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External Sphincterotomy at the 12 O’Clock Position
0022-534 7/79/1214-0462$02. 00/0
Vol. 121, April Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
EXTERNAL SPHINCTEROTOMY AT THE 12 O'CLOCK POSITION HERNAN M. CARRION, B. THOMAS BROWN
AND
VICTOR A. POLITANO
From the Department of Urology, University of Miami School of Medicine and the Spinal Cord Injury Service, Jackson Memorial Hospital and Veterans Administration Hospital, Miami, Florida
ABSTRACT
Transurethral resection of the external sphincter was done at the 12 o'clock position 61 times in 60 men. There was a 2.8 per cent incidence of postoperative impotence and a 75 per cent cure of vesicoureteral reflux but there was only a 65 per cent success rate of decreasing post-voiding residual urine after 6 months. The techniques and applications of the procedure are discussed. Transurethral resection of the external sphincter is now an accepted method of treatment for patients with neurogenic bladders who have functional obstruction at the external sphincter. Since the work of Emmett and associates in 1948 1 various methods of severing the external sphincter have been proposed. We present our experience with 60 patients who have undergone transurethral resection of the external sphincter at the 12 o'clock position. MATERIALS AND METHODS
From March 1976 to February 1978, 60 male patients with spinal cord injuries underwent 61 transurethral resections of the external sphincter at the 12 o'clock position. The patients ranged in age from 19 to 78 years, with an average of 39 years. The etiologies of the 25 cervical and 35 thoracic lesions were predominately gunshot wounds but included diving and trampoline ac<;idents. The interval from the time of injury to the time of operation ranged from 3 months to 28 years and averaged 8 years 3 months. The technique for all patients included an Iglesias resectoscope with a No. 26 cutting loop. The incision began at the verumontanum and extended distally 1 full loop length or 2.7 cm. 2 The depth of incision was 6 to 8 mm. In patients operated upon for reflux the 12 o'clock incision was extended proximally to include the bladder neck. Postoperatively, a 24F Foley catheter was inserted but this was removed in 3 to 4 days. The patients were placed on suppressive antibiotics until the urine was free of infection. Followup studies for residual urine were done in the immediate postoperative period and 3, 6, 9 and 12 months postoperatively. A followup cystogram was done when indicated at 2 to 6 months postoperatively. Of the 60 patients in the study all were followed for 6 months and 37 patients were followed for 12 months. No patient was operated on unless the residual urine was >50 cc preoperatively. Two patients required repeat procedures at 3 months and 3 patients at 6 months owing to severe infection and, thus, were removed from the study. DISCUSSION AND RESULTS
Voiding is a process balancing the expulsive forces of the bladder against the resistant forces of the bladder neck, and prostatic and membranous urethra. Emmett first introduced transurethral resection of the bladder neck in 1940 for retention of urine in a spinal cord injury patient. 3 By 1948 he reasoned that failure oftransurethral resection of the bladder neck was owing to the "inability of the external sphincter muscle to relax". 1 It is now known that the membranous urethra is the greatest source of urethral resistance in the Accepted for publication July 21, 1978. Read at annual meeting of Southeastern Section, American Urological Association, Louisville, Kentucky, April 8-12, 1978.
outflow tract, 2 especially in patients with detrusor-sphincter dyssynergia. Since this concept was accepted a number of operative procedures have been used to aid the spinal cord injury patient in emptying the bladder. Emmett and associates used pudenda! nerve section, sacral rhizotomy and alcohol injections with questionable results. 1 These procedures have now been abandoned owing to the poor results and the increased incidence of impotence. 4 In 1958 Ross and associates pioneered resection of the external sphincter via a cold punch technique. 5 They changed their technique because of excessive postoperative hemorrhage with a Collings knife. 6 During the ensuing years this method ofresection became the treatment of choice in selected patients with an unbalanced bladder. Some variation in technique was reported but most resections were done at the 3 and 9 o'clock positions. 7· 15 In 1974 Schoenfeld and associates first reported a 32 per cent incidence of postoperative impotence after transurethral resection of the external sphincter at the 3 and 9 o'clock positions. 16 This report was followed quickly by other investigators who reported a 2 to 56 per cent incidence of erectile incompetence after external sphincterotomy at the 3 and 9 o'clock positions. 4 • 11-2° Although the etiology of this problem has not been resolved it is believed by most to be secondary to a vascular insult to the deep and dorsal arteries of the corpora cavernosa. This insult is created by the electrocoagulation of the area near these vessels necessary for normal erections. In response to this complication we adopted the 12 o'clock technique first described by Madersbacher and Scott in 1975. 21 Of the 35 patients who had normal erectile function preoperatively only 1 (2.8 per cent) became impotent postoperatively. Interestingly, the 1 T7 paraplegic who had been impotent for 22 years and who received 2 resections at the 12 o'clock position had normal erections after the second procedure. The cause of reflux in the spinal cord injury patient is not known. However, most authorities believe that reflux results from increased intravesical pressure and infection. 9 By obtaining a balanced bladder via external sphincterotomy reflux should disappear. Ross and associates reported in their original series in 1958 that 2 of 4 units with reflux were cured after external sphincterotomy. 5 In an unpublished series from this institution 61 of 71 units with reflux (86 per cent) were cured after sphincterotomy at the 3 and 9 o'clock positions. 22 In the current series 14 patients had 20 units with reflux: 6 had bilateral reflux while 8 had unilateral reflux. In the 12 patients with bilateral reflux 9 units (75 per cent) were c_ured and 3 (25 per cent) remained unchanged. Of the 8 patients with unilateral reflux 6 (75 per cent) were cured and 2 (25 per cent) improved from grade III to grade I reflux. Over-all, 15 of the 20 patients (75 per cent) with reflux were cured, 2 (10 per cent) were improved and 3 (15 per cent) remained the same (table 1).
462
EXTERNAL SPHINCTEROTOMY AT TABLE
Postop. Improved Unchanged
Cured Bilat.
6
Bilat., 4 Unilat., 1
Unilat.
8
6
TABLE
j
1 1 2
2. Residual urine volumes
I
Postop. Volume (cc) 0-50 51-100 101-200 201-300 % Acceptable
Preop.
463
cord patient. In all other patients we prefer the 3 and 9 o'clock positions.
1. Vesicoureteral refiux
Preop.
12 O'CLOCK POSITION
Immediate
3Mos.
6 Mos.
0
52 3
5
38 12 8
38 7 10
24
6 21 33 0
87
65.5
65.5
75
12 Mos. 1 7
Perhaps the most exacting test of the success of a sphincterotomy is its ability to diminish or abolish residual urine, thereby creating a balanced bladder. Acceptable postoperative residual urine volumes vary from <50 cc 11 to <150 cc 13 to just catheter-free." In this study a residual urine volume was considered unacceptable if it was >50 cc. In the immediate postoperative period 52 of the 60 patients (87 per cent) had acceptable residual urine volumes. By 3 months only 38 of the remaining 58 patients in the study (65.5 per cent) had acceptable residual urine volumes. At 6 months 38 of the remaining 55 patients (65.5 per cent) had residual urine volumes <50 cc. At 9 months 29 of 38 patients (76 per cent) and at 1 year 24 of 32 patients (75 per cent) had acceptable results (table 2). Success with decreasing residual urine volumes has been reported as 83 to 100 per cent, depending on the study. 9 • 11. 12 • 14• 22 With an immediate success rate of only 87 per cent and a 6-month success rate of 65 per cent external sphincterotomy at the 12 o'clock position, in our hands, does not appear to be superior in reducing residual urine volumes. This could possibly be owing to the inexperience of the operator using a new technique. It has been shown that an incision must be at least 6 mm. deep and 2 cm. long to sever the external sphincter.:i Therefore, it is possible that the resections were inadequate. In addition, O'Flynn has theorized that healing and restoration of function would be possible with a solitary incision. 10 This may be the case with the 5 patients who had borderline residual urine volumes at 3 months and were totally unacceptable at 6 months to 1 year postoperatively. Complications of the procedure were minimal, with only 3 patients requiring transfusion and only 1 needing repeat hospitalization for post-transurethral resection bleeding. External sphincterotomy at the 12 o'clock position appears to be a viable alternative to the 3 and 9 o'clock positions. The incidence of postoperative impotence appears to be much less at the 12 o'clock position. The disappearance of reflux is approximately equal in both techniques. The 12 o'clock position, in our hands, is not as effective in lowering post-voiding residual urine volumes as the 3 and 9 o'clock positions. For these reasons we recommend the 12 o'clock position for all initial resections of the external sphincter in the potent spinal
REFERENCES
1. Emmett, J. L., Daut, R. V. and Dunn, J. H.: Role of the external urethral sphincter in the normal bladder and cord bladder. J. Urol., 59: 439, 1948. 2. Linker, D. G. and Tanagho, E. A.: Complete external sphincterotomy: correlation between endoscopic observation and the anatomic sphincter. J. Urol., 113: 348, 1975. 3. Emmett, J. L.: Urinary retention from imbalance of detrusor and vesical neck; treatment by transurethral resection. J. Urol., 43: 692, 1940. 4. Thomas, D. G.: The effect of trans-urethral surgery on penile erections in spinal cord injury patients. Paraplegia, 13: 286, 1976. 5. Ross, J. C., Damanski, M. and Gibbon, N.: Resection of the external urethral sphincter in the paraplegic-preliminary report. J. Urol., 79: 742, 1958. 6. Ross, J.C., Gibbon, N. 0. K. and Damanski, M.: Division of the external urethral sphincter in the treatment of the neurogenic bladder. Brit. J. Surg., 54: 627, 1967. 7. Ross, J.C., Gibbon, N. 0. K. and Damanski, M.: Division of the external urethral sphincter in the treatment of the paraplegic bladder. A preliminary report on a new procedure. Brit. J. Urol., 30: 204, 1958. 8. Smythe, C. A.: External sphincterotomy in the management of the neurogenic bladder: a preliminary report. J. Urol., 96: 310, 1966. 9. Currie, R. J., Bilbisi, A. A., Schiebler, J. C. and Bunts, R. C.: External sphincterotomy in paraplegics: technique and results. J. Urol., 103: 64, 1970. 10. O'Flynn, J. D.: External sphincterotomy for the relief of outlet obstruction in neurogenic bladder. Paraplegia, 10: 29, 1972. 11. Malament, M.: External sphincterotomy in neurogenic bladder dysfunction. J. Urol., 108: 554, 1972. 12. Schellhammer, P. F., Hackler, R.H. and Bunts, R. C.: External sphincterotomy: an evaluation of 150 patients with neurogenic bladder. J. Urol., 110: 199, 1973. 13. Nanninga, J.B., Rosen, J. and O'Conor, V. J.: Experience with transurethral external sphincterotomy in patients with spinal cord injury. J. Urol., 112: 72, 1974. 14. Perkash, I.: Modified approach to sphincterotomy in spinal cord injury patients. Indications, technique and results in 32 patients. Paraplegia, 13: 247, 1976. 15. Morrow, J. W. and Bogaard, T. P.: Bladder rehabilitation in patients with old spinal cord injuries with bladder neck incision and external sphincterotomy. J. Urol., 117: 164, 1977. 16. Schoenfeld, L., Carrion, H. M. and Politano, V. A.: Erectile impotence. Complication of external sphincterotomy. Urology, 4: 681, 1974. 17. Rossier, A. B. and Ott, R.: Urinary manometry in spinal cord injury: a follow-up study. Value of cysto-sphinctero-metrography as an indication for sphincterotomy. Brit. J. Urol., 46: 439, 1974. 18. Kiviat, M. D.: Transurethral sphincterotomy: relationship of site of incision to postoperative potency and delayed hemorrhage. J. Urol., 114: 399, 1975. 19. Dollfus, P., Jurascheck, F., Adli, G. and Chapuis, A.: Impairment of erection after external sphincter resection. Paraplegia, 13: 290, 1976. 20. Crane, D. B. and Hackler, R. H.: External sphincterotomy: its effect on erections. J. Urol., 116: 316, 1976. 21. Madersbacher, H. and Scott, F. B.: Twelve o'clock sphincterotomy: technique, indications, results. Urol. Int., 30: 75, 1975. 22. Carrion, H. M., Shessel, F. S. and Politano, V. A.: External sphincterotomy in the treatment of neuropathic bladder. Unpublished data.
Vol. 121, April Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
EXTERNAL SPHINCTEROTOMY AT THE 12 O'CLOCK POSITION HERNAN M. CARRION, B. THOMAS BROWN
AND
VICTOR A. POLITANO
From the Department of Urology, University of Miami School of Medicine and the Spinal Cord Injury Service, Jackson Memorial Hospital and Veterans Administration Hospital, Miami, Florida
ABSTRACT
Transurethral resection of the external sphincter was done at the 12 o'clock position 61 times in 60 men. There was a 2.8 per cent incidence of postoperative impotence and a 75 per cent cure of vesicoureteral reflux but there was only a 65 per cent success rate of decreasing post-voiding residual urine after 6 months. The techniques and applications of the procedure are discussed. Transurethral resection of the external sphincter is now an accepted method of treatment for patients with neurogenic bladders who have functional obstruction at the external sphincter. Since the work of Emmett and associates in 1948 1 various methods of severing the external sphincter have been proposed. We present our experience with 60 patients who have undergone transurethral resection of the external sphincter at the 12 o'clock position. MATERIALS AND METHODS
From March 1976 to February 1978, 60 male patients with spinal cord injuries underwent 61 transurethral resections of the external sphincter at the 12 o'clock position. The patients ranged in age from 19 to 78 years, with an average of 39 years. The etiologies of the 25 cervical and 35 thoracic lesions were predominately gunshot wounds but included diving and trampoline ac<;idents. The interval from the time of injury to the time of operation ranged from 3 months to 28 years and averaged 8 years 3 months. The technique for all patients included an Iglesias resectoscope with a No. 26 cutting loop. The incision began at the verumontanum and extended distally 1 full loop length or 2.7 cm. 2 The depth of incision was 6 to 8 mm. In patients operated upon for reflux the 12 o'clock incision was extended proximally to include the bladder neck. Postoperatively, a 24F Foley catheter was inserted but this was removed in 3 to 4 days. The patients were placed on suppressive antibiotics until the urine was free of infection. Followup studies for residual urine were done in the immediate postoperative period and 3, 6, 9 and 12 months postoperatively. A followup cystogram was done when indicated at 2 to 6 months postoperatively. Of the 60 patients in the study all were followed for 6 months and 37 patients were followed for 12 months. No patient was operated on unless the residual urine was >50 cc preoperatively. Two patients required repeat procedures at 3 months and 3 patients at 6 months owing to severe infection and, thus, were removed from the study. DISCUSSION AND RESULTS
Voiding is a process balancing the expulsive forces of the bladder against the resistant forces of the bladder neck, and prostatic and membranous urethra. Emmett first introduced transurethral resection of the bladder neck in 1940 for retention of urine in a spinal cord injury patient. 3 By 1948 he reasoned that failure oftransurethral resection of the bladder neck was owing to the "inability of the external sphincter muscle to relax". 1 It is now known that the membranous urethra is the greatest source of urethral resistance in the Accepted for publication July 21, 1978. Read at annual meeting of Southeastern Section, American Urological Association, Louisville, Kentucky, April 8-12, 1978.
outflow tract, 2 especially in patients with detrusor-sphincter dyssynergia. Since this concept was accepted a number of operative procedures have been used to aid the spinal cord injury patient in emptying the bladder. Emmett and associates used pudenda! nerve section, sacral rhizotomy and alcohol injections with questionable results. 1 These procedures have now been abandoned owing to the poor results and the increased incidence of impotence. 4 In 1958 Ross and associates pioneered resection of the external sphincter via a cold punch technique. 5 They changed their technique because of excessive postoperative hemorrhage with a Collings knife. 6 During the ensuing years this method ofresection became the treatment of choice in selected patients with an unbalanced bladder. Some variation in technique was reported but most resections were done at the 3 and 9 o'clock positions. 7· 15 In 1974 Schoenfeld and associates first reported a 32 per cent incidence of postoperative impotence after transurethral resection of the external sphincter at the 3 and 9 o'clock positions. 16 This report was followed quickly by other investigators who reported a 2 to 56 per cent incidence of erectile incompetence after external sphincterotomy at the 3 and 9 o'clock positions. 4 • 11-2° Although the etiology of this problem has not been resolved it is believed by most to be secondary to a vascular insult to the deep and dorsal arteries of the corpora cavernosa. This insult is created by the electrocoagulation of the area near these vessels necessary for normal erections. In response to this complication we adopted the 12 o'clock technique first described by Madersbacher and Scott in 1975. 21 Of the 35 patients who had normal erectile function preoperatively only 1 (2.8 per cent) became impotent postoperatively. Interestingly, the 1 T7 paraplegic who had been impotent for 22 years and who received 2 resections at the 12 o'clock position had normal erections after the second procedure. The cause of reflux in the spinal cord injury patient is not known. However, most authorities believe that reflux results from increased intravesical pressure and infection. 9 By obtaining a balanced bladder via external sphincterotomy reflux should disappear. Ross and associates reported in their original series in 1958 that 2 of 4 units with reflux were cured after external sphincterotomy. 5 In an unpublished series from this institution 61 of 71 units with reflux (86 per cent) were cured after sphincterotomy at the 3 and 9 o'clock positions. 22 In the current series 14 patients had 20 units with reflux: 6 had bilateral reflux while 8 had unilateral reflux. In the 12 patients with bilateral reflux 9 units (75 per cent) were c_ured and 3 (25 per cent) remained unchanged. Of the 8 patients with unilateral reflux 6 (75 per cent) were cured and 2 (25 per cent) improved from grade III to grade I reflux. Over-all, 15 of the 20 patients (75 per cent) with reflux were cured, 2 (10 per cent) were improved and 3 (15 per cent) remained the same (table 1).
462
EXTERNAL SPHINCTEROTOMY AT TABLE
Postop. Improved Unchanged
Cured Bilat.
6
Bilat., 4 Unilat., 1
Unilat.
8
6
TABLE
j
1 1 2
2. Residual urine volumes
I
Postop. Volume (cc) 0-50 51-100 101-200 201-300 % Acceptable
Preop.
463
cord patient. In all other patients we prefer the 3 and 9 o'clock positions.
1. Vesicoureteral refiux
Preop.
12 O'CLOCK POSITION
Immediate
3Mos.
6 Mos.
0
52 3
5
38 12 8
38 7 10
24
6 21 33 0
87
65.5
65.5
75
12 Mos. 1 7
Perhaps the most exacting test of the success of a sphincterotomy is its ability to diminish or abolish residual urine, thereby creating a balanced bladder. Acceptable postoperative residual urine volumes vary from <50 cc 11 to <150 cc 13 to just catheter-free." In this study a residual urine volume was considered unacceptable if it was >50 cc. In the immediate postoperative period 52 of the 60 patients (87 per cent) had acceptable residual urine volumes. By 3 months only 38 of the remaining 58 patients in the study (65.5 per cent) had acceptable residual urine volumes. At 6 months 38 of the remaining 55 patients (65.5 per cent) had residual urine volumes <50 cc. At 9 months 29 of 38 patients (76 per cent) and at 1 year 24 of 32 patients (75 per cent) had acceptable results (table 2). Success with decreasing residual urine volumes has been reported as 83 to 100 per cent, depending on the study. 9 • 11. 12 • 14• 22 With an immediate success rate of only 87 per cent and a 6-month success rate of 65 per cent external sphincterotomy at the 12 o'clock position, in our hands, does not appear to be superior in reducing residual urine volumes. This could possibly be owing to the inexperience of the operator using a new technique. It has been shown that an incision must be at least 6 mm. deep and 2 cm. long to sever the external sphincter.:i Therefore, it is possible that the resections were inadequate. In addition, O'Flynn has theorized that healing and restoration of function would be possible with a solitary incision. 10 This may be the case with the 5 patients who had borderline residual urine volumes at 3 months and were totally unacceptable at 6 months to 1 year postoperatively. Complications of the procedure were minimal, with only 3 patients requiring transfusion and only 1 needing repeat hospitalization for post-transurethral resection bleeding. External sphincterotomy at the 12 o'clock position appears to be a viable alternative to the 3 and 9 o'clock positions. The incidence of postoperative impotence appears to be much less at the 12 o'clock position. The disappearance of reflux is approximately equal in both techniques. The 12 o'clock position, in our hands, is not as effective in lowering post-voiding residual urine volumes as the 3 and 9 o'clock positions. For these reasons we recommend the 12 o'clock position for all initial resections of the external sphincter in the potent spinal
REFERENCES
1. Emmett, J. L., Daut, R. V. and Dunn, J. H.: Role of the external urethral sphincter in the normal bladder and cord bladder. J. Urol., 59: 439, 1948. 2. Linker, D. G. and Tanagho, E. A.: Complete external sphincterotomy: correlation between endoscopic observation and the anatomic sphincter. J. Urol., 113: 348, 1975. 3. Emmett, J. L.: Urinary retention from imbalance of detrusor and vesical neck; treatment by transurethral resection. J. Urol., 43: 692, 1940. 4. Thomas, D. G.: The effect of trans-urethral surgery on penile erections in spinal cord injury patients. Paraplegia, 13: 286, 1976. 5. Ross, J. C., Damanski, M. and Gibbon, N.: Resection of the external urethral sphincter in the paraplegic-preliminary report. J. Urol., 79: 742, 1958. 6. Ross, J.C., Gibbon, N. 0. K. and Damanski, M.: Division of the external urethral sphincter in the treatment of the neurogenic bladder. Brit. J. Surg., 54: 627, 1967. 7. Ross, J.C., Gibbon, N. 0. K. and Damanski, M.: Division of the external urethral sphincter in the treatment of the paraplegic bladder. A preliminary report on a new procedure. Brit. J. Urol., 30: 204, 1958. 8. Smythe, C. A.: External sphincterotomy in the management of the neurogenic bladder: a preliminary report. J. Urol., 96: 310, 1966. 9. Currie, R. J., Bilbisi, A. A., Schiebler, J. C. and Bunts, R. C.: External sphincterotomy in paraplegics: technique and results. J. Urol., 103: 64, 1970. 10. O'Flynn, J. D.: External sphincterotomy for the relief of outlet obstruction in neurogenic bladder. Paraplegia, 10: 29, 1972. 11. Malament, M.: External sphincterotomy in neurogenic bladder dysfunction. J. Urol., 108: 554, 1972. 12. Schellhammer, P. F., Hackler, R.H. and Bunts, R. C.: External sphincterotomy: an evaluation of 150 patients with neurogenic bladder. J. Urol., 110: 199, 1973. 13. Nanninga, J.B., Rosen, J. and O'Conor, V. J.: Experience with transurethral external sphincterotomy in patients with spinal cord injury. J. Urol., 112: 72, 1974. 14. Perkash, I.: Modified approach to sphincterotomy in spinal cord injury patients. Indications, technique and results in 32 patients. Paraplegia, 13: 247, 1976. 15. Morrow, J. W. and Bogaard, T. P.: Bladder rehabilitation in patients with old spinal cord injuries with bladder neck incision and external sphincterotomy. J. Urol., 117: 164, 1977. 16. Schoenfeld, L., Carrion, H. M. and Politano, V. A.: Erectile impotence. Complication of external sphincterotomy. Urology, 4: 681, 1974. 17. Rossier, A. B. and Ott, R.: Urinary manometry in spinal cord injury: a follow-up study. Value of cysto-sphinctero-metrography as an indication for sphincterotomy. Brit. J. Urol., 46: 439, 1974. 18. Kiviat, M. D.: Transurethral sphincterotomy: relationship of site of incision to postoperative potency and delayed hemorrhage. J. Urol., 114: 399, 1975. 19. Dollfus, P., Jurascheck, F., Adli, G. and Chapuis, A.: Impairment of erection after external sphincter resection. Paraplegia, 13: 290, 1976. 20. Crane, D. B. and Hackler, R. H.: External sphincterotomy: its effect on erections. J. Urol., 116: 316, 1976. 21. Madersbacher, H. and Scott, F. B.: Twelve o'clock sphincterotomy: technique, indications, results. Urol. Int., 30: 75, 1975. 22. Carrion, H. M., Shessel, F. S. and Politano, V. A.: External sphincterotomy in the treatment of neuropathic bladder. Unpublished data.