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Measurement of Urethral Pressures Following Radical Perineal Prostatectomy
'Vol. f16,.
THE JOURNAL OF' UROLOG:i'.
l)n:nted ·t'.n
Copyright ,'.£) J 966 by The Willian1s & 'Wilkins Co"
AIEASUREl\JE~T OF URETHRAL PRESSURES FOLLOWING RADICAL
PERIN EAL PROSTATECTO iVIY WILLIAM SAMELLAS* Fnnn lhe Dcpartrnwnts of Surgery
, Veterans Adrninislration Hospital and the Slate
(i11/1.versit1;
of ?\'ew York, Downstate jJ1edical Center, Brooklyn, New York
Recently a study was nnclertaken on the control of urination in who have had radical perinea! prostatectomy for carcinoma of the prostate.1 The purpose 1;-as co better understand the physiopathology of micturition in these patients. Retrograde emptying of the fluid column from tbe remnant of the po,,terior urethra adjacent to the external sphincter into the bladder upon voluntary interruption of proved to be essential for urinary continence. It was suggested that the role of the external sphincter in these than in normal becomes more since blockage of the pudenda! nerves produced some dribbling in patients who had rndieal. prostatectomy, whereas it failed to do so in normal people. Further, it. was postulated that the intraurethral resi,stance to urinary flow along the remaining .,egment of the posterior urethra becomes important for urinary continence. This resistance val'ies directly ,\'ith the tension of the urethral wall and inversely with the radius of the lumen of the urethra. The study wa~ undertaken to determine resting pressures in the rernaining portion of the po~terior nrethrn, after radical ,..,na1Q1,,c tomy in patients with and without normal control of urination. METHOD
A total of 12 patients was studied: .5 patients were used as controls with normal urination, 4 had had radical perinea] prostatectorny without incontinence and 3 had incon-tincnce of variable degree after radical prostatectomy. With the patient in supine position an 18F catheter was introduced into the bladder through the urethra. The catheter was connected to a mercury cystometer and fluid was permitted to f-low into the bladder The resting intravesical pressure was recorded and then the ttreihral cathAccepted for publication N overnber H!ti5. * Present address: 18 Ypsilantou Athens Greece 1 W.: l"rinarv control following; radi1.·:tl perinea! prostatectm,;y . .T. UroI., 95: 680, HJGG .
eter was withdra1vn until Hw was 1ocateci between the vesical outlet and tlie external sphincter. The position of the catheter waR iclcnti fied by x-ray examination after the of .2 cc of hypaque into the balloon. After 1-.hc pressures were taken in the sL1pine t.he patient was placed in erect position and intra.urethral pressure recordings were made. So bladder pressures were taken in this dun 1r, technical difficulties. RlDSULTS
The rnsting intrnvesical 1,ressurr: in the position ranged from 2 to 15 mm. Hg in all indi · viduals with slight variations A of The resting intraurethral. pressure:, in position were higher than the in 1rn vcsie1tl pressure in patients with normal control and varied from 18 to 2.'i mm. Hg (part: B of fi.gme). In patients with incontinence, the resting intraurethral pressure in supine position was aimo"t to intrnvesical pressure and varied from 11 to 1 mm. Hg (part C of figure). In standing position the intrnurcthrnJ pre~rnre rose to 41 to 55 mm. Hg in patients 11·ho exhibited normal control. There was slight incre:rne in patients with poor control. However, coutracLion of the pelvic musdes produced pressun;~ up to rnm. Hg. CO}IMENT
indicate The data obtained from Lhis that the resting pressure in the urethra is higher than the resting intm ve.sieal pressure rn supine position in patients with nonnal control. This is in accordance 1yith the ,tuclies of othet·s." In patients with a normal control after radical prostatectomy the intraurethrai. pres~ure was similar to those 1Yith a normal control. Pnt.icn1 s who wen) incontinent folloKing radical prostatectomy exhibited intraurethral prc:;snres almost equal to or slightly highm th,m the: pressure of the bladder. In erect position while tbe with 499
500
SAMELLAS 60
A
350 ml
I
"' 40 :c
....0 ~
20
0'---------------------------'"-----
3°1 B r "'
I
20
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"0
0
E E
;
10~
'l 20
E E IO
0
C
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FIGURE. A, range of resting intravesical pressure (2-15 mm. Hg) in supine position. B, resting intraurethral pressure in supine position is higher than intravesical, in patients with normal control. C, resting intraurethral pressure is almost equal to intravesical pressure in patients with poor urinary control.
normal control showed an increase of the intraurethral pressure, the ones with incontinence showed no change or slight increase. Others have shown that in the erect position the intravcsical pressure is higher (15 to 20 cm.) than in the supine position. 2 • 3 Concomitantly there is a greater increase of the intraurethral pressure. It seems reasonable to attribute the cause of incontinence in these patients to the failure of the remaining posterior urethra to effectively develop higher resistance in the standing position. This is accomplished by the action of the pelvic and external urethral sphincter muscles. They increase the tension of the urethral wall and decrease the 2 Lapides, J., Ajemian, E. P., Stewart, B. IL, Breakey, B. A. and Lichtwardt, J. R.: Further observations on kinetics of urethrovesical sphincter. J. Urol., 84: 86, 1960. 3 Shelley, T.: Measurement of intravesical pressure. Brit. J. Urol., 37: 227, 1965.
lumen of the urethra. It is a well-known observation that patients with poor urinary control leak when they are erect but not when they are recumbent. This is explained by an increase of the intravesical pressure in erect position and failure of the posterior urethra to correspondingly increase the intraurethral pressure. Our previous studies revealed a lack of mobility of the posterior urethra in the patients who were incontinent. The failure to develop adequate intraurethral pressures may be attributed to decreased tension of the urethral wall and increase of the diameter, secondary to muscle or nerve damage, as well as a loss of compliance of urethral tissue. Corrective procedures can be devised to restore control of the urination to normal in patients with post-prostatectomy incontinence. The basic problem seems to be the decreased resistance of the posterior urethra. Surgical procedures should be aimed at this target.
THE JOURNAL OF' UROLOG:i'.
l)n:nted ·t'.n
Copyright ,'.£) J 966 by The Willian1s & 'Wilkins Co"
AIEASUREl\JE~T OF URETHRAL PRESSURES FOLLOWING RADICAL
PERIN EAL PROSTATECTO iVIY WILLIAM SAMELLAS* Fnnn lhe Dcpartrnwnts of Surgery
, Veterans Adrninislration Hospital and the Slate
(i11/1.versit1;
of ?\'ew York, Downstate jJ1edical Center, Brooklyn, New York
Recently a study was nnclertaken on the control of urination in who have had radical perinea! prostatectomy for carcinoma of the prostate.1 The purpose 1;-as co better understand the physiopathology of micturition in these patients. Retrograde emptying of the fluid column from tbe remnant of the po,,terior urethra adjacent to the external sphincter into the bladder upon voluntary interruption of proved to be essential for urinary continence. It was suggested that the role of the external sphincter in these than in normal becomes more since blockage of the pudenda! nerves produced some dribbling in patients who had rndieal. prostatectomy, whereas it failed to do so in normal people. Further, it. was postulated that the intraurethral resi,stance to urinary flow along the remaining .,egment of the posterior urethra becomes important for urinary continence. This resistance val'ies directly ,\'ith the tension of the urethral wall and inversely with the radius of the lumen of the urethra. The study wa~ undertaken to determine resting pressures in the rernaining portion of the po~terior nrethrn, after radical ,..,na1Q1,,c tomy in patients with and without normal control of urination. METHOD
A total of 12 patients was studied: .5 patients were used as controls with normal urination, 4 had had radical perinea] prostatectorny without incontinence and 3 had incon-tincnce of variable degree after radical prostatectomy. With the patient in supine position an 18F catheter was introduced into the bladder through the urethra. The catheter was connected to a mercury cystometer and fluid was permitted to f-low into the bladder The resting intravesical pressure was recorded and then the ttreihral cathAccepted for publication N overnber H!ti5. * Present address: 18 Ypsilantou Athens Greece 1 W.: l"rinarv control following; radi1.·:tl perinea! prostatectm,;y . .T. UroI., 95: 680, HJGG .
eter was withdra1vn until Hw was 1ocateci between the vesical outlet and tlie external sphincter. The position of the catheter waR iclcnti fied by x-ray examination after the of .2 cc of hypaque into the balloon. After 1-.hc pressures were taken in the sL1pine t.he patient was placed in erect position and intra.urethral pressure recordings were made. So bladder pressures were taken in this dun 1r, technical difficulties. RlDSULTS
The rnsting intrnvesical 1,ressurr: in the position ranged from 2 to 15 mm. Hg in all indi · viduals with slight variations A of The resting intraurethral. pressure:, in position were higher than the in 1rn vcsie1tl pressure in patients with normal control and varied from 18 to 2.'i mm. Hg (part: B of fi.gme). In patients with incontinence, the resting intraurethral pressure in supine position was aimo"t to intrnvesical pressure and varied from 11 to 1 mm. Hg (part C of figure). In standing position the intrnurcthrnJ pre~rnre rose to 41 to 55 mm. Hg in patients 11·ho exhibited normal control. There was slight incre:rne in patients with poor control. However, coutracLion of the pelvic musdes produced pressun;~ up to rnm. Hg. CO}IMENT
indicate The data obtained from Lhis that the resting pressure in the urethra is higher than the resting intm ve.sieal pressure rn supine position in patients with nonnal control. This is in accordance 1yith the ,tuclies of othet·s." In patients with a normal control after radical prostatectomy the intraurethrai. pres~ure was similar to those 1Yith a normal control. Pnt.icn1 s who wen) incontinent folloKing radical prostatectomy exhibited intraurethral prc:;snres almost equal to or slightly highm th,m the: pressure of the bladder. In erect position while tbe with 499
500
SAMELLAS 60
A
350 ml
I
"' 40 :c
....0 ~
20
0'---------------------------'"-----
3°1 B r "'
I
20
u.
"0
0
E E
;
10~
'l 20
E E IO
0
C
r~\ .
0
FIGURE. A, range of resting intravesical pressure (2-15 mm. Hg) in supine position. B, resting intraurethral pressure in supine position is higher than intravesical, in patients with normal control. C, resting intraurethral pressure is almost equal to intravesical pressure in patients with poor urinary control.
normal control showed an increase of the intraurethral pressure, the ones with incontinence showed no change or slight increase. Others have shown that in the erect position the intravcsical pressure is higher (15 to 20 cm.) than in the supine position. 2 • 3 Concomitantly there is a greater increase of the intraurethral pressure. It seems reasonable to attribute the cause of incontinence in these patients to the failure of the remaining posterior urethra to effectively develop higher resistance in the standing position. This is accomplished by the action of the pelvic and external urethral sphincter muscles. They increase the tension of the urethral wall and decrease the 2 Lapides, J., Ajemian, E. P., Stewart, B. IL, Breakey, B. A. and Lichtwardt, J. R.: Further observations on kinetics of urethrovesical sphincter. J. Urol., 84: 86, 1960. 3 Shelley, T.: Measurement of intravesical pressure. Brit. J. Urol., 37: 227, 1965.
lumen of the urethra. It is a well-known observation that patients with poor urinary control leak when they are erect but not when they are recumbent. This is explained by an increase of the intravesical pressure in erect position and failure of the posterior urethra to correspondingly increase the intraurethral pressure. Our previous studies revealed a lack of mobility of the posterior urethra in the patients who were incontinent. The failure to develop adequate intraurethral pressures may be attributed to decreased tension of the urethral wall and increase of the diameter, secondary to muscle or nerve damage, as well as a loss of compliance of urethral tissue. Corrective procedures can be devised to restore control of the urination to normal in patients with post-prostatectomy incontinence. The basic problem seems to be the decreased resistance of the posterior urethra. Surgical procedures should be aimed at this target.