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Neurosurgery in diseases of the urinary bladder
NEUROSURGERY IN DISEASES OF THE URINARY BLADDER* JAMES R. LEARMONTH,
CH.M., F.R.C.S.
w
ROCHESTER, MINN.
T
these contributions are termed its IateraI roots. A middIe root reaches their angIe of convergence, from the preaortic nervous
nerves which reach the urinary bIadder beIong to three systems: (I) the sympathetic division of the
HE
./
Hypog&tric ganglia h
fihr-ss-
FIG. 2. Pieri’s operation for vesical pain. Solid and hatched nerves are interrupted.
ufermt maor----
Efferent
inhibitory --“.Trn CL,,,0
FIG. I. Diagram of nerve supply to btadder.
autonomic system, (2) the parasympathetic division of the autonomic system, and (3) the somatic system (Fig. I). ANATOMY
Sympathetic Nerves. Sympathetic fibers for the peIvic viscera, incIuding the bIadder, are finaIIy concentrated in a strand termed the presacra1 nerve. This nerve receives, on each side, a considerabIe contribution from the first and second Iumbar paravertebra1 sympathetic gangIia;
pIexus, and as such it enters into communication with the ceIiac, semiIunar, and aorticorena1 gangIia. SmaIIer branches connect the presacra1 nerve to the third and fourth Iumbar gangIia on each side. At the IeveI of the promontory of the sacrum it divides into the two hypogastric nerves, which join the posterosuperior angIes of the corresponding hypogastric gangIia. The nerve Iies in the median Iine, or a littIe to the Ieft of it, immediateIy under the posterior parieta1 peritoneum. After opening the peritoneum over the nerve,
* Read before the New York Academy of Medicine, December 16, 1931. 270
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al1 its component parts can be resected by removing *the tissue between the Ieft common iIiac vein and the right common iliac artery. Parasympathetic Nerves. Parasympathetic fibers are detached from the anterior primary divisions of the second, third and fourth sacra1 nerves. They reach the posterior borders of the hypogastric gangIia. Hypogastric Ganglia. These gangIia form a firm network of nerve tissue; each gangIion Iies on a IateraI aspect of the rectum. The ceIIs are those of the second reIay of the sympathetic path to the viscus; passing through the ganglia, without any such interruption of their courses, are the efferent fibers of the parasympathetic system, and afferent fibers beIonging to both sympathetic and parasympathetic systems. Vesical Nerves. The uItimate nerves to the bIadder Ieave the anterior borders of the hypogastric gangIia, and spread out over the waIIs of the viscus. From these branches fiIaments pass to the ureters, the vasa deferentia, the semina1 vesicIes, and the prostate gIand. Somatic Nerves. Somatic fibers derived from the anterior primary divisions of the third and fourth sacra1 nerves pass in the pudic nerves to innervate the externa1 sphincter of the bIadder; possibIy the pudic nerves aIso contain some afferent sensory fibers from the posterior urethra.
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observed from the Dosterior urethra. with a Braasch cystoscdpe, foIIowing stimuIation of the presacra1 nerve. Closure can be deduced from the force with which an instrument introduced into the bIadder is grasped, foIIowing such stimulation. (4) Contraction of the muscuIature of the prostate gIand, semina1 vesicIes, and ejacuIatory ducts. On stimuIation of the presacra1 nerve, the expulsion of semina1 fluid into the prostatic urethra can be seen with the cysto-urethroscope. (5, Conveyance of sensations of pain from the bladder. This function has been ascertained by noting the effect of mechanica or eIectrica1 stimuIation of the presacral nerve, whiIe the patient was under the infIuence of a Iow spina anesthetic. (6) Inhibition of the expuIsive mechanism of the bIadder. This has been deduced from the immediate active diIatation of the bIadder which foIlowed the intravenous administration of epinephrine (a hormona1 stimuIant for sympathetic nerves). Parasympathetic Nerves. (I) Initiation and augmentation of the contractions of the muscuIature of the bIadder. Paresis or paralysis of the bIadder is known to foIIow Iesions in any part of the parasympathetic pathway, from the sacral cord to the hypogastric ganglia. (2) Inhibition of the interna sphincter. This has been deduced from the fact that the sphincter opens and closes when required, even after division of the presacra1 (sympathetic) nerve. (3) ConveyPHYSIOLOGY ance of afferent fibers for the micturition The functions ascribed to the various reflex. Micturition can be carried out normally after division of the presacral nerves in the foIIowing section have been nerve; therefore, the reflex fibers must travdetermined in the human being. This point is significant, because the innervaerse the remaining (parasympathetic) pathtion of the bIadder differs from species to way. (4) Conveyance of afferent fibers subserving such sensibility as the bladder and there may be differences species, between the sexes of the same species. possesses, for this is unaItered after symSympathetic Nerves. (I) CIosure of the pathetic neurectomy. ureterovesica1 orifices. (2) Contraction of A study of these functions shows that the trigone; both these effects of stimuIathe sympathetic nerves are “fiIling” or “storing” in function (diIatation of bIadtion of the presacra1 nerve have been der and cIosure of its sphincter), whereas observed with the cystoscope. (3) CIosure the parasympathetic nerves are “emptyof the interna sphincter. This has been
272
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(contraction ing” in function and opening of its sphincter). SURGICAL
of bIadder
CONSIDERATIONS
Parasympathetic Nerves. The parasympathetic nerves of the bIadder are readiIy accessibIe onIy throughout their intraspina course. Here they are sometimes subject to compression as a resuIt of the congenita1 maIformation termed spina bifida occuIta. Not a11 patients with Iumbosacra1 spina bifida occuIta have symptoms referabIe to the bIadder; but there is a group of young aduIts who may give a history of enuresis in chiIdhood, and who may have urinary diffIcuIty expressing itseIf in dysuria, perhaps urgency, and the presence of residua1 urine. With the cystoscope, the interna sphincter is seen to be reIaxed, and the waI1 of the bladder to be fineIy trabecuIated; it is found, aIso, that the bIadder is hypesthetic and has Iost some of its expuIsive power. In a proportion of these cases, expIoration of the spina1’ defect reveaIs compression of the roots of the sacra1 nerves, the reIief of which Ieads to rapid restoration of vesica1 function; aIthough why the pressure shouId affect onIy the viscera1 fibers in the sacra1 nerves is by no means cIear. Among the compressing agents which may be found at operation may be mentioned fibrocartiIaginous bands, masses of fibrofatty tissue, meningoceIe, and bony excrescences. In many cases, however, expIoration for compression is negative; in these the spina bifida occuIta is mereIy an accompaniment of a primary neurogenic defect. Sympathetic Nerves. Sympathetic neurectomy has been undertaken at The Mayo CIinic in cases of three types: I. Paresis of the Musculature of the Bladder. When a bIadder is incapabIe of emptying compIeteIy as a resuIt of injury to any portion of the parasympathetic pathway, it has seemed reasonabIe to suppose that the intact sympathetic contribution to vesica1 innervation provided too effective a brake for the decreased parasympathetic innervation, and that
MAY, rqjz
after sympathetic neurectomy the diminished activity of the evacuant set of nerves wouId be unhampered by this brake. Operation has been carried out in eight cases of this type, one of which has been reported in detai1 e1sewhere.l One patient in the series cannot be traced, and one faiIed to receive benefit. Of the remainder, two are considered cured (for periods of two years and one and a haIf years, respectiveIy), and the expluIsive power of the bIadder, in the other four patients, has been materiaIIy improved; the amount of residua1 urine has been reduced from 200 to 300 c.c. to 20 or 30 c.c. It is necessary to warn men that after the operation, aIthough they wiI1 be abIe to perform the sexual act and to experience a norma ejacuIation wiI1 not occur; no orgasm, detectabIe aIteration in reproductive function foIIows the operation on women. It has been found that after two or three weeks the interna sphincter of male subjects recovers a proportion of its tonus, aIthough the trigone, bereft of its motor nerve suppIy, remains flaccid. A smaI1 quantity of residual urine may persist as a trigona1 ~001; in these cases a channe1 is made from poo1 to posterior urethra by the operating cystoscope, and this operation has often enabIed the bIadder to expe1 its contents compIeteIy. 2. Spasm of the Neck of the Bladder. In two cases in which there was diffIcuIty in starting the ffow of urine, a diagnosis was made of spasm, or better, achaIasia, of the internal vesica1 sphincter. In both cases uroIogic and neuroIogic examinations were negative, and attempts had been made to rectify the condition by punch operations on the neck of the bIadder. Because the sympathetic system provides motor nerves to the interna sphincter, it was thought that its overcontraction wouId be diminished by sympathetic neurectomy. The operation was immediateIy successfu1 in both cases, and neither patient 1Learmonth, J. R., and Braasch, W. F. Resection of the presacra1 nerve in the treatment of cord bladder. surg., Gynec., obst., 61: 494-499 (Oct.) 1930.
NEW
SERIES
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has had any subsequent diffrcuIty in beginning or in compIeting the act of micturition. 3. Inveterate Vesical Pain. Since 1926, when Pieri first performed presacra1 neurectomy for the rehef of vesica1 pain, a number of successful operations has been recorded. Pieri has devised a more compIete procedure, which aims at interrupting a11 possibIe sympathetic paths from the bIadder to the centra1 nervous system (Fig. 2); this he considered necessary, because one or two fine branches may connect the hypogastric ganglia directIy to the sacra1 paravertebra1 sympathetic gangIia (Figs. I and 2). The compIete operation interrupts impulses which, after reaching the hypogastric gangIia, might pass by fibers traversing the paravertebra1 chains either to the sacraI nerves by way of the rami communicantes, and so to the spina cord, or, after ascending in the paravertebral chain, by way of Iumbar or thoracic rami communicantes to the spina cord at a higher IeveI. Among the conditions in which this operation has been tested at The Mayo CIinic are interstitial cystitis, inoperable carcinoma of the bIadder, chronic cystitis of unknown etiology, and the irritabiIity of the bIadder which may remain after nephrectomy for renaI tubercuIosis. The result has been satisfactory in six of eleven cases. There has not been any marked difference between the resuIt after simpIe presacra1 neurectomy, and that after the more extensive operation. The reIief from pain is chiefly relief from the pain to which spasmodic and uncoordinated contractions of the muscuIature give rise. As has been pointed out, the parasympathetic pathway contains many, indeed the majority, of afferent fibers, so that rehef of pain, at best, must be incomHowever, after operation, these pIete. patients appear to respond bet.ter to IocaI and this has been uroIogic treatment, directed to increasing the capacity of t.he bIadder, which the operation does not directIy do.
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In concIusion, I must emphasize that in outIining our experience I am the spokesman of a group, which consists of uroIogists, neuroIogists, and uroIogic surgeons. The operations on the nerves of the bIadder which I have described should be undertaken onIy after most carefu1 and critica examination of the patient, whose preoperative and postoperative treatment must be carried out from a11 possibIe cIinica1 angIes. DISCUSSION
N. P. RATHBUN: My reaction to the matter is that these cases wiIl have to be very carefuIIy seIected with the very carefuI cooperation of the neuroIogist and urologist, and that DR.
these cases wil1 not be very great in number. I have in my wards at the present time a reIativeIy young woman, who, foIIowing an operation for some peIvic condition under spina anesthesia four years ago, has had compIete inabiIity to urinate. She was offered some neuroIogica1 operation, I presume it \~as resection of the presacral nerve, at another hospital. Her condition at present is so grave from renaI infection and stasis that she is in no condition for anv kind of surgery. I have another patient with paralysis of the bladder foIIowing repeated sacra1 anesthesias. I am wondering if such a case is suitable for the operation under discussion. If the work that Dr. Learmonth is doing offers anything to a group of tabetic bladders, of which we a11 see so many, it wiI1 indeed be a GocIsend. I have seen a number of these in years gone back where I have been driven to do a permanent cystostomy, which of course is an unsatisfactory operation, but which seemed to offer them more relief than any other thing that we couId do. DR. EDWIN BEER: Experience in this field is very limited, even in Iarge institutions in the big cities. At Mount Sinai, only one case of presacral nerve excision has been done and that in a case of tabes without any improvement in expuIsive force. Perhaps in this type of case the disturbance is in the centripeta1 fibers and naturalI?; it would IX fooIish to expect any resuIt. In connection with cases of enuresis in the young and enuresis in adults, Dr. Learmonth has caIIed attention to the finding of a band pressing the dural sac in the sncra1 region,
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and after reIief of the pressure by excision of this Iigamentum (subffavum) the bIadder condition was markedIy benefited. These cases have been reported in the Continenta Iiterature by numerous writers on numerous occasions. Francois and DeIbet have reported severa series of satisfactory resuIts. Legueu, on the other hand, has faiIed on Iaminectomy in these cases, associated with spina bifida, to even find such mispIaced ligaments. WhiIe enuresis in chiIdren is a common compIaint and may be associated with nonfusion of the Iamina of the fifth Iumbar or first sacra1, enuresis in aduIts is, in our experience, very rare. Marion in his clinic cIaims that onIy one case has been seen, and that a doubtfu1 one, in over 150,ooo admissions. In view of these contradictions and diffIcuIty, the question arises, how and when shaI1 we decide to interfere surgicaIIy? If a IipiodoI intraspina1 injection can demonstrate a block at the site of the vertebra1 pathoIogy or injection through the coccygeal foramen, as recommended by DeIbet, can demonstrate a bIock from beIow, naturaIIy one can be under the impression that operation for compression of the dura may be indicated, but as yet very few such observations have been made. The recognition of a spina bifida of this type is so common that we hesitate to assign this pathoIogy as the cause of some of the atypica1 or typica bIadder disturbances. In connection with these cases in chiIdren which for years we have been encountering and diagnosing as neuromuscuIar disturbances or disharmony between sphincter and detrusor, it is just possibIe that such an operation as has been described by the French (Rochet) and Dr. Learmonth combined may effectiveIy contro1 the spastic sphincter and make for more harmonious muscuIar expuIsion. On the other hand, in the few cases that have come to operation, excision of a wedge at the neck of the bIadder has seemed to contro1 the condition compIeteIy, and others that were not operated upon, simpIe diIatations of the sphincter have been effective in estabIishing norma cooperation between the detrusor and the sphincter muscIe. In connection with stimuIation of the detrusor muscIe by drugs, Dr. Learmonth in his paper has spoken of the great vaIue of acetocholine, which we have tried, and with the bIadder connected with a cystometer we have reguIarIy faiIed to get any muscuIar contrac-
May, I$?jZ
tion. Again other drugs have been equaIIy unsatisfactory, except piIocarpin, which aImost reguIarIy produces an increase in pressure, due to detrusor contraction. Moreover in postoperative retention, piIocarpin is very effective. It wouId be most encouraging if some pre-operative test couId be made by injecting drugs which wouId cIearIy show which cases are suitabIe for presacra1 nerve resection, which are suitabIe for hypogastric gangIion resection, and which are suitabIe for operations on the pudic system. UntiI further steps are made, in view of the fact that the genera1 nervous system gives no evidence of disturbance in the majority of these cases, progress must be sIow and carefu1 so that patients are not UnnecessariIy submitted to operations of this sort, which wiI1 bring the whoIe experimenta study into discredit. DR. JAMES R. LEARMONTH, closing: Not onIy did stimuIation of the centra1 end of the cut presacra1 nerve give rise to painfu1 sensations which were IocaIized in the bIadder waI1, but aIso there was not any compIaint of pain referred to the tweIfth thoracic and first Iumbar segments; these are said to be the somatic segments associated with the pain of overdistension of the bladder. With regard to Dr. Beer’s questions: I have not operated on any patient whose onIy complaint was enuresis. My patients may have had a history of enuresis in chiIdhood, but the condition which determined operation was paresis of the bIadder. Like Dr. Beer, I have been disappointed that in these cases the epidura1 injection of IipiodoI gives IittIe heIp in determining the presence or absence of compression of the cauda equina. In such cases I think it worth whiIe to explore the region of the spina b&da occuIta, and if dura1 sac compression is present, to reIieve this. I have not, myseIf, operated on patients whose diffIcuIty in micturition was due to tabes. In such cases, the Iesion is probabIy in the afferent pathway, and one wouId not expect section of the presacra1 nerve to help. The cases most suitabIe for resection of the presacral nerve are those in which there is evidence of over-baIance of the fiIIing or storing set of nerves (sympathetic) to the bIadder. These nerves pIay a part in carrying out the function assigned by Bernard to the whole sympathetic system : reguIating the composition of the body fIuids.
CH.M., F.R.C.S.
w
ROCHESTER, MINN.
T
these contributions are termed its IateraI roots. A middIe root reaches their angIe of convergence, from the preaortic nervous
nerves which reach the urinary bIadder beIong to three systems: (I) the sympathetic division of the
HE
./
Hypog&tric ganglia h
fihr-ss-
FIG. 2. Pieri’s operation for vesical pain. Solid and hatched nerves are interrupted.
ufermt maor----
Efferent
inhibitory --“.Trn CL,,,0
FIG. I. Diagram of nerve supply to btadder.
autonomic system, (2) the parasympathetic division of the autonomic system, and (3) the somatic system (Fig. I). ANATOMY
Sympathetic Nerves. Sympathetic fibers for the peIvic viscera, incIuding the bIadder, are finaIIy concentrated in a strand termed the presacra1 nerve. This nerve receives, on each side, a considerabIe contribution from the first and second Iumbar paravertebra1 sympathetic gangIia;
pIexus, and as such it enters into communication with the ceIiac, semiIunar, and aorticorena1 gangIia. SmaIIer branches connect the presacra1 nerve to the third and fourth Iumbar gangIia on each side. At the IeveI of the promontory of the sacrum it divides into the two hypogastric nerves, which join the posterosuperior angIes of the corresponding hypogastric gangIia. The nerve Iies in the median Iine, or a littIe to the Ieft of it, immediateIy under the posterior parieta1 peritoneum. After opening the peritoneum over the nerve,
* Read before the New York Academy of Medicine, December 16, 1931. 270
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al1 its component parts can be resected by removing *the tissue between the Ieft common iIiac vein and the right common iliac artery. Parasympathetic Nerves. Parasympathetic fibers are detached from the anterior primary divisions of the second, third and fourth sacra1 nerves. They reach the posterior borders of the hypogastric gangIia. Hypogastric Ganglia. These gangIia form a firm network of nerve tissue; each gangIion Iies on a IateraI aspect of the rectum. The ceIIs are those of the second reIay of the sympathetic path to the viscus; passing through the ganglia, without any such interruption of their courses, are the efferent fibers of the parasympathetic system, and afferent fibers beIonging to both sympathetic and parasympathetic systems. Vesical Nerves. The uItimate nerves to the bIadder Ieave the anterior borders of the hypogastric gangIia, and spread out over the waIIs of the viscus. From these branches fiIaments pass to the ureters, the vasa deferentia, the semina1 vesicIes, and the prostate gIand. Somatic Nerves. Somatic fibers derived from the anterior primary divisions of the third and fourth sacra1 nerves pass in the pudic nerves to innervate the externa1 sphincter of the bIadder; possibIy the pudic nerves aIso contain some afferent sensory fibers from the posterior urethra.
American Journnl of Surgery
271
observed from the Dosterior urethra. with a Braasch cystoscdpe, foIIowing stimuIation of the presacra1 nerve. Closure can be deduced from the force with which an instrument introduced into the bIadder is grasped, foIIowing such stimulation. (4) Contraction of the muscuIature of the prostate gIand, semina1 vesicIes, and ejacuIatory ducts. On stimuIation of the presacra1 nerve, the expulsion of semina1 fluid into the prostatic urethra can be seen with the cysto-urethroscope. (5, Conveyance of sensations of pain from the bladder. This function has been ascertained by noting the effect of mechanica or eIectrica1 stimuIation of the presacral nerve, whiIe the patient was under the infIuence of a Iow spina anesthetic. (6) Inhibition of the expuIsive mechanism of the bIadder. This has been deduced from the immediate active diIatation of the bIadder which foIlowed the intravenous administration of epinephrine (a hormona1 stimuIant for sympathetic nerves). Parasympathetic Nerves. (I) Initiation and augmentation of the contractions of the muscuIature of the bIadder. Paresis or paralysis of the bIadder is known to foIIow Iesions in any part of the parasympathetic pathway, from the sacral cord to the hypogastric ganglia. (2) Inhibition of the interna sphincter. This has been deduced from the fact that the sphincter opens and closes when required, even after division of the presacra1 (sympathetic) nerve. (3) ConveyPHYSIOLOGY ance of afferent fibers for the micturition The functions ascribed to the various reflex. Micturition can be carried out normally after division of the presacral nerves in the foIIowing section have been nerve; therefore, the reflex fibers must travdetermined in the human being. This point is significant, because the innervaerse the remaining (parasympathetic) pathtion of the bIadder differs from species to way. (4) Conveyance of afferent fibers subserving such sensibility as the bladder and there may be differences species, between the sexes of the same species. possesses, for this is unaItered after symSympathetic Nerves. (I) CIosure of the pathetic neurectomy. ureterovesica1 orifices. (2) Contraction of A study of these functions shows that the trigone; both these effects of stimuIathe sympathetic nerves are “fiIling” or “storing” in function (diIatation of bIadtion of the presacra1 nerve have been der and cIosure of its sphincter), whereas observed with the cystoscope. (3) CIosure the parasympathetic nerves are “emptyof the interna sphincter. This has been
272
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(contraction ing” in function and opening of its sphincter). SURGICAL
of bIadder
CONSIDERATIONS
Parasympathetic Nerves. The parasympathetic nerves of the bIadder are readiIy accessibIe onIy throughout their intraspina course. Here they are sometimes subject to compression as a resuIt of the congenita1 maIformation termed spina bifida occuIta. Not a11 patients with Iumbosacra1 spina bifida occuIta have symptoms referabIe to the bIadder; but there is a group of young aduIts who may give a history of enuresis in chiIdhood, and who may have urinary diffIcuIty expressing itseIf in dysuria, perhaps urgency, and the presence of residua1 urine. With the cystoscope, the interna sphincter is seen to be reIaxed, and the waI1 of the bladder to be fineIy trabecuIated; it is found, aIso, that the bIadder is hypesthetic and has Iost some of its expuIsive power. In a proportion of these cases, expIoration of the spina1’ defect reveaIs compression of the roots of the sacra1 nerves, the reIief of which Ieads to rapid restoration of vesica1 function; aIthough why the pressure shouId affect onIy the viscera1 fibers in the sacra1 nerves is by no means cIear. Among the compressing agents which may be found at operation may be mentioned fibrocartiIaginous bands, masses of fibrofatty tissue, meningoceIe, and bony excrescences. In many cases, however, expIoration for compression is negative; in these the spina bifida occuIta is mereIy an accompaniment of a primary neurogenic defect. Sympathetic Nerves. Sympathetic neurectomy has been undertaken at The Mayo CIinic in cases of three types: I. Paresis of the Musculature of the Bladder. When a bIadder is incapabIe of emptying compIeteIy as a resuIt of injury to any portion of the parasympathetic pathway, it has seemed reasonabIe to suppose that the intact sympathetic contribution to vesica1 innervation provided too effective a brake for the decreased parasympathetic innervation, and that
MAY, rqjz
after sympathetic neurectomy the diminished activity of the evacuant set of nerves wouId be unhampered by this brake. Operation has been carried out in eight cases of this type, one of which has been reported in detai1 e1sewhere.l One patient in the series cannot be traced, and one faiIed to receive benefit. Of the remainder, two are considered cured (for periods of two years and one and a haIf years, respectiveIy), and the expluIsive power of the bIadder, in the other four patients, has been materiaIIy improved; the amount of residua1 urine has been reduced from 200 to 300 c.c. to 20 or 30 c.c. It is necessary to warn men that after the operation, aIthough they wiI1 be abIe to perform the sexual act and to experience a norma ejacuIation wiI1 not occur; no orgasm, detectabIe aIteration in reproductive function foIIows the operation on women. It has been found that after two or three weeks the interna sphincter of male subjects recovers a proportion of its tonus, aIthough the trigone, bereft of its motor nerve suppIy, remains flaccid. A smaI1 quantity of residual urine may persist as a trigona1 ~001; in these cases a channe1 is made from poo1 to posterior urethra by the operating cystoscope, and this operation has often enabIed the bIadder to expe1 its contents compIeteIy. 2. Spasm of the Neck of the Bladder. In two cases in which there was diffIcuIty in starting the ffow of urine, a diagnosis was made of spasm, or better, achaIasia, of the internal vesica1 sphincter. In both cases uroIogic and neuroIogic examinations were negative, and attempts had been made to rectify the condition by punch operations on the neck of the bIadder. Because the sympathetic system provides motor nerves to the interna sphincter, it was thought that its overcontraction wouId be diminished by sympathetic neurectomy. The operation was immediateIy successfu1 in both cases, and neither patient 1Learmonth, J. R., and Braasch, W. F. Resection of the presacra1 nerve in the treatment of cord bladder. surg., Gynec., obst., 61: 494-499 (Oct.) 1930.
NEW
SERIES
VOL.XVl,
NW 2
Learmonth-Neurosurgery
has had any subsequent diffrcuIty in beginning or in compIeting the act of micturition. 3. Inveterate Vesical Pain. Since 1926, when Pieri first performed presacra1 neurectomy for the rehef of vesica1 pain, a number of successful operations has been recorded. Pieri has devised a more compIete procedure, which aims at interrupting a11 possibIe sympathetic paths from the bIadder to the centra1 nervous system (Fig. 2); this he considered necessary, because one or two fine branches may connect the hypogastric ganglia directIy to the sacra1 paravertebra1 sympathetic gangIia (Figs. I and 2). The compIete operation interrupts impulses which, after reaching the hypogastric gangIia, might pass by fibers traversing the paravertebra1 chains either to the sacraI nerves by way of the rami communicantes, and so to the spina cord, or, after ascending in the paravertebral chain, by way of Iumbar or thoracic rami communicantes to the spina cord at a higher IeveI. Among the conditions in which this operation has been tested at The Mayo CIinic are interstitial cystitis, inoperable carcinoma of the bIadder, chronic cystitis of unknown etiology, and the irritabiIity of the bIadder which may remain after nephrectomy for renaI tubercuIosis. The result has been satisfactory in six of eleven cases. There has not been any marked difference between the resuIt after simpIe presacra1 neurectomy, and that after the more extensive operation. The reIief from pain is chiefly relief from the pain to which spasmodic and uncoordinated contractions of the muscuIature give rise. As has been pointed out, the parasympathetic pathway contains many, indeed the majority, of afferent fibers, so that rehef of pain, at best, must be incomHowever, after operation, these pIete. patients appear to respond bet.ter to IocaI and this has been uroIogic treatment, directed to increasing the capacity of t.he bIadder, which the operation does not directIy do.
American
Journal
of Surgcrv
271
In concIusion, I must emphasize that in outIining our experience I am the spokesman of a group, which consists of uroIogists, neuroIogists, and uroIogic surgeons. The operations on the nerves of the bIadder which I have described should be undertaken onIy after most carefu1 and critica examination of the patient, whose preoperative and postoperative treatment must be carried out from a11 possibIe cIinica1 angIes. DISCUSSION
N. P. RATHBUN: My reaction to the matter is that these cases wiIl have to be very carefuIIy seIected with the very carefuI cooperation of the neuroIogist and urologist, and that DR.
these cases wil1 not be very great in number. I have in my wards at the present time a reIativeIy young woman, who, foIIowing an operation for some peIvic condition under spina anesthesia four years ago, has had compIete inabiIity to urinate. She was offered some neuroIogica1 operation, I presume it \~as resection of the presacral nerve, at another hospital. Her condition at present is so grave from renaI infection and stasis that she is in no condition for anv kind of surgery. I have another patient with paralysis of the bladder foIIowing repeated sacra1 anesthesias. I am wondering if such a case is suitable for the operation under discussion. If the work that Dr. Learmonth is doing offers anything to a group of tabetic bladders, of which we a11 see so many, it wiI1 indeed be a GocIsend. I have seen a number of these in years gone back where I have been driven to do a permanent cystostomy, which of course is an unsatisfactory operation, but which seemed to offer them more relief than any other thing that we couId do. DR. EDWIN BEER: Experience in this field is very limited, even in Iarge institutions in the big cities. At Mount Sinai, only one case of presacral nerve excision has been done and that in a case of tabes without any improvement in expuIsive force. Perhaps in this type of case the disturbance is in the centripeta1 fibers and naturalI?; it would IX fooIish to expect any resuIt. In connection with cases of enuresis in the young and enuresis in adults, Dr. Learmonth has caIIed attention to the finding of a band pressing the dural sac in the sncra1 region,
274
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and after reIief of the pressure by excision of this Iigamentum (subffavum) the bIadder condition was markedIy benefited. These cases have been reported in the Continenta Iiterature by numerous writers on numerous occasions. Francois and DeIbet have reported severa series of satisfactory resuIts. Legueu, on the other hand, has faiIed on Iaminectomy in these cases, associated with spina bifida, to even find such mispIaced ligaments. WhiIe enuresis in chiIdren is a common compIaint and may be associated with nonfusion of the Iamina of the fifth Iumbar or first sacra1, enuresis in aduIts is, in our experience, very rare. Marion in his clinic cIaims that onIy one case has been seen, and that a doubtfu1 one, in over 150,ooo admissions. In view of these contradictions and diffIcuIty, the question arises, how and when shaI1 we decide to interfere surgicaIIy? If a IipiodoI intraspina1 injection can demonstrate a block at the site of the vertebra1 pathoIogy or injection through the coccygeal foramen, as recommended by DeIbet, can demonstrate a bIock from beIow, naturaIIy one can be under the impression that operation for compression of the dura may be indicated, but as yet very few such observations have been made. The recognition of a spina bifida of this type is so common that we hesitate to assign this pathoIogy as the cause of some of the atypica1 or typica bIadder disturbances. In connection with these cases in chiIdren which for years we have been encountering and diagnosing as neuromuscuIar disturbances or disharmony between sphincter and detrusor, it is just possibIe that such an operation as has been described by the French (Rochet) and Dr. Learmonth combined may effectiveIy contro1 the spastic sphincter and make for more harmonious muscuIar expuIsion. On the other hand, in the few cases that have come to operation, excision of a wedge at the neck of the bIadder has seemed to contro1 the condition compIeteIy, and others that were not operated upon, simpIe diIatations of the sphincter have been effective in estabIishing norma cooperation between the detrusor and the sphincter muscIe. In connection with stimuIation of the detrusor muscIe by drugs, Dr. Learmonth in his paper has spoken of the great vaIue of acetocholine, which we have tried, and with the bIadder connected with a cystometer we have reguIarIy faiIed to get any muscuIar contrac-
May, I$?jZ
tion. Again other drugs have been equaIIy unsatisfactory, except piIocarpin, which aImost reguIarIy produces an increase in pressure, due to detrusor contraction. Moreover in postoperative retention, piIocarpin is very effective. It wouId be most encouraging if some pre-operative test couId be made by injecting drugs which wouId cIearIy show which cases are suitabIe for presacra1 nerve resection, which are suitabIe for hypogastric gangIion resection, and which are suitabIe for operations on the pudic system. UntiI further steps are made, in view of the fact that the genera1 nervous system gives no evidence of disturbance in the majority of these cases, progress must be sIow and carefu1 so that patients are not UnnecessariIy submitted to operations of this sort, which wiI1 bring the whoIe experimenta study into discredit. DR. JAMES R. LEARMONTH, closing: Not onIy did stimuIation of the centra1 end of the cut presacra1 nerve give rise to painfu1 sensations which were IocaIized in the bIadder waI1, but aIso there was not any compIaint of pain referred to the tweIfth thoracic and first Iumbar segments; these are said to be the somatic segments associated with the pain of overdistension of the bladder. With regard to Dr. Beer’s questions: I have not operated on any patient whose onIy complaint was enuresis. My patients may have had a history of enuresis in chiIdhood, but the condition which determined operation was paresis of the bIadder. Like Dr. Beer, I have been disappointed that in these cases the epidura1 injection of IipiodoI gives IittIe heIp in determining the presence or absence of compression of the cauda equina. In such cases I think it worth whiIe to explore the region of the spina b&da occuIta, and if dura1 sac compression is present, to reIieve this. I have not, myseIf, operated on patients whose diffIcuIty in micturition was due to tabes. In such cases, the Iesion is probabIy in the afferent pathway, and one wouId not expect section of the presacra1 nerve to help. The cases most suitabIe for resection of the presacral nerve are those in which there is evidence of over-baIance of the fiIIing or storing set of nerves (sympathetic) to the bIadder. These nerves pIay a part in carrying out the function assigned by Bernard to the whole sympathetic system : reguIating the composition of the body fIuids.