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Neurosurgery in the Treatment of Diseases of the Urinary Bladder II. Treatment of Vesical Pain1
NEUROSURGERY IN THE TREATMENT OF DISEASES OF THE URINARY BLADDER IL TREATMENT OF VESICAL PAIN1 JAMES R. LEARMONTH Section on Neurologic Surgery, The Mayo Clinic, Rochester, Minnesota
As long ago as 1898, it had occurred to the fertile brain of Jaboulay that impulses of pain arising in pelvic viscera might reach the central nervous system along fibers travelling with sympathetic nerves. The operations introduced by Jaboulay sought to interrupt the sacral rami communicantes, or the sacral sympathetic chaim, after these structures had been exposed by a retrorectal approach. Among the procedures tried were actual resection of the chain after removal of the coccyx; rupture of the rami by stripping the rectum from the front of the sacrum, and distention of the retrorectal space with salt solution. One or another of these operations succeeded in abolishing pain in a number of cases of "neuralgia of the pelvis," but in the absence of accurate knowledge of the distribution of the sympathetic nerves of the pelvis the indications for their use were difficult to define. After an accurate description of the visceral nerves of the pelvis had been provided by Latarjet and his collaborators, it became possible to choose the particular nerves to be divided on an anatomic basis, and in 1921 Rochet published an important paper on the treatment of painful cystitis. He stated that pain referred to the lower part of the urinary tract may be produced in three ways: (a) by colic in the vesical part of the ureter; (b) by painful contractions of the wall of the bladder, and (c) by lesions of the vesico-urethral sphincter apparatus. COLIC IN THE VESICAL PART OF THE URETER
In certain cases of renal tuberculosis, Rochet felt that the pain began in the intramural part of the ureter on the affected side; 1
Submitted for publication January 14, 1931. 13
14
JAMES R. LE ARMONTH
in such conditions he advised that periureteral sympathectomy be performed on the lowest 5 to 6 cm. of the ureter. He reported 3 cases. In the first case, the disease was unilateral, but the patient refused nephrectomy; the palliative operation relieved the painful crises until death four months later. In the second case the disease was bilateral, and the kidney more affected had been removed. The painful crises appeared to originate in the stump of ureter left after nephrectomy. Removal of the nerves around this stump led to complete stopping of the painful crises, although some frequency persisted; this betterment was maintained for at least two years. In the third case the tuberculous disease was bilateral; the result of operation was good for three weeks, ·when a different type of pain appeared. This was found to be due to a perivesical abscess, and drainage of this through a cystostomy wound led to complete relief from all forms of pain.
It seems to me that, in the present state of knowledge, the mode of action of periureteral sympathectomy must remain uncertain. The possibilities are: (a) stoppage of the painful spasms as a result of division of motor sympathetic nerves, (b) desensitization of the lower ureteric area as a result of division of sensory nerves, and (c) a combination of (a) and (b). It is unlikely that division of its extrinsic nerves would completely suppress the activity of a nonstriated muscular tube such as the ureter, but in this regard it is to be remembered that after nephrectomy, adequate stimuli for ureteric contractions should be absent, although there is a possibility that they may be started by the presence of caseous tuberculous debris. On the other hand, it is known that sensory nerves reach this part of the ureter, certainly by way of the hypogastric nerves and possibly by way of pelvic parasympathetic nerves. Probably the third explanation is correct, and the absence of painful crises is to be attributed partly to direct desensitization of the ureter and partly to reduction in its tonus as a result of division of its extrinsic motor nerves; moreover, some reflex reduction in tonus could be expected as a result of interruption of the afferent nerves. I have not had any experience of operation in cases of this type; in all three of Rochet's cases,
NEUROSURGERY IN DISEASES OF URINARY BLADDER
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the bacillus of tuberculosis was present in the urine, and in 1 case there were tuberculous pumonary lesions; it would appear that only the insistence of a patient could justify operation in such circumstances. Painful cystitis. Under this heading Rochet included cases of renal tuberculosis, in which painful vesical crises, frequency, and dysuria were distressing symptoms. Obviously neurectomy is to be considered in these cases only when the disease persists in spite of the usual surgical and urologic measures applicable to tuberculous disease of the urinary tract. In his two original cases Rochet attacked the hypogastric ganglia by the extraperitoneal route. Both patients were relieved until their deaths, seven months and one month respectively after operation. Since the operation interrupts both the sensory and the motor nerves to the bladder, without paralyzing the external sphincter, postoperative retention of urine is to be expected; in the first case this lasted for a month, when semi-incontinence was established, but observation on the power of the bladder was not possible in the second case, as a suprapubic urinary fistula developed after operation. Later Rochet modified his technic, so that only the larger nerves were divided, and that more anteriorly on the neck of the bladder. Of two patients with renal tuberculosis, one lived for sixteen months, still suffering from frequency, but untroubled by painful spasms ; the other was considerably relieved until death ten months later, the frequency persisting, but the spasms being absent. The first patient required catheterization for many days, after which micturition was reestablished; the second patient had retention only for ten days.
In 3 cases I felt justified in advising an operation of this type. Case 1. A man, aged fifty-two years, had had a tumor of the bladder removed elsewhere in 1924. His symptoms returned in 1929 and he underwent an extensive course of deep roentgen-ray t reatment and electrocoagulation. In spite of this symptoms persisted, and he lost much weight and sleep on account of dysuria and frequency. At his last visit to The Mayo Clinic, March 18, 1930, the report after cystoscopic examination was "Diffuse involvement of entire upper sphincter by necrotic masses. Very apparent diffuse malignant involvement of the bladder with probably perivesical extension. Inoperable car-
16
JAMES R. LEARMONTH
cinoma." In addition to painful vesical spasms, he had continuous pain around the neck of the bladder. He asked that an attempt be made to mitigate the pain, and as renal function was unimpaired, it was decided to divide the vesical branches of the hypogastric ganglia. March 26, under spinal analgesia, I attempted to do this by the extraperitoneal route. However, the bladder was so adherent to the peritoneum and extravesical tissue that I abandoned this route, and opened the peritoneum. By following the technic described in part I of this series, I was able to identify and divide the larger anterior efferent branches of the hypogastric gangliaj for a reason to be explained later, the presacral nerve was divided also. After the operation the patient experienced immediate relief from all forms of vesical distress. The bladder was drained by an indwelling catheter. On the third day the blood urea rose to 75 mgm. for each 100 cc., and there was some abdominal distention; these signs disappeared, under appropriate treatment. On the seventh day after treatment the distention reappeared, as well as signs of rapidly advancing bronchopneumonia, and the patient died on the eighth day. At necropsy it was found that the perforation of a large gastric ulcer had given rise to general peritonitis; this complication was quite unexpected. Advanced bilateral bronchopneumonia was also present. The vesical growth had extended from the base of the bladder into the prostate gland and the posterior urethra.
In the course of this operation I had occasion to grasp the presacral nerve with a hemostat. When the nerve was pulled, the patient immediately complained of severe pain. After the nerve was divided, traction on its central end gave rise to pain which the patient described as a crushing pain in the bladder. As the patient was unaware of what was being done, this experience offers convincing proof that sensory nerves from the bladder reach the central nervous system along the thoracicolumbar sympathetic nerves. The exact level of their entrance into the spinal cord is doubtful. In this instance the effect of the spinal anesthetic was beginning to disappear, from above downward; the patient was analgesic to pin prick as high as the tenth thoracic segment, so that in all likelihood the impulses reach the cord above this level, possibly along the roots of the splanchnic nerves. The experience in this case proved that at least a ·proportion of vesical pain would be abolished by section of the presacral nerve
NEUROSURGERY IN DISEASES OF URINARY BLADDER
17
alone. In addition, it was interesting to realize, after necropsy, that the constant pain around the neck of the bladder, doubtless due to invasion of the prostate gland and posterior urethra, had been suppressed by division of the efferent branches of the ganglion. This observation seems to indicate that at least part of the sensory nerves for the posterior urethra reach it by way of these autonomic nerves, and not, as is usually stated in textbooks of anatomy, by way of the pudic nerves. On several occasions Cabot found that section of the pudic nerves did not relieve P,ain originating in lesions of the posterior urethra. Case 2. The patient, a man, aged forty-five years, had had a tuberculous kidney removed elsewhere five and a half years previously. Symptoms of tuberculous cystitis appeared after three years, and these increased in severity until the man became a typical morphine addict, with loss of moral fiber. Cystoscopic examination at The Mayo Clinic showed a small ulcerated bladder, but the bacillus of tuberculosis could not be isolated from the urine. Local treatment did not relieve the condition, and finally, June 5, 1930, an attempt was made to divide the efferent branches of the hypogastric ganglia. This proved to be relatively easy on the right side, but on the left, the side of the original tuberculous process, the ganglion and its branches were obscured by periureteritis, and only one or two of the larger branches could be identified and divided. On account of the observations made at operation in case 1, the presacral nerve was divided also. After operation the bladder was drained by an indwelling catheter. For three days some pain persisted, referred to the glans penis, but thereafter all morphine could be stopped. The patient was much better, ate and slept well, and was happy at the result of the operation. Three times a day the bladder was gently distended, without causing any discomfort. On the fourteenth day the stitches were removed. Shortly afterward the patient pulled himself out of bed, and the abdominal wound reopened; at the secondary operation there was no sign of healing in the deep tissues. After this intervention bronchopneumonia developed, and the patient died eight days after the second operation. At necropsy the abdominal cavity was found to be free from infection. Gross evidence of tuberculosis of the bladder was absent, but on microscopic examination numerous tubercles were found in the wall.
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JAMES R. LEARMONTH
Case 3. In this case, I essayed the operation in an attempt to relieve pain due to an inoperable carcinoma of the bladder, involving the trigone in the region of the left ureteric orifice. After the peritoneum was opened, direct palpation showed that the growth had extended into the perivesical tissues, to such a degree that exposure of the hypogastric ganglia w~s out of the question. As a secondary measure, the presacral nerve was divided. The patient experienced considerable relief from this procedure, and curiously enough, the relief became more marked after the indwelling catheter was removed on the eighth day. The patient was able to sleep throughout the night, and stated that pain, "like a little toothache," was felt only after each act of micturition. Comment. Judging from the results in the published cases of neurectomy of the vesical branches of the hypogastric ganglia, as well as from my own experience in this field, this operation appears to be effective in controlling pain originating in the bladder, the prostate gland, and the posterior urethra. However, the indic•ations for so hazardous and so deforming an operation must be few; when the patient urgently demands relief, it may be considered in cases of inoperable tumor of the bladder, in which all other therapeutic measures have been exhausted. The subsequent paralysis of the bladder may be dealt with by regular catheterization; this of itself is a small price to pay for relief from pain, since the alternative is continuous drainage, either by an indwelling urethral catheter or by the suprapubic route. It may prove possible to accomplish the denervation by transvesical injection of alcohol into the ganglia through an operating cystoscope, and by this method the hazards of the treatment would be reduced. Investigations on this point are in progress. A modified procedure has been tried by Bonnet, in a case in which obstinate perineal pain made its appearance a year after suprapubic prostatectomy for benign hypertrophy of the gland. Rectal examination disclosed a point on each side, over the hypogastric plexus, where pressure produced the painful crises. Pararectal injections of procaine were first tried, with temporary effect, although after one such treatment the relief lasted for five months. Finally Bonnet achieved immediate cure by freeing the indurated plexuses with his finger, after incising the perineum between the bladder and the rectum. Four months later, when the case was reported pain had not returned.
NEUROSURGERY IN DISEASES OF URINARY BLADDER
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Briefly it may be said: Vesical pain due to inoperable tumor can be relieved by section of the vesical branches of the hypogastric gan,glia. This operation appears to relieve pain originating in lesions of the posterior urethra. It is followed by retention, necessitating regular catheterization for the remainder of the patient's life. Therefore indications for the operatipn rarely arise; they are chiefly the requests of the patients themselves. A less hazardous method of accomplishing the denervation by transvesical injection of alcohol into the ganglia in being studied. PAINFUL CONTRACTIONS OF THE WALL OF THE BLADDER
Apart from cases of vesical pain secondary to tuberculosis or malignant disease, there is a large group of cases in which complaint is made of more or less constant pain in the hypogastrium or around the neck of the bladder, complicated by crises of vesical spasm, and accompanied by frequency of urination and dysuria. These cases fall into two subgroups. In the first subgroup, a local lesion can be detected by cystoscopic examination, but the condition is resistant to all forms of treatment; of this subgroup the condition known as panmural fibrosis or Runner's ulcer is the outstanding example. The second subgroup consists of cases in which a history can be obtained of a previous attack of acute cystitis; however, the urine is found to be physically, chemically, and bacteriologically normal, and the bladder appears normal on cystoscopic examination. The only sequels of the original illness are vesical pain and frequency. In considering this group, Viannay pointed out that the lesions are microscopic, and consist of thickening of the vessels in the wall of the bladder, the symptoms being due to involvement of periarterial nerve fibers in the general sclerotic process. In both subgroups, the similarity to neuralgia elsewhere in the body has directed attention to the possibility of treating the condition by section of appropriate sensory nerves. The accessibility of the presacral nerve, and the fact that its section is not followed by any deleterious effect on function, has led to the trial of this operation in a considerable number of cases; Pieri, in 1926, was the first to perform the operation as a treatment for painful cystitis.
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JAMES R. LEARMONTH
For two reasons it seems to me that such a procedure is logical. First, a certain amount of relief from pain ought to follow the procedure, which from this standpoint is merely symptomatic treatment. On the other h~nd, there is a possibility that the procedure may have a more extended effect of a curative nature. This possibility is based on the success with which chronic ulcerative processes elsewhere in the body, for example in the legs, have been treated by sympathetic ramisection or ganglionectomy. The underlying principle of such treatment is the improvement in local nutrition as a result of the vasodilatation which follows the sympathectomy; after correct operations some vasodilatation is permanent. It has been possible to see with the cystoscope vasoconstriction of the vessels of the bladder on faradic stimulation o'f the presacral nerve, and vasodilatation of these vessels after its section. I am hopeful, therefore, that in addition to an immediate symptomatic result in cases of panmural fibrosis, there will be ultimate improvement in the vesical lesions as a result of improved nutrition. I have perfomed this operation in 4 cases of panmural fibrosis, and in 1 case of inveterate cy~titis following nephrectomy for tuberculosis of the kidney. In all these cases urologic and general treatment had been tried with only temporary success. Case 4. A woman, aged twenty-nine years, had had symptoms of interstitial cystitis for seven years, relieved for brief periods by urologic measures. The condition was limited to areas on the dome and lateral wall. An uneventful convalescence followed neurectomy. Three weeks after operation urine was retained from three to six hours without discomfort, and subjective relief of symptoms was marked; however, the cystoscopic picture was unchanged. Six weeks after operation, only slight pain remained; the urine was held from two to four hours by day and from six to eight hours by night. Twelve weeks after the operation, the patient returned to her work as school teacher. There was still some discomfort in the hypogastrium, which was increased by walking. Case 5. A man, aged forty years, had had symptoms of interstitial cystitis for five years. The condition was limited to the trigone and
NEUROSURGERY IN DISEASES OF URINARY BLADDER
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base of the bladder. An uneventful convalescence followed neurectomy. Three weeks after the operation, the cystoscopic appearance was not changed. Objective improvement was marked, but subjective improvement was slight. Eight weeks after operation the patient was definitely better although he still experienced some pain when passing urine. Case 6. A woman, aged thirty-four years, had had symptoms of interstitial cystitis for two years. The condition was diffuse. Convalescence was uneventful after neurectomy. Three weeks after the operation cystoscopic examination disclosed that the condition of the bladder was greatly improved. After the patient returned home the condition relapsed, and seven weeks after operation she was still having considerable pain on urination. Case 7. A man, aged fifty-nine years, had had symptoms of interstitial cystitis for fourteen years. The condition was diffuse, but was most marked in the right wall, a short distance above the base of the bladder. Convalescence was slow following neurectomy, and little objective or subjective change was present. Three weeks afterward, however, after the patient had been at home for a week, both pain and frequency diminished, and after another four weeks there was marked improvement as regards both pain and frequency. Case 8. A woman, aged thirty-eight years, had had nephrectomy for right renal tuberculosis nine years previously. For six years she had suffered from painful cystitis, of areal t ype. The bacillus of tuberculosis was never isolated in urine, nor after inoculation of guinea pigs. R apid convalescence occurred after neurectomy and there was considerable improvement subjectively and objectively. However, after a month, one or two attacks of frequency occurred, lasting four to six hours. Comment. At the beginning of a consideration of the results obtained by neurectomy in these cases, it is essential to emphasize that the longest interval since operation has been four mont hs. No final estimate of the value of neurectomy is at present possible, and what follows is of the nature of a preliminary report. In brief, the immediate improvement has been more objective than subjective; later, however, subjective relief has been reported in all cases but one. I do not feel that vesical pain can be com-
22
JAMES R. LEARMONTH
pletely controlled by section of the presacral nerve; Pieri stated that he has had better results by combining section of the presacral nerve with division of the sympathetic chains at the level of the sacral promontory. There has been a striking similarity in the postoperative course in all cases, both as regards frequency and quantity of urine p~ssed at each act of micturition. This is well brought out in figure 1, in which the quantity of urine passed at each act is charted on the ordinate, and the number of acts is charted on the abscissa. It will be seen that on the third, fourth,
t,j
500
ti 450
-~ 400 c;:.350 § 300 -~ 2.50
Qzoo
~ 150
i; 100
~ 50 1
2..
3 @Days
FIG.
1.
(CASE
5.)
5 6 !I Nights
FREQUENCY OF URINATION AND CAPACITY OF BLADDER AFTER ReSECTibN OF PRESACRAL NERVE
and fifth postoper-ative days and nights there is marked increase in frequency and a diminution in the capacity of the bladder. By the seventh day improvement begins, and reduction in frequency and incease in vesical capacity make their appearance. It appears to me that the initial aggravation of symptoms is explained by the division of the inhibitory fibers in the presacral nerve. None of the patients was immediately and completely relieved of pain; all have improved somewhat following the operation. The amount of relief does not seem to have any relationship to the site of the vesical lesion or lesions. Although
NEUROSURGERY IN DISEASES OF URINARY BLADDER
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the effect of rest in bed cannot be discounted, it is the impression of my colleagues in the Section of Urology of the clinic that the relief is greater than can be ascribed to this factor. I am, therefore, inclined to regard the outlook for these patients as guardedly good; final results will be reported at a later date. It may be noted that when the operation is offered to male patients, they should be warned that it will be followed by loss of the power of ejaculation, although the psychic orgasm persists unchanged. In all other respects the genito-urinary functions are unimpaired. In summary it may be said: In long-standing cases of cystitis in which the pain and frequency do not yield to ordinary measures, resection of the presacral nerve offers an additional method of treatment. Resection of the presacral nerve may be combined with division of the sympathetic chains at the level of the sacral promontory. These procedures act in two ways: by interrupting a certain number of afferent pain fibers from the bladder, and by improving the local blood supply. Therefore, both immediate and late effects of the operation may be expected. The immediate effects have been encouraging; the early late effects have also been encouraging. LESIONS OF THE VESICO-URETHRAL SPHINCTER APPARATUS
In conditions of spasm of the internal sphincter, and irritability ·of the prostatic portion of the urethra, Rochet advised that any operative interference should be on the pudic nerves, which he considered provided sensory fibers for the posterior urethra. It appears to me, however, that in view of my observation in case 1, in which pain at the neck of the bladder was relieved by section of branches of the hypogastric ganglia, as well as the confirmatory experience of Cabot, a better plan would be to attempt to reduce the tonus of the internal sphincter directly, by division of the presacral nerve which supplies it with motor fibers. At present I have under observation 2 cases of this type, in which this procedure has been adopted; the results will be reported at a later date. In summary it may be said: In irritability of the vesico-urethral sphincter apparatus, Rochet has advised neurectomy of the pudic
24
JAMES R. LEARMONTH
nerves. It is doubtful whether the posterior urethra derives the whole of its sensory nerve supply from the pudic nerves; probably some sensory fibers reach it from the hypogastric ganglia. In cases of irritability of the posterior urethra with spasm of the internal sphincter, it is suggested that a direct attempt be made to reduce the tonus of the internal sphincter by division of the esacral nerve. REFERENCES (1) BoNNET, PAUL: Nevralg_:ie pelvienne rebelle, secondaire a une prostatectomie hypogastrique. Action directe sur le plexus hypogastrique periprostatique par perineotomie. Guerison datant de quatre mois. Lyon. chir., January-February, 1927, xxiv, 117-119. (2) CABOT, HUGH: Personal communication to the author. (3) PIERI, Grno: Enervation ou ramisection? Presse med., September 8, 1926, xxxiv, 1141-1142. (4) RocHET, V.: Traitement chirurgical des cystites douloureuses. Lyon chir., July-August, 1921, xviii, 462-480. (5) VrANNAY, C.: Du traitement des cystites douloureuses arrivees au stade de "cystalgie," par les interventions sur le sympathique pelvien, et, en particulier, par la resection du nerf pre-sacre. Arch. franco-belges de chir., March, 1927, xxx, 229-236.
As long ago as 1898, it had occurred to the fertile brain of Jaboulay that impulses of pain arising in pelvic viscera might reach the central nervous system along fibers travelling with sympathetic nerves. The operations introduced by Jaboulay sought to interrupt the sacral rami communicantes, or the sacral sympathetic chaim, after these structures had been exposed by a retrorectal approach. Among the procedures tried were actual resection of the chain after removal of the coccyx; rupture of the rami by stripping the rectum from the front of the sacrum, and distention of the retrorectal space with salt solution. One or another of these operations succeeded in abolishing pain in a number of cases of "neuralgia of the pelvis," but in the absence of accurate knowledge of the distribution of the sympathetic nerves of the pelvis the indications for their use were difficult to define. After an accurate description of the visceral nerves of the pelvis had been provided by Latarjet and his collaborators, it became possible to choose the particular nerves to be divided on an anatomic basis, and in 1921 Rochet published an important paper on the treatment of painful cystitis. He stated that pain referred to the lower part of the urinary tract may be produced in three ways: (a) by colic in the vesical part of the ureter; (b) by painful contractions of the wall of the bladder, and (c) by lesions of the vesico-urethral sphincter apparatus. COLIC IN THE VESICAL PART OF THE URETER
In certain cases of renal tuberculosis, Rochet felt that the pain began in the intramural part of the ureter on the affected side; 1
Submitted for publication January 14, 1931. 13
14
JAMES R. LE ARMONTH
in such conditions he advised that periureteral sympathectomy be performed on the lowest 5 to 6 cm. of the ureter. He reported 3 cases. In the first case, the disease was unilateral, but the patient refused nephrectomy; the palliative operation relieved the painful crises until death four months later. In the second case the disease was bilateral, and the kidney more affected had been removed. The painful crises appeared to originate in the stump of ureter left after nephrectomy. Removal of the nerves around this stump led to complete stopping of the painful crises, although some frequency persisted; this betterment was maintained for at least two years. In the third case the tuberculous disease was bilateral; the result of operation was good for three weeks, ·when a different type of pain appeared. This was found to be due to a perivesical abscess, and drainage of this through a cystostomy wound led to complete relief from all forms of pain.
It seems to me that, in the present state of knowledge, the mode of action of periureteral sympathectomy must remain uncertain. The possibilities are: (a) stoppage of the painful spasms as a result of division of motor sympathetic nerves, (b) desensitization of the lower ureteric area as a result of division of sensory nerves, and (c) a combination of (a) and (b). It is unlikely that division of its extrinsic nerves would completely suppress the activity of a nonstriated muscular tube such as the ureter, but in this regard it is to be remembered that after nephrectomy, adequate stimuli for ureteric contractions should be absent, although there is a possibility that they may be started by the presence of caseous tuberculous debris. On the other hand, it is known that sensory nerves reach this part of the ureter, certainly by way of the hypogastric nerves and possibly by way of pelvic parasympathetic nerves. Probably the third explanation is correct, and the absence of painful crises is to be attributed partly to direct desensitization of the ureter and partly to reduction in its tonus as a result of division of its extrinsic motor nerves; moreover, some reflex reduction in tonus could be expected as a result of interruption of the afferent nerves. I have not had any experience of operation in cases of this type; in all three of Rochet's cases,
NEUROSURGERY IN DISEASES OF URINARY BLADDER
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the bacillus of tuberculosis was present in the urine, and in 1 case there were tuberculous pumonary lesions; it would appear that only the insistence of a patient could justify operation in such circumstances. Painful cystitis. Under this heading Rochet included cases of renal tuberculosis, in which painful vesical crises, frequency, and dysuria were distressing symptoms. Obviously neurectomy is to be considered in these cases only when the disease persists in spite of the usual surgical and urologic measures applicable to tuberculous disease of the urinary tract. In his two original cases Rochet attacked the hypogastric ganglia by the extraperitoneal route. Both patients were relieved until their deaths, seven months and one month respectively after operation. Since the operation interrupts both the sensory and the motor nerves to the bladder, without paralyzing the external sphincter, postoperative retention of urine is to be expected; in the first case this lasted for a month, when semi-incontinence was established, but observation on the power of the bladder was not possible in the second case, as a suprapubic urinary fistula developed after operation. Later Rochet modified his technic, so that only the larger nerves were divided, and that more anteriorly on the neck of the bladder. Of two patients with renal tuberculosis, one lived for sixteen months, still suffering from frequency, but untroubled by painful spasms ; the other was considerably relieved until death ten months later, the frequency persisting, but the spasms being absent. The first patient required catheterization for many days, after which micturition was reestablished; the second patient had retention only for ten days.
In 3 cases I felt justified in advising an operation of this type. Case 1. A man, aged fifty-two years, had had a tumor of the bladder removed elsewhere in 1924. His symptoms returned in 1929 and he underwent an extensive course of deep roentgen-ray t reatment and electrocoagulation. In spite of this symptoms persisted, and he lost much weight and sleep on account of dysuria and frequency. At his last visit to The Mayo Clinic, March 18, 1930, the report after cystoscopic examination was "Diffuse involvement of entire upper sphincter by necrotic masses. Very apparent diffuse malignant involvement of the bladder with probably perivesical extension. Inoperable car-
16
JAMES R. LEARMONTH
cinoma." In addition to painful vesical spasms, he had continuous pain around the neck of the bladder. He asked that an attempt be made to mitigate the pain, and as renal function was unimpaired, it was decided to divide the vesical branches of the hypogastric ganglia. March 26, under spinal analgesia, I attempted to do this by the extraperitoneal route. However, the bladder was so adherent to the peritoneum and extravesical tissue that I abandoned this route, and opened the peritoneum. By following the technic described in part I of this series, I was able to identify and divide the larger anterior efferent branches of the hypogastric gangliaj for a reason to be explained later, the presacral nerve was divided also. After the operation the patient experienced immediate relief from all forms of vesical distress. The bladder was drained by an indwelling catheter. On the third day the blood urea rose to 75 mgm. for each 100 cc., and there was some abdominal distention; these signs disappeared, under appropriate treatment. On the seventh day after treatment the distention reappeared, as well as signs of rapidly advancing bronchopneumonia, and the patient died on the eighth day. At necropsy it was found that the perforation of a large gastric ulcer had given rise to general peritonitis; this complication was quite unexpected. Advanced bilateral bronchopneumonia was also present. The vesical growth had extended from the base of the bladder into the prostate gland and the posterior urethra.
In the course of this operation I had occasion to grasp the presacral nerve with a hemostat. When the nerve was pulled, the patient immediately complained of severe pain. After the nerve was divided, traction on its central end gave rise to pain which the patient described as a crushing pain in the bladder. As the patient was unaware of what was being done, this experience offers convincing proof that sensory nerves from the bladder reach the central nervous system along the thoracicolumbar sympathetic nerves. The exact level of their entrance into the spinal cord is doubtful. In this instance the effect of the spinal anesthetic was beginning to disappear, from above downward; the patient was analgesic to pin prick as high as the tenth thoracic segment, so that in all likelihood the impulses reach the cord above this level, possibly along the roots of the splanchnic nerves. The experience in this case proved that at least a ·proportion of vesical pain would be abolished by section of the presacral nerve
NEUROSURGERY IN DISEASES OF URINARY BLADDER
17
alone. In addition, it was interesting to realize, after necropsy, that the constant pain around the neck of the bladder, doubtless due to invasion of the prostate gland and posterior urethra, had been suppressed by division of the efferent branches of the ganglion. This observation seems to indicate that at least part of the sensory nerves for the posterior urethra reach it by way of these autonomic nerves, and not, as is usually stated in textbooks of anatomy, by way of the pudic nerves. On several occasions Cabot found that section of the pudic nerves did not relieve P,ain originating in lesions of the posterior urethra. Case 2. The patient, a man, aged forty-five years, had had a tuberculous kidney removed elsewhere five and a half years previously. Symptoms of tuberculous cystitis appeared after three years, and these increased in severity until the man became a typical morphine addict, with loss of moral fiber. Cystoscopic examination at The Mayo Clinic showed a small ulcerated bladder, but the bacillus of tuberculosis could not be isolated from the urine. Local treatment did not relieve the condition, and finally, June 5, 1930, an attempt was made to divide the efferent branches of the hypogastric ganglia. This proved to be relatively easy on the right side, but on the left, the side of the original tuberculous process, the ganglion and its branches were obscured by periureteritis, and only one or two of the larger branches could be identified and divided. On account of the observations made at operation in case 1, the presacral nerve was divided also. After operation the bladder was drained by an indwelling catheter. For three days some pain persisted, referred to the glans penis, but thereafter all morphine could be stopped. The patient was much better, ate and slept well, and was happy at the result of the operation. Three times a day the bladder was gently distended, without causing any discomfort. On the fourteenth day the stitches were removed. Shortly afterward the patient pulled himself out of bed, and the abdominal wound reopened; at the secondary operation there was no sign of healing in the deep tissues. After this intervention bronchopneumonia developed, and the patient died eight days after the second operation. At necropsy the abdominal cavity was found to be free from infection. Gross evidence of tuberculosis of the bladder was absent, but on microscopic examination numerous tubercles were found in the wall.
18
JAMES R. LEARMONTH
Case 3. In this case, I essayed the operation in an attempt to relieve pain due to an inoperable carcinoma of the bladder, involving the trigone in the region of the left ureteric orifice. After the peritoneum was opened, direct palpation showed that the growth had extended into the perivesical tissues, to such a degree that exposure of the hypogastric ganglia w~s out of the question. As a secondary measure, the presacral nerve was divided. The patient experienced considerable relief from this procedure, and curiously enough, the relief became more marked after the indwelling catheter was removed on the eighth day. The patient was able to sleep throughout the night, and stated that pain, "like a little toothache," was felt only after each act of micturition. Comment. Judging from the results in the published cases of neurectomy of the vesical branches of the hypogastric ganglia, as well as from my own experience in this field, this operation appears to be effective in controlling pain originating in the bladder, the prostate gland, and the posterior urethra. However, the indic•ations for so hazardous and so deforming an operation must be few; when the patient urgently demands relief, it may be considered in cases of inoperable tumor of the bladder, in which all other therapeutic measures have been exhausted. The subsequent paralysis of the bladder may be dealt with by regular catheterization; this of itself is a small price to pay for relief from pain, since the alternative is continuous drainage, either by an indwelling urethral catheter or by the suprapubic route. It may prove possible to accomplish the denervation by transvesical injection of alcohol into the ganglia through an operating cystoscope, and by this method the hazards of the treatment would be reduced. Investigations on this point are in progress. A modified procedure has been tried by Bonnet, in a case in which obstinate perineal pain made its appearance a year after suprapubic prostatectomy for benign hypertrophy of the gland. Rectal examination disclosed a point on each side, over the hypogastric plexus, where pressure produced the painful crises. Pararectal injections of procaine were first tried, with temporary effect, although after one such treatment the relief lasted for five months. Finally Bonnet achieved immediate cure by freeing the indurated plexuses with his finger, after incising the perineum between the bladder and the rectum. Four months later, when the case was reported pain had not returned.
NEUROSURGERY IN DISEASES OF URINARY BLADDER
19
Briefly it may be said: Vesical pain due to inoperable tumor can be relieved by section of the vesical branches of the hypogastric gan,glia. This operation appears to relieve pain originating in lesions of the posterior urethra. It is followed by retention, necessitating regular catheterization for the remainder of the patient's life. Therefore indications for the operatipn rarely arise; they are chiefly the requests of the patients themselves. A less hazardous method of accomplishing the denervation by transvesical injection of alcohol into the ganglia in being studied. PAINFUL CONTRACTIONS OF THE WALL OF THE BLADDER
Apart from cases of vesical pain secondary to tuberculosis or malignant disease, there is a large group of cases in which complaint is made of more or less constant pain in the hypogastrium or around the neck of the bladder, complicated by crises of vesical spasm, and accompanied by frequency of urination and dysuria. These cases fall into two subgroups. In the first subgroup, a local lesion can be detected by cystoscopic examination, but the condition is resistant to all forms of treatment; of this subgroup the condition known as panmural fibrosis or Runner's ulcer is the outstanding example. The second subgroup consists of cases in which a history can be obtained of a previous attack of acute cystitis; however, the urine is found to be physically, chemically, and bacteriologically normal, and the bladder appears normal on cystoscopic examination. The only sequels of the original illness are vesical pain and frequency. In considering this group, Viannay pointed out that the lesions are microscopic, and consist of thickening of the vessels in the wall of the bladder, the symptoms being due to involvement of periarterial nerve fibers in the general sclerotic process. In both subgroups, the similarity to neuralgia elsewhere in the body has directed attention to the possibility of treating the condition by section of appropriate sensory nerves. The accessibility of the presacral nerve, and the fact that its section is not followed by any deleterious effect on function, has led to the trial of this operation in a considerable number of cases; Pieri, in 1926, was the first to perform the operation as a treatment for painful cystitis.
20
JAMES R. LEARMONTH
For two reasons it seems to me that such a procedure is logical. First, a certain amount of relief from pain ought to follow the procedure, which from this standpoint is merely symptomatic treatment. On the other h~nd, there is a possibility that the procedure may have a more extended effect of a curative nature. This possibility is based on the success with which chronic ulcerative processes elsewhere in the body, for example in the legs, have been treated by sympathetic ramisection or ganglionectomy. The underlying principle of such treatment is the improvement in local nutrition as a result of the vasodilatation which follows the sympathectomy; after correct operations some vasodilatation is permanent. It has been possible to see with the cystoscope vasoconstriction of the vessels of the bladder on faradic stimulation o'f the presacral nerve, and vasodilatation of these vessels after its section. I am hopeful, therefore, that in addition to an immediate symptomatic result in cases of panmural fibrosis, there will be ultimate improvement in the vesical lesions as a result of improved nutrition. I have perfomed this operation in 4 cases of panmural fibrosis, and in 1 case of inveterate cy~titis following nephrectomy for tuberculosis of the kidney. In all these cases urologic and general treatment had been tried with only temporary success. Case 4. A woman, aged twenty-nine years, had had symptoms of interstitial cystitis for seven years, relieved for brief periods by urologic measures. The condition was limited to areas on the dome and lateral wall. An uneventful convalescence followed neurectomy. Three weeks after operation urine was retained from three to six hours without discomfort, and subjective relief of symptoms was marked; however, the cystoscopic picture was unchanged. Six weeks after operation, only slight pain remained; the urine was held from two to four hours by day and from six to eight hours by night. Twelve weeks after the operation, the patient returned to her work as school teacher. There was still some discomfort in the hypogastrium, which was increased by walking. Case 5. A man, aged forty years, had had symptoms of interstitial cystitis for five years. The condition was limited to the trigone and
NEUROSURGERY IN DISEASES OF URINARY BLADDER
21
base of the bladder. An uneventful convalescence followed neurectomy. Three weeks after the operation, the cystoscopic appearance was not changed. Objective improvement was marked, but subjective improvement was slight. Eight weeks after operation the patient was definitely better although he still experienced some pain when passing urine. Case 6. A woman, aged thirty-four years, had had symptoms of interstitial cystitis for two years. The condition was diffuse. Convalescence was uneventful after neurectomy. Three weeks after the operation cystoscopic examination disclosed that the condition of the bladder was greatly improved. After the patient returned home the condition relapsed, and seven weeks after operation she was still having considerable pain on urination. Case 7. A man, aged fifty-nine years, had had symptoms of interstitial cystitis for fourteen years. The condition was diffuse, but was most marked in the right wall, a short distance above the base of the bladder. Convalescence was slow following neurectomy, and little objective or subjective change was present. Three weeks afterward, however, after the patient had been at home for a week, both pain and frequency diminished, and after another four weeks there was marked improvement as regards both pain and frequency. Case 8. A woman, aged thirty-eight years, had had nephrectomy for right renal tuberculosis nine years previously. For six years she had suffered from painful cystitis, of areal t ype. The bacillus of tuberculosis was never isolated in urine, nor after inoculation of guinea pigs. R apid convalescence occurred after neurectomy and there was considerable improvement subjectively and objectively. However, after a month, one or two attacks of frequency occurred, lasting four to six hours. Comment. At the beginning of a consideration of the results obtained by neurectomy in these cases, it is essential to emphasize that the longest interval since operation has been four mont hs. No final estimate of the value of neurectomy is at present possible, and what follows is of the nature of a preliminary report. In brief, the immediate improvement has been more objective than subjective; later, however, subjective relief has been reported in all cases but one. I do not feel that vesical pain can be com-
22
JAMES R. LEARMONTH
pletely controlled by section of the presacral nerve; Pieri stated that he has had better results by combining section of the presacral nerve with division of the sympathetic chains at the level of the sacral promontory. There has been a striking similarity in the postoperative course in all cases, both as regards frequency and quantity of urine p~ssed at each act of micturition. This is well brought out in figure 1, in which the quantity of urine passed at each act is charted on the ordinate, and the number of acts is charted on the abscissa. It will be seen that on the third, fourth,
t,j
500
ti 450
-~ 400 c;:.350 § 300 -~ 2.50
Qzoo
~ 150
i; 100
~ 50 1
2..
3 @Days
FIG.
1.
(CASE
5.)
5 6 !I Nights
FREQUENCY OF URINATION AND CAPACITY OF BLADDER AFTER ReSECTibN OF PRESACRAL NERVE
and fifth postoper-ative days and nights there is marked increase in frequency and a diminution in the capacity of the bladder. By the seventh day improvement begins, and reduction in frequency and incease in vesical capacity make their appearance. It appears to me that the initial aggravation of symptoms is explained by the division of the inhibitory fibers in the presacral nerve. None of the patients was immediately and completely relieved of pain; all have improved somewhat following the operation. The amount of relief does not seem to have any relationship to the site of the vesical lesion or lesions. Although
NEUROSURGERY IN DISEASES OF URINARY BLADDER
23
the effect of rest in bed cannot be discounted, it is the impression of my colleagues in the Section of Urology of the clinic that the relief is greater than can be ascribed to this factor. I am, therefore, inclined to regard the outlook for these patients as guardedly good; final results will be reported at a later date. It may be noted that when the operation is offered to male patients, they should be warned that it will be followed by loss of the power of ejaculation, although the psychic orgasm persists unchanged. In all other respects the genito-urinary functions are unimpaired. In summary it may be said: In long-standing cases of cystitis in which the pain and frequency do not yield to ordinary measures, resection of the presacral nerve offers an additional method of treatment. Resection of the presacral nerve may be combined with division of the sympathetic chains at the level of the sacral promontory. These procedures act in two ways: by interrupting a certain number of afferent pain fibers from the bladder, and by improving the local blood supply. Therefore, both immediate and late effects of the operation may be expected. The immediate effects have been encouraging; the early late effects have also been encouraging. LESIONS OF THE VESICO-URETHRAL SPHINCTER APPARATUS
In conditions of spasm of the internal sphincter, and irritability ·of the prostatic portion of the urethra, Rochet advised that any operative interference should be on the pudic nerves, which he considered provided sensory fibers for the posterior urethra. It appears to me, however, that in view of my observation in case 1, in which pain at the neck of the bladder was relieved by section of branches of the hypogastric ganglia, as well as the confirmatory experience of Cabot, a better plan would be to attempt to reduce the tonus of the internal sphincter directly, by division of the presacral nerve which supplies it with motor fibers. At present I have under observation 2 cases of this type, in which this procedure has been adopted; the results will be reported at a later date. In summary it may be said: In irritability of the vesico-urethral sphincter apparatus, Rochet has advised neurectomy of the pudic
24
JAMES R. LEARMONTH
nerves. It is doubtful whether the posterior urethra derives the whole of its sensory nerve supply from the pudic nerves; probably some sensory fibers reach it from the hypogastric ganglia. In cases of irritability of the posterior urethra with spasm of the internal sphincter, it is suggested that a direct attempt be made to reduce the tonus of the internal sphincter by division of the esacral nerve. REFERENCES (1) BoNNET, PAUL: Nevralg_:ie pelvienne rebelle, secondaire a une prostatectomie hypogastrique. Action directe sur le plexus hypogastrique periprostatique par perineotomie. Guerison datant de quatre mois. Lyon. chir., January-February, 1927, xxiv, 117-119. (2) CABOT, HUGH: Personal communication to the author. (3) PIERI, Grno: Enervation ou ramisection? Presse med., September 8, 1926, xxxiv, 1141-1142. (4) RocHET, V.: Traitement chirurgical des cystites douloureuses. Lyon chir., July-August, 1921, xviii, 462-480. (5) VrANNAY, C.: Du traitement des cystites douloureuses arrivees au stade de "cystalgie," par les interventions sur le sympathique pelvien, et, en particulier, par la resection du nerf pre-sacre. Arch. franco-belges de chir., March, 1927, xxx, 229-236.