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Intravenous papaverine in constructing continent urinary reservoir
INTRAVENOUS PAPAVERINE IN CONSTRUCTING CONTINENT S. BRUCE
URINARY RESERVOIR
MALKOWICZ,
M.D.
JOHN F. VILJOEN,
MARK R. AVON, M.D.
DONALD
DURAIYAH THANGATHURAI,
M.D.
G. SKINNER,
M.D.
M .D.
From the Division of Urology, Department of Surgery, and Department of Anesthesiology, University of California School of Medicine, Los Angeles, California
Continent urinary diversion is a proved and desirable technique which has been increasingly applied to oncologic and reconstructive urologic surgery. l Creating a low-pressure reservoir of adequate capacity is a major goal of such surgery and requires the approximation of a reasonable length of bowel along reinforced suture lines of considerable length. This part of the procedure can be hampered by spastic bowel or a thickened mesentery which can lead to overincorporation of bowel into the suture line. If this occurs, the potential volume of the reservoir can be compromised. Spasticity or a thick, short mesentery also makes the tissue more difficult to handle and adds to the technical difficulties encountered during surgery. This problem can be remedied by a safe, easily administered, short-acting agent which decreases the tonicity of the bowel during suture placement. Papaverine, a nonspecific smooth muscle relaxant, can achieve this goal. The drug is a receptor-independent agent which acts by phosphodiesterase inhibition. This in turn increases the level of cyclic AMP in smooth muscle tissue. The increased levels of cyclic AMP promote the dissociation of the catalytic subunit from the regulatory subunit of cyclic AMP dependent protein kinase and allows the catalytic subunit to inhibit muscle contraction.2-3 Papaverine has been used safely in the attempted treatment of peripheral vascular disease, cerebral ischemia, and pulmonary embolism. Side effects include facial flushing, reflex
UROLOGY
/
MAY 1989
/
VOLUME XXXIII,
NUMBER 5
tachycardia, and drowsiness. In very high doses it can produce hepatic toxicity and has been shown to decrease A-V nodal and intraventricular conduction.4,5 Technique During mobilization and selection of the bowel segment for the reservoir, an intravenous infusion comprised of 300 mg of papaverine in 500 cc of saline is initiated by the anesthesiologist. If a vasodilator such as nitroglycerine is being given, its administration should be suspended during the papaverine infusion. A contraindication to the use of intravenous papaverine exists if this cannot be done within a reasonable margin of safety. The patient should preferably be normotensive at the initiation of papaverine administration. An initial dose of 20-50 mg is infused over a period of ten minutes and is titrated according to the arterial pressure until a 10 to 15 mm Hg fall in systolic blood pressure is noted. The maximum effectiveness of papaverine on the bowel coincides with this fall in blood pressure. The maintenance dose is approximately 1 to 5 mg per minute, and the total dose ranges from 150300 mg. A total of 300 mg has been arbitrarily selected as an upper limit to avoid severe hypotension or oozing from dilated capillary beds. The physiologic and therapeutic effects of papaverine dissipate approximately fifteen minutes after cessation of the infusion. The effects of papaverine can be reversed more rapidly by the infusion of calcium chloride. Papaverine’s
431
Department of Urology USC Medical Center GH 5900 2025 Zonal Avenue Los Angeles, California 90033 (DR. SKINNER)
effect on the bowel is readily evident in that tonic and spastic segments quickly relax and allow for precise and trouble-free alignment and approximation. This technique has been employed in over 100 continent urinary diversions without significant intraoperative or postoperative side effects. Summary The use of intravenous papaverine as an adjunct in the construction of a continent urinary reservoir is a safe and effective method to facilitate an important but sometimes restrictive portion of this procedure. Additionally, it does not seem unreasonable to extend this technique to other procedures which involve the use of small bowel.
432
1. Skinner DG, Lieskovsky G, and Boyd SD: Continuing experience with the continent ileal reservoir (Kock pouch) as an alternative to cutaneous urinary diversion: an update after 250 cases, J Urol 137: 1140 (1987). 2. Bolton TB: Mechanisms of action of transmitters and other substances on smooth muscle, Physiol Rev 59: 606 (1979). 3. Kerrick WC, and Hoor PE: Inhibition of smooth muscle tension by cyclic AMP dependent protein kinase, Nature 297: 253 (1981). 4. Asby GR Jr, et al: Hemodynamic effects of ethaverine hydrochloride in patients with peripheral vascular disease, Curr Ther Res 16: 1096 (1974). 5. Coffman JD: Vasodilator drugs in peripheral vascular disease, N Engl J Med 300: 713 (1979).
UROLOGY
/
MAY 1989
/ VOLUME
XXXIII,
NUMBER
5
URINARY RESERVOIR
MALKOWICZ,
M.D.
JOHN F. VILJOEN,
MARK R. AVON, M.D.
DONALD
DURAIYAH THANGATHURAI,
M.D.
G. SKINNER,
M.D.
M .D.
From the Division of Urology, Department of Surgery, and Department of Anesthesiology, University of California School of Medicine, Los Angeles, California
Continent urinary diversion is a proved and desirable technique which has been increasingly applied to oncologic and reconstructive urologic surgery. l Creating a low-pressure reservoir of adequate capacity is a major goal of such surgery and requires the approximation of a reasonable length of bowel along reinforced suture lines of considerable length. This part of the procedure can be hampered by spastic bowel or a thickened mesentery which can lead to overincorporation of bowel into the suture line. If this occurs, the potential volume of the reservoir can be compromised. Spasticity or a thick, short mesentery also makes the tissue more difficult to handle and adds to the technical difficulties encountered during surgery. This problem can be remedied by a safe, easily administered, short-acting agent which decreases the tonicity of the bowel during suture placement. Papaverine, a nonspecific smooth muscle relaxant, can achieve this goal. The drug is a receptor-independent agent which acts by phosphodiesterase inhibition. This in turn increases the level of cyclic AMP in smooth muscle tissue. The increased levels of cyclic AMP promote the dissociation of the catalytic subunit from the regulatory subunit of cyclic AMP dependent protein kinase and allows the catalytic subunit to inhibit muscle contraction.2-3 Papaverine has been used safely in the attempted treatment of peripheral vascular disease, cerebral ischemia, and pulmonary embolism. Side effects include facial flushing, reflex
UROLOGY
/
MAY 1989
/
VOLUME XXXIII,
NUMBER 5
tachycardia, and drowsiness. In very high doses it can produce hepatic toxicity and has been shown to decrease A-V nodal and intraventricular conduction.4,5 Technique During mobilization and selection of the bowel segment for the reservoir, an intravenous infusion comprised of 300 mg of papaverine in 500 cc of saline is initiated by the anesthesiologist. If a vasodilator such as nitroglycerine is being given, its administration should be suspended during the papaverine infusion. A contraindication to the use of intravenous papaverine exists if this cannot be done within a reasonable margin of safety. The patient should preferably be normotensive at the initiation of papaverine administration. An initial dose of 20-50 mg is infused over a period of ten minutes and is titrated according to the arterial pressure until a 10 to 15 mm Hg fall in systolic blood pressure is noted. The maximum effectiveness of papaverine on the bowel coincides with this fall in blood pressure. The maintenance dose is approximately 1 to 5 mg per minute, and the total dose ranges from 150300 mg. A total of 300 mg has been arbitrarily selected as an upper limit to avoid severe hypotension or oozing from dilated capillary beds. The physiologic and therapeutic effects of papaverine dissipate approximately fifteen minutes after cessation of the infusion. The effects of papaverine can be reversed more rapidly by the infusion of calcium chloride. Papaverine’s
431
Department of Urology USC Medical Center GH 5900 2025 Zonal Avenue Los Angeles, California 90033 (DR. SKINNER)
effect on the bowel is readily evident in that tonic and spastic segments quickly relax and allow for precise and trouble-free alignment and approximation. This technique has been employed in over 100 continent urinary diversions without significant intraoperative or postoperative side effects. Summary The use of intravenous papaverine as an adjunct in the construction of a continent urinary reservoir is a safe and effective method to facilitate an important but sometimes restrictive portion of this procedure. Additionally, it does not seem unreasonable to extend this technique to other procedures which involve the use of small bowel.
432
1. Skinner DG, Lieskovsky G, and Boyd SD: Continuing experience with the continent ileal reservoir (Kock pouch) as an alternative to cutaneous urinary diversion: an update after 250 cases, J Urol 137: 1140 (1987). 2. Bolton TB: Mechanisms of action of transmitters and other substances on smooth muscle, Physiol Rev 59: 606 (1979). 3. Kerrick WC, and Hoor PE: Inhibition of smooth muscle tension by cyclic AMP dependent protein kinase, Nature 297: 253 (1981). 4. Asby GR Jr, et al: Hemodynamic effects of ethaverine hydrochloride in patients with peripheral vascular disease, Curr Ther Res 16: 1096 (1974). 5. Coffman JD: Vasodilator drugs in peripheral vascular disease, N Engl J Med 300: 713 (1979).
UROLOGY
/
MAY 1989
/ VOLUME
XXXIII,
NUMBER
5