal resection have been described by Smith and Ballantyne. 15 Parasympathetic fibers traverse the pelvic nerve and intermingle with sympathetic fibers in the hypogastric plexus. 16 The main trunks of the nerves to the bladder and proximal urethra lie outside of the pelvic fascia. 15 Consequently, these nerves usually are not injured unless the fascial plane is disrupted during a radical operation. The pudendal nerve exits the pelvis via Alcock's canal, and lies along the undersurface of the ischium and pubic bone to innervate the striated external urethral sphincter. 16 This nerve may be injured during the perinea! portion of the dissection. Sympathetic denervation causes loss of proximal urethral pressure, 11- 19 presumably owing to loss of a-mediated innervation to the smooth muscle fibers of the bladder neck and
CHARACTERISTICS OF NEURAL INJURY AFTER ABDOMINOPERINEAL RESECTION
87
,__ ' - ;__ :- --:-~: -~- p,~jJQw;_4m'/:••,c. _; __:_~_ ·',---:'·,~'"'· •:- ·!-;
. . ... ,
;Y..Ql:.uJne;1:14.0.:101l,-~"
···-·
. . . . ,.,.
.
., ,,
-- _ .
----- -~ ~~'. ·;::t :s,-·.~ -~ ,:• ::tb:r· ~:::,;~~-{::~ : i : ~ FIG. 4. Urinary flow rate obtained simultaneously with voiding noted in figure 3, C
proximal urethra. 20 • 21 Parasympathetic denervation causes paralysis of the detrusor and pudendal denervation results in a pressure decrease in the distal prostatic and membranous urethra, 17' 18 as well as electromyographic abnormalities. 13 Our series was highly selected since all patients had persistent urinary symptoms after abdominoperineal resection of the rectum. Accordingly, the data should not be considered necessarily representative of the usual findings encountered after abdominoperineal resection. Nevertheless, there was clinical and urodynamic evidence of parasympathetic denervation in 38 per cent of the patients, pudendal denervation in 54 per cent and sympathetic denervation in all patients. These data strongly suggest that surgical denervation does, in fact, have an important role in patients with persistent voiding dysfunction after abdominoperineal resection. To determine the over-all incidence of neural injury after abdominoperineal resection as well as the extent and duration of recovery, a prospective serial urodynamic study before and after surgery should be undertaken. We were surprised to find that patients with an open bladder neck (presumably owing to sympathetic denervation) also could have prostatic obstruction. In these patients the site of obstruction was the distal prostatic urethra. It was difficult to distinguish prostatic obstruction from a membranous urethral stricture. However, urethroscopy, retrograde urethrography and the ultimate response to prostatectomy confirmed the diagnosis. These findings suggest that the influence of sympathetic innervation on prostatic obstruction should be the subject of future investigations. Treatment of voiding dysfunction after abdominoperineal resection should be individualized according to clinical and urodynamic findings. Although this retrospective series was not designed to evaluate therapy, certain guidelines seem apparent. The high incidence of voiding dysfunction in the immediate postoperative period mandates the use of a temporary means of emptying the bladder, either an indwelling vesical catheter or intermittent catheterization. If voiding has not improved by 2 to 4 weeks postoperatively urodynamic study should be performed. On the basis of clinical and urodynamic findings voiding dysfunction may be classified as storage problems, emptying problems and combinations of storage and emptying problems. Treatment then should be individualized according to the underlying urodynamic abnormalities but special caution should .be exercised in patients with storage and emptying problems because of the likelihood of extensive sympathetic, parasympathetic and pudendal denervation. These patients in particular may be made worse by empiric prostatectomy. REFERENCES 1.
Marshall, V. F., Pollack, R. S. and Miller, C.: Observations on urinary dysfunction after excision of the rectum. J. Urol., 55: 409, 1946.
2. Gerstenberg, T. C., Nielsen, M. L., Clausen, S., Blaabjerg, J. and Lindenberg, J.: Bladder function after abdominoperineal resection of the rectum for anorectal cancer. Urodynamic investigation before and after operation in a consecutive series. Ann. Surg., 191: 81, 1980.
3. Eickenberg, H.-U., Amin, M., Klompus, W. and Lich, R., Jr.: Urologic complications following abdominoperineal resection. J. Urol., 115: 180, 1976. 4. Baumrucker, G. 0. and Shaw, J. W.: Urological complications following abdominoperineal resection of the rectum. Arch. Surg., 67: 502, 1953.
5. Kontturi, M., Larmi, T. K. and Tuononen, S.: Bladder dysfunction and its manifestations following abdominoperineal extirpation of the rectum. Ann. Surg., 179: 179, 1974. 6. Levin, I. A. and Tarantino, M. J.: Complications of abdominal perinea! resection. South. Med. J., 65: 33, 1972. 7; Fowler, J. W., Bremner, D. N. and Moffat, L. E. F.: The incidence and consequences of damage to the parasympathetic nerve supply to the bladder after abdominoperineal resection of the rectum for carcinoma. Brit. J. Urol., 50: 95, 1978. 8. Glass, R. L. and Spratt, J. S.: Urinary complications after abdominoperineal resection of the rectum in men. Amer. Surg., 34: 238, 1968.
9. Ward, J. N. and Nay, H. R.: Immediate and delayed urologic complications associated with abdominoperineal resection. Amer. J. Surg., 123: 642, 1972. 10. Campbell, E. W. and Gislason, G. J.: Urologic invalidism following abdominoperinealrectosigmoidectomy. Ann. Surg., 132: 85, 1950. 11. McGuire, E. J.: Urodynamic evaluation after abdominal-perinea! resection and lumbar intervertebral disc herniation. Urology, 6: 63, 1975. 12. Emmett, J. L. and Cristo!, D. S.: Urinary retention following
surgical operation on the rectum and sigmoid; treatment by transurethral resection. J.A.M.A., 126: 1077, 1944. 13. Blaivas, J. G., Labib, K. B., Bauer, S. B. and Retik, A. B.: A new approach to electromyography of the external urethral sphincter. J. Urol., 117: 773, 1977. 14. Blaivas, J. G. and Fischer, D. M.: Combined radiographic and urodynamic monitoring: advances in technique. J. Urol., 125: 693, 1981. 15. Smith, P. H. and Ballantyne, B.: The neuroanatomical basis for
denervation of the urinary bladder following major pelvic surgery. Brit. J. Surg., 55: 929, 1968. 16. Kuru, M.: Nervous control of micturition. Physiol. Rev., 45: 425, 1965. 17. Albert, N. E., Sparks, F. C. and McGuire, E. J.: Effect of pelvic and
retroperitoneal surgery on the urethral pressure profile and perinea! floor electromyogram in dogs. Invest. Urol., 15: 140, 1977. 18. McGuire, E. J .: Combined radiographic and manometric assessment of urethral sphincter function. J. Urol., 118: 632, 1977. 19. Woodside, J. R. and McGuire, E. J.: Urethral hypotonicity after suprasacral spinal cord injury. J. Urol., 121: 783, 1979. 20. McGuire, E. J. and Wagner, F. C.: The effects of sacral denervation on bladder and urethral function. Surg., Gynec. & Obst., 144: 343, 1977. 21. Norlen, L.: The autonomous bladder; a clinical and experimental study. Scand. J. Urol. Nephrol., suppl. 36, p. 1, 1976.
Vol. 129, January
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1983 by The Williams & Wilkins Co.
CHARACTERISTICS OF NEURAL INJURY AFTER ABDOMINOPERINEAL RESECTION J. G. BLAIVAS
AND
G. A. BARBALIAS
From the Departments of Urology, Columbia University College of Physicians and Surgeons, New York, New York, and Tufts-New England Medical Center Hospital, New Haven, Connecticut
ABSTRACT
A total of 13 men underwent synchronous video/pressure/flow electromyography studies after abdominoperineal resection of the rectum. All patients had diminished pressure in the proximal urethra and an incompetent vesical neck suggestive of sympathetic denervation. Five patients (38 per cent) had cystometric evidence of parasympathetic denervation and 7 (54 per cent) had electromyographic evidence of pudenda! denervation. These data suggest that denervation owing to surgical injury is an important cause of persistent symptoms after abdominoperineal resection of the rectum. bladder. The catheter was withdrawn slowly under fluoroscopic control and a urethral pressure profile was performed. The radiopaque marker at the site of the urethral pressure measurement served as a visual control. The catheter was held stationary for 5 seconds at 1 cm. intervals beginning at the bladder neck. The radiographic appearance of the bladder and urethra was observed carefully during the study and selected views were recorded on videotape. During bladder filling the patient was asked to cough and perform Valsalva's maneuver. If involuntary detrusor contractions occurred the patient was asked to try to inhibit them and the ability to do so was noted. The patient was instructed to void when a severe urge occurred or when he felt uncomfortably full.
Voiding dysfunction is common after abdominoperineal resection of the rectum, with a reported incidence of 7.5 to 69 per cent. 1- 6 The symptoms usually are transitory, subsiding within 3 to 6 months postoperatively. However, permanent treatment (surgery or an indwelling catheter) has been necessary in 3 to 33 per cent of the patients. 1• 3 ' 4 ' 7- 9 Urinary retention and obstructive urinary symptoms are most common but urinary incontinence and irritative symptoms may occur as well. The etiology of these symptoms has been attributed variously to exacerbation of pre-existing outlet obstruction, 2 - 4 , 9 •· 10 surgical denervation of the bladder and urethra,2· :i, 7 • 9 • 11 and disturbances of the anatomic relationship between the bladder and sphincters owing to loss of posterior support. 1' 12 Nevertheless, few scientific investigations have documented these contentions. We herein report our experience with complete neurourologic evaluation of 13 men with voiding dysfunction after abdominoperineal resection of the rectum.
RESULTS
The 13 men ranged from 31 to 77 years old, with an average age of 59 years. Abdominoperineal resection was performed in 8 patients (62 per cent) because of adenocarcinoma of the rectum and in 5 (38 per cent) because of ulcerative colitis. Two patients had undergone transurethral prostatectomy, 1 before and 1 after abdominoperineal resection. Seven patients had acute urinary retention after removal of the indwelling Foley catheter that had been inserted at the time of operation. Bladder symptoms that occurred after the removal of the catheter for the second time were obstructive in 5 patients (38 per cent), irritative in 2 (15 per cent), and obstructive and irritative in 6 (46 per cent). The interval between abdominoperineal resection and urodynamic evaluation varied from 11 days to 26 years (<3 months in 8 patients and 2, 5, 12, 25 and 26 years, respectively, in 5). The most striking finding in all patients was incompetence of the proximal (bladder neck) sphincteric mechanism, which was manifested by 2 occurrences. 1) During the urethral pressure profile the proximal 1 cm. of the urethra was isobaric with the bladder in all patients and the proximal 2 cm. were isobaric in 9 (fig. l, A). Figure 2 is a composite of the mean urethral closure pressure profiles of the patients after abdominoperineal resection compared to an equal number of randomly selected agematched controls. 2) The bladder neck was open radiographically in 9 patients: during bladder filling in 6 and during cough or Valsalva's maneuver in 3 (fig. 1, B). Cystometric and sphincter electromyography findings are given in the table. After the urodynamic study 5 patients (38 per cent) had clinical problems relating to incomplete bladder emptying, 3 (23 per cent) had urinary storage problems, 4 (31 per cent) had problems involving storage and emptying, and 1 (8 per cent) had normal findings. Incomplete bladder emptying was owing to an acontractile bladder in 1 patient and to pros-
MATERIALS AND METHODS
The 13 men were referred because of severe bladder symptoms after abdominoperineal resection of the rectum. Each patient underwent a detailed neurourologic history, physical examination and laboratory investigation. Simultaneous video/ pressure/flow electromyography studies were performed as described previously. J:J, 14 After preliminary uroflow determination a lOF triple lumen catheter was inserted into the bladder transurethrally and post-void residual urine was measured. One lumen was used for bladder filling. The second lumen located 1 cm. proximal to the catheter tip was used to record intravesical pressure. Its position was marked by a radiopaque marker. Urethral pressures were monitored via the third lumen through a 1 mm. side hole located 8 cm. proximal to the catheter tip. Normal saline was infused at a constant rate of 1.9 ml. per minute. Intra-abdominal pressures were monitored through the colostomy by a water-filled balloon catheter. All pressures were transduced electronically and recorded on a 6-channel strip chart recorder. Electromyography of the external urethral sphincter was performed by an experienced electromyographer using coaxial needle electrodes with oscilloscopic and audiographic observation. 13 Instantaneous urinary flow rate determinations were transduced electronically with a DISA uroflowmeter. With the patient in a supine, oblique position on the fluoroscopy table the catheters were inserted and manometers were zeroed at the level of the pubic symphysis. Bladder filling with room temperature meglumine diatrizoate was begun at a rate of approximately 50 ml. per minute with 50 to 100 ml. in the Accepted for publication March 12, 1982. 84
85
CI--IAR.ACTERJSTICS OF f\IETJB,AL I~'\!JUICY AFTER ABDO.MTNOPE,FGN'EAL 1lESECTI0l"i
with had small (<250 ml.) with tractions and an open bladder neck One had undergone uneventful osta1Ce(:to,n:1v 5 years before abdominoperineal resection. ""'"''"""~ were unresponsive to maximum doses of propantheline 45 and 60 mg. orally 4 times daily, respectively). Cystoscopic examination and random bladder biopsies failed to demonstrate evidence of bladder tumor but l patient died of recurrent adenocarcinoma of the colon involving the bladder 1 year postoperatively. The remaining 2 patients are being managed with condom catheter drainage. The 4 patients with storage and emptying problems had evidence of extensive neurologic damage characterized by detrusor areflexia (parasympathetic denervation), an open bladder neck at rest (sympathetic denervation), and clinical and electromyography evidence of lower motor neuron disease of the external urethral sphincter (pudendal denervation). Of these 4 patients 2 had return of voluntary bladder contractions 5 and 9 months postoperatively, respectively. Both patients then suffered prostatic obstruction: 1 underwent transurethral prostatectomy 2 years after abdominoperineal resection while 1 refused a further Two m,,.,...,,.,, had no recovery 2 and 11 years after abdominoperineal resection, reand they are being rnanaged with intermittent selfca1thEite1nz:1t1,:in. Of these 2 patients 1 50 mg. ephedrine pror;,rancllol 4 times to remain while l has and remains incontinent DISCUSSION
The routine use of an indwelling vesical catheter for 7 to 10 after =~·m0,v1,r,,,1>,<.,•\"a"pn;ao resection of the rectum is to the deleterious effect of this Even afte:r :removal of lower UPP (;J.>-c{!, CONTROLS @-/4) AP RESECT!ON
80 60
A, urethral closure presthat proxin1al urethra a:re isobaric vvith Vesical and urethral pressure channels are superin1p,JsE,d on each ancl as 1 line until increase in pressure occurs :3 cm. from neck Numbers indicate distance from bladder neck in centimeters at urethral is measured. B, incompetent sphincter mechanism month after abdominoperineal "'''"''hn,n Note of radiographic contrast material in posterior urethra maneuver ( U, urethral pressure measured at indicated by arrow. V, pressure. E, integrated sphincter ehictrrnm_','og;ram
tatic obstruction in 4. Despite prostatic obstruction the bladder neck was open radiographically in 3 of the 4 patients (figs. 3 and 4). Incontinence was prevented by the integrity of the distal sphincteric mechanism. Two of these patients had electromyographic evidence of an incomplete lower motor neuron lesion of the external urethral sphincter. The patient with an acontractile bladder was treated with intermittent self-catheterization and was voiding without residual urine after 5 months. Of the 4 patients with prostatic obstruction 2 underwent uneventful transurethral prostatectomy and were asymptomatic 9 months and l year later, respectively. The remaining 2 patients had
20
8 FIG. 2. Mean urethral closure pressure profiles after abdominoperineal resection compared to matched controls. Numbers indicate distance from centimeters at which urethral pressures were measured. B, bladder. BN, bladder neck.
Mos. After Abdominoperineal Resection (No. pts.)
<3
Cystometry findings Areflexia Hyperreflexia Normal
4
2 2
Electromyography findings Normal Complete or incomplete lower motor neuron lesion of external urethral sphincter
3 5
>3
86
BLAIVAS AND BARBALIAS
Fm. 3. Video/pressure study 6 weeks after abdominoperineal resection shows incompetence of proximal sphincteric mechanism and concomitant prostatic obstruction. A, urethral closure pressure profile shows that proximal 3 cm. of urethra are isobaric with bladder. B, there is minimal opening of bladder neck during cough (small arrows). C, obvious compression of prostatic urethra by obstructing prostate is noted during voiding. U, urethral pressure. V, vesical pressure. b, bladder. n, vesical neck.
urinary tract dysfunction (excluding surgical complications) has been reported in 62, 7 60, 1 55,3 23 2 and 22 per cent of the patients4 but the symptoms subsided spontaneously within 3 to 6 months in most instances. The pathophysiology of voiding symptoms after abdominoperineal resection has been attributed variously to malalignment of the bladder and urethra owing to loss of posterior supporting structures,1· 12 pre-existing bladder outlet obstruction2· 4' 9 • 10 and neurologic dysfunction.2· 3' 7• 9 ' 11 Marshall and associates reviewed a retrospective series of 600 consecutive patients who underwent large bowel surgery and found that the incidence of bladder symptoms was much higher in the patients who underwent abdominoperineal resection (60 per cent) than in those who underwent colostomy (8 per cent). 1 They offered several theories to explain these findings but concluded that malalignment of the bladder, posterior urethra and external sphincter was the main cause of incomplete bladder emptying and urinary incontinence after abdominoperineal resection. These investigators likened the external sphincter to an iris mechanism that lies within the triangular ligament. If 1 portion of the iris was pulled out of alignment (sagging of the prostate caused by loss of posterior support), it would no longer function as a sphincter and continence would be compromised. If, in addition, a cystocele occurred angulation could result in mechanical obstruction. To test this hypothesis 3 patients with persistent residual urine and severe incontinence after abdominoperineal resection were evaluated. These patients were able to contract the external urethral sphincter voluntarily and interrupt the stream but, nevertheless, still had dribbling incontinence. The incontinence and residual urine subsided when perineal pressure was applied during voiding, and 1 patient was improved markedly after an operation that suspended the prostate, bladder neck and anterior urethra from the symphysis pubis-the forerunner of the Marshall-Marchetti-Krantz procedure for stress urinary incontinence. However, most recent studies have suggested that voiding dysfunction after abdominoperineal resection usually is caused by intraoperative injury to pelvic and hypogastric nerves, often superimposed upon pre-existing bladder outlet obstruction.2-4· 7• 9• 11 In these series the incidence of neurogenic vesicourethral dysfunction after abdominoperineal resection varied from 7.5 to 72 per cent. Except for the study by Gerstenberg and associates2 all of these series evaluated patients with persistent, problematic symptoms and probably are not representative. However, Gerstenberg and associates studied 26 patients before and 6 to 12 months after abdominoperineal resection, and found that 2 (7.5 per cent) had clear-cut evidence of persistent neurogenic vesicourethral dysfunction. Although urodynamic studies also were done 3 months postoperatively these data were not included in the results. Accordingly, the over-all incidence of neural injury, including those that healed during the first 6 months, was not recorded and probably is higher than the 7.5 per cent. The neuroanatomical relationships underlying the mechanism of neural injury after abdominoperineal resection have been described by Smith and Ballantyne. 15 Parasympathetic fibers traverse the pelvic nerve and intermingle with sympathetic fibers in the hypogastric plexus. 16 The main trunks of the nerves to the bladder and proximal urethra lie outside of the pelvic fascia. 15 Consequently, these nerves usually are not injured unless the fascial plane is disrupted during a radical operation. The pudendal nerve exits the pelvis via Alcock's canal, and lies along the undersurface of the ischium and pubic bone to innervate the striated external urethral sphincter. 16 This nerve may be injured during the perinea! portion of the dissection. Sympathetic denervation causes loss of proximal urethral pressure, 11- 19 presumably owing to loss of a-mediated innervation to the smooth muscle fibers of the bladder neck and
CHARACTERISTICS OF NEURAL INJURY AFTER ABDOMINOPERINEAL RESECTION
87
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. . ... ,
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.
., ,,
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proximal urethra. 20 • 21 Parasympathetic denervation causes paralysis of the detrusor and pudendal denervation results in a pressure decrease in the distal prostatic and membranous urethra, 17' 18 as well as electromyographic abnormalities. 13 Our series was highly selected since all patients had persistent urinary symptoms after abdominoperineal resection of the rectum. Accordingly, the data should not be considered necessarily representative of the usual findings encountered after abdominoperineal resection. Nevertheless, there was clinical and urodynamic evidence of parasympathetic denervation in 38 per cent of the patients, pudendal denervation in 54 per cent and sympathetic denervation in all patients. These data strongly suggest that surgical denervation does, in fact, have an important role in patients with persistent voiding dysfunction after abdominoperineal resection. To determine the over-all incidence of neural injury after abdominoperineal resection as well as the extent and duration of recovery, a prospective serial urodynamic study before and after surgery should be undertaken. We were surprised to find that patients with an open bladder neck (presumably owing to sympathetic denervation) also could have prostatic obstruction. In these patients the site of obstruction was the distal prostatic urethra. It was difficult to distinguish prostatic obstruction from a membranous urethral stricture. However, urethroscopy, retrograde urethrography and the ultimate response to prostatectomy confirmed the diagnosis. These findings suggest that the influence of sympathetic innervation on prostatic obstruction should be the subject of future investigations. Treatment of voiding dysfunction after abdominoperineal resection should be individualized according to clinical and urodynamic findings. Although this retrospective series was not designed to evaluate therapy, certain guidelines seem apparent. The high incidence of voiding dysfunction in the immediate postoperative period mandates the use of a temporary means of emptying the bladder, either an indwelling vesical catheter or intermittent catheterization. If voiding has not improved by 2 to 4 weeks postoperatively urodynamic study should be performed. On the basis of clinical and urodynamic findings voiding dysfunction may be classified as storage problems, emptying problems and combinations of storage and emptying problems. Treatment then should be individualized according to the underlying urodynamic abnormalities but special caution should .be exercised in patients with storage and emptying problems because of the likelihood of extensive sympathetic, parasympathetic and pudendal denervation. These patients in particular may be made worse by empiric prostatectomy. REFERENCES 1.
Marshall, V. F., Pollack, R. S. and Miller, C.: Observations on urinary dysfunction after excision of the rectum. J. Urol., 55: 409, 1946.
2. Gerstenberg, T. C., Nielsen, M. L., Clausen, S., Blaabjerg, J. and Lindenberg, J.: Bladder function after abdominoperineal resection of the rectum for anorectal cancer. Urodynamic investigation before and after operation in a consecutive series. Ann. Surg., 191: 81, 1980.
3. Eickenberg, H.-U., Amin, M., Klompus, W. and Lich, R., Jr.: Urologic complications following abdominoperineal resection. J. Urol., 115: 180, 1976. 4. Baumrucker, G. 0. and Shaw, J. W.: Urological complications following abdominoperineal resection of the rectum. Arch. Surg., 67: 502, 1953.
5. Kontturi, M., Larmi, T. K. and Tuononen, S.: Bladder dysfunction and its manifestations following abdominoperineal extirpation of the rectum. Ann. Surg., 179: 179, 1974. 6. Levin, I. A. and Tarantino, M. J.: Complications of abdominal perinea! resection. South. Med. J., 65: 33, 1972. 7; Fowler, J. W., Bremner, D. N. and Moffat, L. E. F.: The incidence and consequences of damage to the parasympathetic nerve supply to the bladder after abdominoperineal resection of the rectum for carcinoma. Brit. J. Urol., 50: 95, 1978. 8. Glass, R. L. and Spratt, J. S.: Urinary complications after abdominoperineal resection of the rectum in men. Amer. Surg., 34: 238, 1968.
9. Ward, J. N. and Nay, H. R.: Immediate and delayed urologic complications associated with abdominoperineal resection. Amer. J. Surg., 123: 642, 1972. 10. Campbell, E. W. and Gislason, G. J.: Urologic invalidism following abdominoperinealrectosigmoidectomy. Ann. Surg., 132: 85, 1950. 11. McGuire, E. J.: Urodynamic evaluation after abdominal-perinea! resection and lumbar intervertebral disc herniation. Urology, 6: 63, 1975. 12. Emmett, J. L. and Cristo!, D. S.: Urinary retention following
surgical operation on the rectum and sigmoid; treatment by transurethral resection. J.A.M.A., 126: 1077, 1944. 13. Blaivas, J. G., Labib, K. B., Bauer, S. B. and Retik, A. B.: A new approach to electromyography of the external urethral sphincter. J. Urol., 117: 773, 1977. 14. Blaivas, J. G. and Fischer, D. M.: Combined radiographic and urodynamic monitoring: advances in technique. J. Urol., 125: 693, 1981. 15. Smith, P. H. and Ballantyne, B.: The neuroanatomical basis for
denervation of the urinary bladder following major pelvic surgery. Brit. J. Surg., 55: 929, 1968. 16. Kuru, M.: Nervous control of micturition. Physiol. Rev., 45: 425, 1965. 17. Albert, N. E., Sparks, F. C. and McGuire, E. J.: Effect of pelvic and
retroperitoneal surgery on the urethral pressure profile and perinea! floor electromyogram in dogs. Invest. Urol., 15: 140, 1977. 18. McGuire, E. J .: Combined radiographic and manometric assessment of urethral sphincter function. J. Urol., 118: 632, 1977. 19. Woodside, J. R. and McGuire, E. J.: Urethral hypotonicity after suprasacral spinal cord injury. J. Urol., 121: 783, 1979. 20. McGuire, E. J. and Wagner, F. C.: The effects of sacral denervation on bladder and urethral function. Surg., Gynec. & Obst., 144: 343, 1977. 21. Norlen, L.: The autonomous bladder; a clinical and experimental study. Scand. J. Urol. Nephrol., suppl. 36, p. 1, 1976.