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New Concept of Vesical Innervation and its Clinical Application
THE JOURNAL OF UROLOGY
Vol. 71, No. 5, May 1954
Printed in U.S.A.
NEW CONCEPT OF VESICAL INNERVATION AND ITS CLINICAL APPLICATION LOWRAIN E. McCREA
AND
DONALD L. KIMMEL
From Departments of Urology and Anatomy, Temple University School of Medicine and Hospital, Philadelphia, Pa.
Many theories have been advanced by investigators as to the cause of vesical dysfunction following abdominoperineal proctosigmoidectomy or total hysterectomy with extended pelvic dissection. It is our confirmed belief that vesical dysfunction following such a surgical procedure is of neurologic origin. It was originally considered that the behavior of the bladder following surgery suggested an imbalance due to a predominance of sympathetic innervation after the parasympathetic innervation had been subjected to trauma or excision. It was also considered that regeneration of the parasympathetic innervation permitted a return to normal function. Many of these statements have now been shown to be incorrect. Regeneration of the nerve tissue is impossible, due not only to the extended excision of the nerve plexus, but also to massive scar formation in the tissues following surgery. It was to prove the cause and to prevent, if possible, the occurrence of vesical dysfunction that basic research on the innervation of the bladder was undertaken. This study has consisted of the examination of serial sections of human fetuses ranging in size from 7.5 to 106 mm. crown-rump length. This procedure or study has demonstrated that an accessory nerve supply to the bladder exists. The nerve fibres are given off from the second, third and fourth sacral roots, traverse the deep layers of the endopelvic fascia by a perivascular route along the blood vessels within the lateral walls of the bony pelvis. These nerves enter the bladder at the level of the insertion of the ureters (fig. 1). They completely circumvent the usually acknowledged nervous pathways to the bladder through the pelvic plexus. It has also been demonstrated that the newly described nerves are distributed in a pattern so as to completely overlap the distribution of the fibres which reach the bladder by way of the acknowledged pathway through the pelvic plexus (fig. 2). It has been demonstrated that some of the fibres join the anterior part of the pelvic plexus, interrelating the two nerve routes to the bladder. Nerves occupying a similar position have been indicated by Curtis, Anson, Ashley and Jones. Pernkoff clearly demonstrates these nerves in their course to the bladder. His illustrations, since based on gross dissections only, fail to show a representative number of these nerves lateral to the pudendal venus plexus. The usually acknowledge innervation of the bladder, according to Learmouth, arises from three sources. These sources are the somatic, sympathetic and parasympathetic. The somatic innervation is supplied through the pudendal nerve, usually derived This study was supported by a grant from Hoffman-LaRoche, Inc. Read at annual meeting, American Urological Association, St. Louis, Mo. :May 13, 1953.
549
550
LOWRAIN E. McCREA AND DONALD L. KIMMEL
Sup. gluteal
artery
Inf. gluteal
urtery Branches
,,, t6 ureter
Branches to
bowel Int. pudenda.I
nerve
Branches 'to external sphincter
Frn. 1. Dissection showing parasympathetic nerves to bladder.
from the second, third and fourth sacral roots. The distribution of this nerve is to the external sphincter, the striated muscle around the urethra. It is through this nerve that the only volutional impulses of urination are carried. The sympathetic fibres which innervate the bladder are given off the thoracolumbar outflow from the first and second lumbar segments and possibly the twelfth thoracic segment. The sympathetic fibres to the bladder and other pelvic viscera are finally concentrated in a strand called the presacral nerve. At the promontory of the sacrum, the presacral nerve divides into the two hypogastric nerves which join the posterior superior angles of the corresponding ganglia or pelvic plexuses. From here, fibres pass onward to innervate the trigone, including the muscles of Bell, and the muscles of the crest of the urethra. The parasympathetic fibres arise from the second, third and fourth sacral segments of the spinal cord and run through the pelvic plexuses which lie on the lateral surfaces of the rectum, to the bladder musculature. In the surgical procedure of abdominoperineal proctosigmoidectomy, or in hysterectomy there is a disruption of the nerve fibres passing through the pelvic
551
VESICAL INNERVATION
50.crn-il1ac
lumbaso.cro.J rrurik ( L4-L51,
_ ,£noopelvlc tasc1a - 5ymphysis
pub,s
eplum
Pro\lat1c capsule
Venous· ple::i:ys uboul bla.dde'r ,
Fm. 2. Parasympathetic nerves seen to enter inferior hypogastric or pelvic plexus together with sympathetic fibres. Pudendal nerve is in a normal position and is not in direct communication with other nerves that control urination. It is through pudendal that only volutional impulses or urination are carried.
plexus. It is believed that the newly described accessory fibres completely take over the function of the innervation of the bladder when the posterior portion of pelvic plexus is disrupted. It is further believed that vesical atonia or dysfunction is usually temporary, but may be permanent. It is not believed that vesical dysfunction is due to obstructive uropathy as some investigators would lead us to believe. If this were true, it would be difficult to explain how urinary dysfunction following proctosigmoidectomy or hysterectomy occurs in women or in men below the "prostatic age" without visible or palpable evidence of benign prostate hyperplastic change. Granted, a certain percentage of individuals, on whom bowel resection is done, are within the prostatic age and may develop urinary retention. There is no disagreement as to the cause of treatment of such retention. However, it is not considered necessary to do transurethral resection in every instance of temporary vesical atonia following such surgery. Permanent vesical atonia would result when the pelvic plexus, which is considered to be the primary nerve pathway to the bladder is excised, and there was extensive trauma to the accessory nerves coursing to the bladder in the lateral endopelvic fascia. When once established it is doubtful whether transurethral resection is the answer. A bladder in such a state is dilated or easily dilatable and is without tone as interpreted by the cystometer.
552
LOWRAIN E. McCREA AND DONALD L. KIMMEL
· Ilium
3rd. Sacral verleti_ra
Colon
Peritoneal cavily ·
Nerve to bladder in laleraJ pelvic wall
Inf, gluteal artery
Veins of
pelvic
pleius
Hemo-· rrhoidal and vesica.1 plexuses
--lschium
Head of femur
Fioers to blttdder
orifice
Bladder
Fm. 3. Cross section through pelvis of an adult male showing position of nerves to bladder as they course through endopelvic fascia. Note particularly relationship of nerves to blood vessels and their later position in endopelvic fascia.
It is established that nerves reach the bladder by two separate and distinct routes. These routes are 1) the established pathways through the inferior hypogastric or pelvic plexuses and 2) the newly described pathways, coursing to the bladder by a perivascular route. The nerves of the newly described pathways are given off from the second, third and fourth sacral roots and course to the bladder along the blood vessels in the endopelvic fascia within the lateral walls of the bony pelvis (fig. 3). Many of these nerves run to their termination on the ureter and bladder independently of the pelvic plexus. Others join the pelvic plexus anteriorly to the rectum in the lateral wall of the rectovesical fossa. It is believed that the presence of these nerves in their lateral position explains normal bladder function following removal of the rectum or the uterus. It is believed that trauma to the nerve supply of the bladder rather than obstructive uropathy, is the cause of vesical dysfunction following extended pelvic surgery such as abdominoperineal proctosigmoidectomy or total hysterectomy with extended dissection. CONCLUSION
An accessory innervation to the bladder has been demonstrated. As stated it is believed that these nerves do and are capable of maintaining normal vesical function following many types of pelvic surgery.
1930 Chestnut St., Philadelphia, Pa.
VESICAL INNERVATION
553
REFERENCES BACON, H. E.: Abdominoperineal proctosigmoidectomy for cancer of rectum. Am. J. Surg., 71: 728, 1946. BACON, H. E. AND McCREA, L. E.: Abdominoperineal proctosigmoidectomy for rectal cancer. The management of associated vesical dysfunction. J.A.M.A., 134: 523, 1947. HILL, M. R., BARNES, R. W. AND COURVILLE, C. B.: Vesical dysfunction following abdominoperineal resection. J.A.M.A., 109: 1184, 1937. KIMMEL, D. L. AND MOYER, E. K.: The course of visceral branches of sacral nerves to the urinary bladder in human fetuses. Read at a meeting of the American Association of Anatomists, Detroit, March 1951. KIMMEL, D. L. AND Mo YER, E. L.: Dorsal roots following anastomosis of the central stumps. J. Comp. Neurol., 87: 289, 1947. McCREA, L. E.: Cystometry and its interpretation, Urol. & Cutan. Rev., 44: 362, 1940. McCREA, L. E.: Vesical dysfunction in anorectal disease. Urol. & Cutan. Rev., 47: 211, 1943. McCREA, L. E.: Management of vesical dysfunction in anorectal disease. Proc. Proct. Soc. 1946. McCREA, L. E.: Management of vesical dysfunction following operation on lower bowel. Read before the Post Graduate Medical Assembly of South Texas, Houston, December 5, 1946. McCREA, L. E.: Management of vesical dysfunction following abdominoperineal proctosigmoidectomy. J. Internat. Coll. Surg., 10: 629, 1947. McCREA L. E. AND KIMMEL, D. L.: The importance of nerve supply of the urinary bladder in su'rgery of the rectosigmoid. J. Int. Coll. Surg., 17: 651-657, 1952. McCREA L. E. AND KIMMEL, D. L.: A new concept of vesical innervation and its relationship' to bladder management following abdominoperineal proctosigmoidectomy. Am. J. Surg., 84: 518-523, 1952.
Vol. 71, No. 5, May 1954
Printed in U.S.A.
NEW CONCEPT OF VESICAL INNERVATION AND ITS CLINICAL APPLICATION LOWRAIN E. McCREA
AND
DONALD L. KIMMEL
From Departments of Urology and Anatomy, Temple University School of Medicine and Hospital, Philadelphia, Pa.
Many theories have been advanced by investigators as to the cause of vesical dysfunction following abdominoperineal proctosigmoidectomy or total hysterectomy with extended pelvic dissection. It is our confirmed belief that vesical dysfunction following such a surgical procedure is of neurologic origin. It was originally considered that the behavior of the bladder following surgery suggested an imbalance due to a predominance of sympathetic innervation after the parasympathetic innervation had been subjected to trauma or excision. It was also considered that regeneration of the parasympathetic innervation permitted a return to normal function. Many of these statements have now been shown to be incorrect. Regeneration of the nerve tissue is impossible, due not only to the extended excision of the nerve plexus, but also to massive scar formation in the tissues following surgery. It was to prove the cause and to prevent, if possible, the occurrence of vesical dysfunction that basic research on the innervation of the bladder was undertaken. This study has consisted of the examination of serial sections of human fetuses ranging in size from 7.5 to 106 mm. crown-rump length. This procedure or study has demonstrated that an accessory nerve supply to the bladder exists. The nerve fibres are given off from the second, third and fourth sacral roots, traverse the deep layers of the endopelvic fascia by a perivascular route along the blood vessels within the lateral walls of the bony pelvis. These nerves enter the bladder at the level of the insertion of the ureters (fig. 1). They completely circumvent the usually acknowledged nervous pathways to the bladder through the pelvic plexus. It has also been demonstrated that the newly described nerves are distributed in a pattern so as to completely overlap the distribution of the fibres which reach the bladder by way of the acknowledged pathway through the pelvic plexus (fig. 2). It has been demonstrated that some of the fibres join the anterior part of the pelvic plexus, interrelating the two nerve routes to the bladder. Nerves occupying a similar position have been indicated by Curtis, Anson, Ashley and Jones. Pernkoff clearly demonstrates these nerves in their course to the bladder. His illustrations, since based on gross dissections only, fail to show a representative number of these nerves lateral to the pudendal venus plexus. The usually acknowledge innervation of the bladder, according to Learmouth, arises from three sources. These sources are the somatic, sympathetic and parasympathetic. The somatic innervation is supplied through the pudendal nerve, usually derived This study was supported by a grant from Hoffman-LaRoche, Inc. Read at annual meeting, American Urological Association, St. Louis, Mo. :May 13, 1953.
549
550
LOWRAIN E. McCREA AND DONALD L. KIMMEL
Sup. gluteal
artery
Inf. gluteal
urtery Branches
,,, t6 ureter
Branches to
bowel Int. pudenda.I
nerve
Branches 'to external sphincter
Frn. 1. Dissection showing parasympathetic nerves to bladder.
from the second, third and fourth sacral roots. The distribution of this nerve is to the external sphincter, the striated muscle around the urethra. It is through this nerve that the only volutional impulses of urination are carried. The sympathetic fibres which innervate the bladder are given off the thoracolumbar outflow from the first and second lumbar segments and possibly the twelfth thoracic segment. The sympathetic fibres to the bladder and other pelvic viscera are finally concentrated in a strand called the presacral nerve. At the promontory of the sacrum, the presacral nerve divides into the two hypogastric nerves which join the posterior superior angles of the corresponding ganglia or pelvic plexuses. From here, fibres pass onward to innervate the trigone, including the muscles of Bell, and the muscles of the crest of the urethra. The parasympathetic fibres arise from the second, third and fourth sacral segments of the spinal cord and run through the pelvic plexuses which lie on the lateral surfaces of the rectum, to the bladder musculature. In the surgical procedure of abdominoperineal proctosigmoidectomy, or in hysterectomy there is a disruption of the nerve fibres passing through the pelvic
551
VESICAL INNERVATION
50.crn-il1ac
lumbaso.cro.J rrurik ( L4-L51,
_ ,£noopelvlc tasc1a - 5ymphysis
pub,s
eplum
Pro\lat1c capsule
Venous· ple::i:ys uboul bla.dde'r ,
Fm. 2. Parasympathetic nerves seen to enter inferior hypogastric or pelvic plexus together with sympathetic fibres. Pudendal nerve is in a normal position and is not in direct communication with other nerves that control urination. It is through pudendal that only volutional impulses or urination are carried.
plexus. It is believed that the newly described accessory fibres completely take over the function of the innervation of the bladder when the posterior portion of pelvic plexus is disrupted. It is further believed that vesical atonia or dysfunction is usually temporary, but may be permanent. It is not believed that vesical dysfunction is due to obstructive uropathy as some investigators would lead us to believe. If this were true, it would be difficult to explain how urinary dysfunction following proctosigmoidectomy or hysterectomy occurs in women or in men below the "prostatic age" without visible or palpable evidence of benign prostate hyperplastic change. Granted, a certain percentage of individuals, on whom bowel resection is done, are within the prostatic age and may develop urinary retention. There is no disagreement as to the cause of treatment of such retention. However, it is not considered necessary to do transurethral resection in every instance of temporary vesical atonia following such surgery. Permanent vesical atonia would result when the pelvic plexus, which is considered to be the primary nerve pathway to the bladder is excised, and there was extensive trauma to the accessory nerves coursing to the bladder in the lateral endopelvic fascia. When once established it is doubtful whether transurethral resection is the answer. A bladder in such a state is dilated or easily dilatable and is without tone as interpreted by the cystometer.
552
LOWRAIN E. McCREA AND DONALD L. KIMMEL
· Ilium
3rd. Sacral verleti_ra
Colon
Peritoneal cavily ·
Nerve to bladder in laleraJ pelvic wall
Inf, gluteal artery
Veins of
pelvic
pleius
Hemo-· rrhoidal and vesica.1 plexuses
--lschium
Head of femur
Fioers to blttdder
orifice
Bladder
Fm. 3. Cross section through pelvis of an adult male showing position of nerves to bladder as they course through endopelvic fascia. Note particularly relationship of nerves to blood vessels and their later position in endopelvic fascia.
It is established that nerves reach the bladder by two separate and distinct routes. These routes are 1) the established pathways through the inferior hypogastric or pelvic plexuses and 2) the newly described pathways, coursing to the bladder by a perivascular route. The nerves of the newly described pathways are given off from the second, third and fourth sacral roots and course to the bladder along the blood vessels in the endopelvic fascia within the lateral walls of the bony pelvis (fig. 3). Many of these nerves run to their termination on the ureter and bladder independently of the pelvic plexus. Others join the pelvic plexus anteriorly to the rectum in the lateral wall of the rectovesical fossa. It is believed that the presence of these nerves in their lateral position explains normal bladder function following removal of the rectum or the uterus. It is believed that trauma to the nerve supply of the bladder rather than obstructive uropathy, is the cause of vesical dysfunction following extended pelvic surgery such as abdominoperineal proctosigmoidectomy or total hysterectomy with extended dissection. CONCLUSION
An accessory innervation to the bladder has been demonstrated. As stated it is believed that these nerves do and are capable of maintaining normal vesical function following many types of pelvic surgery.
1930 Chestnut St., Philadelphia, Pa.
VESICAL INNERVATION
553
REFERENCES BACON, H. E.: Abdominoperineal proctosigmoidectomy for cancer of rectum. Am. J. Surg., 71: 728, 1946. BACON, H. E. AND McCREA, L. E.: Abdominoperineal proctosigmoidectomy for rectal cancer. The management of associated vesical dysfunction. J.A.M.A., 134: 523, 1947. HILL, M. R., BARNES, R. W. AND COURVILLE, C. B.: Vesical dysfunction following abdominoperineal resection. J.A.M.A., 109: 1184, 1937. KIMMEL, D. L. AND MOYER, E. K.: The course of visceral branches of sacral nerves to the urinary bladder in human fetuses. Read at a meeting of the American Association of Anatomists, Detroit, March 1951. KIMMEL, D. L. AND Mo YER, E. L.: Dorsal roots following anastomosis of the central stumps. J. Comp. Neurol., 87: 289, 1947. McCREA, L. E.: Cystometry and its interpretation, Urol. & Cutan. Rev., 44: 362, 1940. McCREA, L. E.: Vesical dysfunction in anorectal disease. Urol. & Cutan. Rev., 47: 211, 1943. McCREA, L. E.: Management of vesical dysfunction in anorectal disease. Proc. Proct. Soc. 1946. McCREA, L. E.: Management of vesical dysfunction following operation on lower bowel. Read before the Post Graduate Medical Assembly of South Texas, Houston, December 5, 1946. McCREA, L. E.: Management of vesical dysfunction following abdominoperineal proctosigmoidectomy. J. Internat. Coll. Surg., 10: 629, 1947. McCREA L. E. AND KIMMEL, D. L.: The importance of nerve supply of the urinary bladder in su'rgery of the rectosigmoid. J. Int. Coll. Surg., 17: 651-657, 1952. McCREA L. E. AND KIMMEL, D. L.: A new concept of vesical innervation and its relationship' to bladder management following abdominoperineal proctosigmoidectomy. Am. J. Surg., 84: 518-523, 1952.