- Email: [email protected]
External Sphincterotomy: An Evaluation of 150 Patients with Neurogenic Bladder
OF
TIENTS V/ITH
NJ:3:UJ~,O(}EJ\fIC BLADDER PAUL F. SCEELLHA.IVHvfER, rt03ERT H. HACKLER
ANI}
K CA~L BUNTS
Urological 8ection Surgic:;i,! Service, M·:::Guire Veterans Ad:ninistration I-Iospita( Ric.hmond Virginia 1
1
resectoscope fitted 'iNith a k:nife electrode. Incisions are the
bulbous urethra. The incisions are made with several passages of the electrical 2). This lateral may result ir.. an invvard lobes. In several cas,2s an unsuccessful terotomiss Vv e herein evaluate the resi.1lts of 173
150 examinations. Iv1ATERIALS AND lviETHODS
The results of our fi::st series of 85 external in 19SE Cur:tie ana associates. s 'VVe have contin~.Jed to foll·Jw these
ber 22 3-way m for 7 After removal of the catheter residual mine less than a third of the total bl adder (90 cc n2aximum) csnsidered .successful :rssult. rf'he 1s follo\ved at least once a year v1ith residual Ul ine m.easur0:Y1ent and IVF·, 0
RESULTS
h2~\re included in this report been eval"Gated sifi..::e l
)l
an{! cne have been trial, If residual urine of per cent of b1addet (SO cc
pYessur,?s are deterCurrie Hnd a cystor:neL~cVIitl'.'"1 elevated
residual urme vvas of th2se patients have been to 5 yea:sj 40 fron:i l to 3 years and the cathete1\ The other 10 3 vve1e unable tu vvear the external condom because of a 2 ,,;yere to the various consb'1.Js~t an external ~''""'''"'·"lo lmv pr,,;ssure reflux which 2 had sacral decubiti and 1 C:f the 110 ~;vitb a reflex b1r.1dder) 95 (86 pBr cent) had successful results. In soPtrast, with ncr,-reflex biadder2
de:' as one 'Phich contrs_ctio:o. as dernonst;.-ated noE-r:::;flex bladder sb.ows either a flat curve or a pressures but ~Nith no reflex contraction. Ii n.or:;-refiex bladdeI in cervical or thoracic .::ord lesions rnay be caused ir.hi_bition of the reflex axe in the stur11n of the cord or or " in the cord below the uppermost motor and sensory level. Preoperative pressures m patients
Division n~e:nt o~· 1958.
199
200
SCHELLHAMMER, HACKLER AND BUNTS CYSTOMETRIC READINGS
DATE _ _ _ _ _ __
MILLIMETERS OF MERCURY
-=!===I=·'=!·
/14 :J-----____:_--==--E:
130
--~
120
12
=-~-
140 _ 130 12
_ ---r
"""=t~~ r -i'°-:=-t~~Jc
i------: - ~130
120_
11
~--:--no 100 --
100
cl'--::
A
Jc-- -:f
t_=cJ f +
,_ 70_ 60
- 60
-i--
--·----~-- -=_~-=_-_111_-._- _- _-._=__ -_.. 50 _--_
- _ :..:_
40-
40
,, -
30
3
-
10 MINUTES
!5
___
r
-42-_\_~~~o :~~t== d. -
~-- ~6
20,~r=c-;=
20
tl 0
O_
·:-:- 50 __
,--
-=f_:
+ MINUTES
10
MINUTES
15
FIG. 1. Cystometrogram of bladder with reflex contractur~. ~re~p_erative external sphincter pressure is equal to maximal detrusor pressure. Postoperative sphincter pressure 1s s1gmf1cantly decreased.
with successful sphincterotomy were higher than maximum bladder pressure in a third of the patients, equal in a third and lower in a third. In this last group the sphincter pressures, although lower than cystometrogram pressures, were still higher than normal. Regardless of the level of spinal cord damage the retrograde urethral pressure in the postoperative period was decreased as compared to the preoperative level. We divided our 39 failures (26 per cent) into a group which demonstrated an initial success period from 1 month to 5 years post-sphincterotomy and another group which demonstrated immediate and persistent postoperative failure. These 2 groups were then analyzed as to the level of the lesion and the condition of the bladder. The initial success group and the persistent failure group were similarly distributed between cervical, thoracic and lumbosacral lesions. However, in the group with the initially successful sphincterotomies, 12 had reflex bladders and 8 non-reflex bladders. This is in contrast to the total failure group which included only 2 patients with reflex bladders. The operation was repeated in 21 patients because of an initial or late failure. In 2 patients 3 procedures were necessary before success was achieved. Of the 19 who had only secondary procedures 13 were successful. On 3 occasions, after an unsuccessful postoperative result in a repeat sphincterotomy, cystoscopy revealed inward collapse of prostatic tissue. Resection of this tissue resulted in satisfactory bladder emptying. Analyzing the bladder condition in the procedures that were successfully repeated, it was noted that the majority (11 of 15) had reflex bladders. This pattern again demonstrates that a reflex bladder will yield a higher rate of successful catheter-free voiding post-sphincterotomy. In the successful sphincterotomy group (111 patients), 30 had undergone unsuccessful procedures on the bladder neck for the purpose of lowering resistance to voiding.
INCISED
FIG. 2. Schema demonstrates front and cross section views oflocation and extent of sphincterotomy incisions.
DISCUSSION
The principal reason for ineffective voiding by patients with neurogenic bladder is imbalance between the expulsive forces of the detrusor muscle and the forces maintaining urinary continence. In most instances the upper motor neuron bladder will initiate reflex contractions. Vesical emptying may be incomplete because of failure of the spastic striated external sphincter and the pelvic floor musculature to relax. The lower motor neuron bladder usually lacks effective expulsive power and depends on manual external pressure or heightened intra-abdominal pressure to empty. While the flaccid pelvic floor and external sphincter
Fm. 3. A, preoperative voiding cystourethrogram demonstrates patent bladder neck and prostatic urethra. There is narrowing in area of membranous urethra. B, postoperative voiding cystourethrogram reveals widely patent prostatomembranous urethra.
cause little obstruction, any area of resistance in the prostatomembranous urethra could signifiemptying. That the imbalance between the forces of micturition and continence in a cord bladder may be surgically altered has been re,co1~n1zE,a and diverse modes of infravesical resistance to have been used. Pressure studies have shown that the area of greatest resistance to voiding in the nerve-intact individual is the membranous and distal urethra.•· 5 Ascoli" and Damanski7 used to identify the membranous urethra as the of obstruction to antegrade flovv of contrast medium. The cystourethrograms reviewed in our dem onstrated similar findings. The bladder neck was open in with no of bladder neck resection and
O'Flynn showed after external spnu:1c1;ero-uJrn,:,; 12 He commented that the bladder neck obstruction seen in spinal cord was secondary to increased P"''"'""'"' pressure initially causing detrusor and associated bladder neck We do not agree with this concept. The demonstrable of the bladder neck on cystourethrogindicate that bladder neck hypertrophy is not a significant factor. Bladder neck hypertrophy may occur along with deJrusor hyperas a result of uncontrolled nerve impulses from the isolated reflex centers in the stump of the spinal cord. n11vv,,v,-er this n,rrn,rr.rnnrrv does not imply obstruction. The lack of success with bladder neck resection in who subsequently had successful. ~,a-.,,~,rnn would support this contention. Failures should be subject to re evaluation and undergo a second vu_,..vva"•J if reflex contractions are noted on the cystometrogram and if the ,_..,... ,-"-" pressures remain elevated. This fact can be from our 71 success rate with repeat causes for failure should be consideredo The undermined prostate may present the sole obstruction to Malament noted a incidence of this 0
grams tatomem.branous urethra preoperative x-rays have with success men1branous urethra in an effort to reduce resist3 · 11 The most recent report ance to 4 En1anuel, Iv:L: .ft.. nevv catheter-type sphincterometer. J. 5 • J. Ajemian 1 P,, Ste•;vart, B. H.) B. A. and rhhwP.nit J. R.: Further observations on kinetics of the urethiovesical sphincter, J. Urol., 84~ 86j 1960. 6 Ascoli, R. R.: Radiological paraplegia secondary to spinal 235, 1967. 7 Damanski M · ,ys,to-m·e-cnr<)g1·arJny in paraplegia: its practical appli~·ation. Brit. J. 67, 1961. 6 Donovan, H.: Care of urinary tract in paraplegic patients: review of 82 cases. Lancet, 1: 515, 1947.
10 Rossj JO Co 1 Division of the external op,,rn,u," neurogenic bladder. Brit. Surg., 54: 627, 1967. 11 Smythe, C. A.: External sphincterotomy in the management of the neurogenic bladder: a preliminary report. J. UroL, 96: 310, 1966. 12 O'Flynn, J. D.: External sphincterotomy for the relief of outlet obstruction in neurogenic bladder. Paraplegia, IO: 29, 1972.
202
SCHELLHAMMER, HACKLER AND BUNTS
complication, which may be caused by his technique of starting the lateral incisions at the bladder neck rather than just proximal to the verumontanum, thereby undermining the prostatic lobes. 13 Stricture and benign prostatic hypertrophy should be considered in the initially successful procedure which later fails. Incomplete division of the striated musculature of the external sphincter may also result in failure. It has been demonstrated that the external sphincter is not anatomically confined between the inferior and superior fascia of the urogenital diaphragm. Bundles of striated musculature have been demonstrated extending along the anterolateral aspect of the prostatic urethra to the trigone. 1 • Striated musculature has been demonstrated to surround the distal portion of the prostatic urethra and has been termed the paraurethral sphincter. 15 Perhaps failure to divide these bundles of striated muscle in the prostatic urethra may be an explanation for the occasional post-sphincterotomy failure. However, while the success of sphincterotomy may result in part from the division of the muscles of the external sphinc13 Malament, M.: External sphincterotomy in neurogenic bladder dysfunction. J. Urol., 108: 554, 1972. 14 Manley, C. B., Jr.: The striated muscle of the prostate. J. Urol., 95: 234, 1966. 15 Hutch, J. A.: A new theory of the anatomy of the internal urinary sphincter and the physiology of micturition. IV. The urinary sphincteric mechanism. J. Urol., 97: 705, 1967.
ter, we think that another factor is of equal importance. We suggest that after incisional healing takes place fixation of the prostatomembranous urethra occurs. This fixed tube or conduit eliminates the obstructing effect of the asynchronous contractions of the external sphincter and pelvic musculature and thereby lowers urethral resistance. Petersen attributes post-prostatectomy incontinence to scarring and rigidity of the external sphincter. 16 Resection of scarred areas restored sphincter function in his series. Our incisions may result in similar rigidity and loss of function of the membranous urethra. SUMMARY
External sphincterotomy, a procedure for lowering urethral resistance in the neurogenic bladder in order to restore efficient voiding and eliminate catheter drainage, is described. The technique is simple, the morbidity low and the success rate high. External sphincterotomy is most useful in the treatment ofreflex upper motor neuron bladder but should be considered for all catheter-bound neurogenic bladders. Since multiple procedures may be required, failures should be re-evaluated. Our experience with 173 operations on 150 patients is reviewed. 16 Petersen, R. A.: Plastic repair of the external urinary sphincter: a new technique for correction of postoperative incontinence in men. J. Urol., 97: 1050, 1967.
TIENTS V/ITH
NJ:3:UJ~,O(}EJ\fIC BLADDER PAUL F. SCEELLHA.IVHvfER, rt03ERT H. HACKLER
ANI}
K CA~L BUNTS
Urological 8ection Surgic:;i,! Service, M·:::Guire Veterans Ad:ninistration I-Iospita( Ric.hmond Virginia 1
1
resectoscope fitted 'iNith a k:nife electrode. Incisions are the
bulbous urethra. The incisions are made with several passages of the electrical 2). This lateral may result ir.. an invvard lobes. In several cas,2s an unsuccessful terotomiss Vv e herein evaluate the resi.1lts of 173
150 examinations. Iv1ATERIALS AND lviETHODS
The results of our fi::st series of 85 external in 19SE Cur:tie ana associates. s 'VVe have contin~.Jed to foll·Jw these
ber 22 3-way m for 7 After removal of the catheter residual mine less than a third of the total bl adder (90 cc n2aximum) csnsidered .successful :rssult. rf'he 1s follo\ved at least once a year v1ith residual Ul ine m.easur0:Y1ent and IVF·, 0
RESULTS
h2~\re included in this report been eval"Gated sifi..::e l
)l
an{! cne have been trial, If residual urine of per cent of b1addet (SO cc
pYessur,?s are deterCurrie Hnd a cystor:neL~cVIitl'.'"1 elevated
residual urme vvas of th2se patients have been to 5 yea:sj 40 fron:i l to 3 years and the cathete1\ The other 10 3 vve1e unable tu vvear the external condom because of a 2 ,,;yere to the various consb'1.Js~t an external ~''""'''"'·"lo lmv pr,,;ssure reflux which 2 had sacral decubiti and 1 C:f the 110 ~;vitb a reflex b1r.1dder) 95 (86 pBr cent) had successful results. In soPtrast, with ncr,-reflex biadder2
de:' as one 'Phich contrs_ctio:o. as dernonst;.-ated noE-r:::;flex bladder sb.ows either a flat curve or a pressures but ~Nith no reflex contraction. Ii n.or:;-refiex bladdeI in cervical or thoracic .::ord lesions rnay be caused ir.hi_bition of the reflex axe in the stur11n of the cord or or " in the cord below the uppermost motor and sensory level. Preoperative pressures m patients
Division n~e:nt o~· 1958.
199
200
SCHELLHAMMER, HACKLER AND BUNTS CYSTOMETRIC READINGS
DATE _ _ _ _ _ __
MILLIMETERS OF MERCURY
-=!===I=·'=!·
/14 :J-----____:_--==--E:
130
--~
120
12
=-~-
140 _ 130 12
_ ---r
"""=t~~ r -i'°-:=-t~~Jc
i------: - ~130
120_
11
~--:--no 100 --
100
cl'--::
A
Jc-- -:f
t_=cJ f +
,_ 70_ 60
- 60
-i--
--·----~-- -=_~-=_-_111_-._- _- _-._=__ -_.. 50 _--_
- _ :..:_
40-
40
,, -
30
3
-
10 MINUTES
!5
___
r
-42-_\_~~~o :~~t== d. -
~-- ~6
20,~r=c-;=
20
tl 0
O_
·:-:- 50 __
,--
-=f_:
+ MINUTES
10
MINUTES
15
FIG. 1. Cystometrogram of bladder with reflex contractur~. ~re~p_erative external sphincter pressure is equal to maximal detrusor pressure. Postoperative sphincter pressure 1s s1gmf1cantly decreased.
with successful sphincterotomy were higher than maximum bladder pressure in a third of the patients, equal in a third and lower in a third. In this last group the sphincter pressures, although lower than cystometrogram pressures, were still higher than normal. Regardless of the level of spinal cord damage the retrograde urethral pressure in the postoperative period was decreased as compared to the preoperative level. We divided our 39 failures (26 per cent) into a group which demonstrated an initial success period from 1 month to 5 years post-sphincterotomy and another group which demonstrated immediate and persistent postoperative failure. These 2 groups were then analyzed as to the level of the lesion and the condition of the bladder. The initial success group and the persistent failure group were similarly distributed between cervical, thoracic and lumbosacral lesions. However, in the group with the initially successful sphincterotomies, 12 had reflex bladders and 8 non-reflex bladders. This is in contrast to the total failure group which included only 2 patients with reflex bladders. The operation was repeated in 21 patients because of an initial or late failure. In 2 patients 3 procedures were necessary before success was achieved. Of the 19 who had only secondary procedures 13 were successful. On 3 occasions, after an unsuccessful postoperative result in a repeat sphincterotomy, cystoscopy revealed inward collapse of prostatic tissue. Resection of this tissue resulted in satisfactory bladder emptying. Analyzing the bladder condition in the procedures that were successfully repeated, it was noted that the majority (11 of 15) had reflex bladders. This pattern again demonstrates that a reflex bladder will yield a higher rate of successful catheter-free voiding post-sphincterotomy. In the successful sphincterotomy group (111 patients), 30 had undergone unsuccessful procedures on the bladder neck for the purpose of lowering resistance to voiding.
INCISED
FIG. 2. Schema demonstrates front and cross section views oflocation and extent of sphincterotomy incisions.
DISCUSSION
The principal reason for ineffective voiding by patients with neurogenic bladder is imbalance between the expulsive forces of the detrusor muscle and the forces maintaining urinary continence. In most instances the upper motor neuron bladder will initiate reflex contractions. Vesical emptying may be incomplete because of failure of the spastic striated external sphincter and the pelvic floor musculature to relax. The lower motor neuron bladder usually lacks effective expulsive power and depends on manual external pressure or heightened intra-abdominal pressure to empty. While the flaccid pelvic floor and external sphincter
Fm. 3. A, preoperative voiding cystourethrogram demonstrates patent bladder neck and prostatic urethra. There is narrowing in area of membranous urethra. B, postoperative voiding cystourethrogram reveals widely patent prostatomembranous urethra.
cause little obstruction, any area of resistance in the prostatomembranous urethra could signifiemptying. That the imbalance between the forces of micturition and continence in a cord bladder may be surgically altered has been re,co1~n1zE,a and diverse modes of infravesical resistance to have been used. Pressure studies have shown that the area of greatest resistance to voiding in the nerve-intact individual is the membranous and distal urethra.•· 5 Ascoli" and Damanski7 used to identify the membranous urethra as the of obstruction to antegrade flovv of contrast medium. The cystourethrograms reviewed in our dem onstrated similar findings. The bladder neck was open in with no of bladder neck resection and
O'Flynn showed after external spnu:1c1;ero-uJrn,:,; 12 He commented that the bladder neck obstruction seen in spinal cord was secondary to increased P"''"'""'"' pressure initially causing detrusor and associated bladder neck We do not agree with this concept. The demonstrable of the bladder neck on cystourethrogindicate that bladder neck hypertrophy is not a significant factor. Bladder neck hypertrophy may occur along with deJrusor hyperas a result of uncontrolled nerve impulses from the isolated reflex centers in the stump of the spinal cord. n11vv,,v,-er this n,rrn,rr.rnnrrv does not imply obstruction. The lack of success with bladder neck resection in who subsequently had successful. ~,a-.,,~,rnn would support this contention. Failures should be subject to re evaluation and undergo a second vu_,..vva"•J if reflex contractions are noted on the cystometrogram and if the ,_..,... ,-"-" pressures remain elevated. This fact can be from our 71 success rate with repeat causes for failure should be consideredo The undermined prostate may present the sole obstruction to Malament noted a incidence of this 0
grams tatomem.branous urethra preoperative x-rays have with success men1branous urethra in an effort to reduce resist3 · 11 The most recent report ance to 4 En1anuel, Iv:L: .ft.. nevv catheter-type sphincterometer. J. 5 • J. Ajemian 1 P,, Ste•;vart, B. H.) B. A. and rhhwP.nit J. R.: Further observations on kinetics of the urethiovesical sphincter, J. Urol., 84~ 86j 1960. 6 Ascoli, R. R.: Radiological paraplegia secondary to spinal 235, 1967. 7 Damanski M · ,ys,to-m·e-cnr<)g1·arJny in paraplegia: its practical appli~·ation. Brit. J. 67, 1961. 6 Donovan, H.: Care of urinary tract in paraplegic patients: review of 82 cases. Lancet, 1: 515, 1947.
10 Rossj JO Co 1 Division of the external op,,rn,u," neurogenic bladder. Brit. Surg., 54: 627, 1967. 11 Smythe, C. A.: External sphincterotomy in the management of the neurogenic bladder: a preliminary report. J. UroL, 96: 310, 1966. 12 O'Flynn, J. D.: External sphincterotomy for the relief of outlet obstruction in neurogenic bladder. Paraplegia, IO: 29, 1972.
202
SCHELLHAMMER, HACKLER AND BUNTS
complication, which may be caused by his technique of starting the lateral incisions at the bladder neck rather than just proximal to the verumontanum, thereby undermining the prostatic lobes. 13 Stricture and benign prostatic hypertrophy should be considered in the initially successful procedure which later fails. Incomplete division of the striated musculature of the external sphincter may also result in failure. It has been demonstrated that the external sphincter is not anatomically confined between the inferior and superior fascia of the urogenital diaphragm. Bundles of striated musculature have been demonstrated extending along the anterolateral aspect of the prostatic urethra to the trigone. 1 • Striated musculature has been demonstrated to surround the distal portion of the prostatic urethra and has been termed the paraurethral sphincter. 15 Perhaps failure to divide these bundles of striated muscle in the prostatic urethra may be an explanation for the occasional post-sphincterotomy failure. However, while the success of sphincterotomy may result in part from the division of the muscles of the external sphinc13 Malament, M.: External sphincterotomy in neurogenic bladder dysfunction. J. Urol., 108: 554, 1972. 14 Manley, C. B., Jr.: The striated muscle of the prostate. J. Urol., 95: 234, 1966. 15 Hutch, J. A.: A new theory of the anatomy of the internal urinary sphincter and the physiology of micturition. IV. The urinary sphincteric mechanism. J. Urol., 97: 705, 1967.
ter, we think that another factor is of equal importance. We suggest that after incisional healing takes place fixation of the prostatomembranous urethra occurs. This fixed tube or conduit eliminates the obstructing effect of the asynchronous contractions of the external sphincter and pelvic musculature and thereby lowers urethral resistance. Petersen attributes post-prostatectomy incontinence to scarring and rigidity of the external sphincter. 16 Resection of scarred areas restored sphincter function in his series. Our incisions may result in similar rigidity and loss of function of the membranous urethra. SUMMARY
External sphincterotomy, a procedure for lowering urethral resistance in the neurogenic bladder in order to restore efficient voiding and eliminate catheter drainage, is described. The technique is simple, the morbidity low and the success rate high. External sphincterotomy is most useful in the treatment ofreflex upper motor neuron bladder but should be considered for all catheter-bound neurogenic bladders. Since multiple procedures may be required, failures should be re-evaluated. Our experience with 173 operations on 150 patients is reviewed. 16 Petersen, R. A.: Plastic repair of the external urinary sphincter: a new technique for correction of postoperative incontinence in men. J. Urol., 97: 1050, 1967.