Percutaneous Radiofrequency Sacral Rhizotomy in the Treatment of the Hyperreflexic Bladder

0022-5347 /78/1205-0557$02.00/0 Vol. 120, November Printed in U.S.A.

THE JOURNAL OF UROWGY

Copyright © 1978 by The Williams & Wilkins Co.

PERCUTANEOUS RADIOFREQUENCY SACRAL RHIZOTOMY IN THE TREATMENT OF THE HYPERREFLEXIC BLADDER JOHN J. MULCAHY*

AND

A. BRYON YOUNG

From the Division of Urology, University of Kentucky Medical Center, Lexington, Kentucky

ABSTRACT

Percutaneous radiofrequency rhizotomy was performed on 7 patients with a hyperreflexic bladder to augment bladder capacity and to make intermittent clean catheterization more feasible or stop precipitous micturition. Urodynamic evaluations were done before and after rhizotomy. A successful result was achieved in 6 patients. Patient selection and methodology are discussed and some of the previously reported series ofrhizotomies are compared to the present study. The hyperreflexic bladder accompanying certain chronic neurologic lesions is characterized by a relatively small capacity with involuntary passage of small volumes of urine at frequent intervals. In men an external catheter may be applied to the penis to prevent soilage of clothes or bed linen or an indwelling urethral catheter or suprapubic tube may be used. In women there is presently no satisfactory external appliance for the collection of urine and an indwelling urethral catheter is used most often. All of these methods are frought with complications, including penile erosion, urinary infection, stone formation, periurethral abscess and urethrocutaneous fistula. In addition, these external tubes and appliances may add a severe psychologic handicap and inconvenience to a person with limited physical capabilities. Intermittent clean catheterization is a successful method to drain a bladder that does not empty spontaneously and has the capacity to store at least a modest volume of urine.' The patient catheterizes himself at 4-hour intervals to prevent leakage of urine between catheterizations. To all external appearances the patient has nothing wrong with the urinary tract. Interruption of sacral nerve roots may result in less bladder irritability and enable the viscus to hold more urine before emptying. In this more areflexic state intermittent clean catheterization may be feasible. METHODS

Patients were selected for evaluation when involuntary precipitous micturition was present. Base line urodynamic evaluations, including the cystometrogram, anal sphincter electromyogram and urethral pressure profile, were obtained. On successive days various combinations of the S2,. S3 and S4 nerve roots were anesthetized, using 1 to 2 cc bupivacaine hydrochloride instilled into the sacral foramen under fluoroscopic control. An hour after the sacral block a repeat urodynamic evaluation was done and the effect on bladder and urethral function was ascertained. In addition, the interval between catheterizations, the volume of urine obtained at each catheterization at approximately 4-hour intervals and the amount of urinary leakage if any between catheterizations were noted by the patient. If the local anesthetic block did not increase significantly the intravesical volume the patients were not considered candidates for rhizotomy and other forms of therapy were used. When the desired bladder capacity was obtained the appropriate anterior and posterior nerve roots were ablated by percutaneous radiofrequency electrocoagulation. 2 A 12 gauge needle with stylet was advanced into the appropriate foramen under fluoroscopic control. The electrode was advanced through the needle to the area of the anterior Accepted for publication March 29, 1978. * Current address: Wishard Memorial Hospital, 1001 West 10th St., Indianapolis, Indiana 46202.

and posterior nerve roots and thermocoagulation at a temperature of greater than 70C was maintained for at least 3 minutes at each location. RESULTS

The results are shown in the table. In no instance was there a change in urethral pressure profile and no incontinence was noted after instillation of the local anesthetic or the rhizotomy. All patients had active anal sphincter contractions after the rhizotomy. One patient, an ambitious quadriplegic who can easily catheterize himself (B. A.), noted a slight diminution in the intensity ofreflex erections after the rhizotomy. The other male patient in the series (D. R.) had been impotent for 4 years before the block. Despite ablating roots S2, S3 and S4 bilaterally, this patient had minimal change in bladder capacity, although with the bupivacaine hydrochloride block the intravesical volume doubled. In 5 patients bladder capacity was increased to a volume at which intermittent catheterization was practical. In patient F.L. urine leaked per urethram despite the presence of a suprapubic tube. Rhizotomy decreased the bladder spasticity to the extent that leakage no longer occurs. DISCUSSION

Despite progress made in recent years in the treatment of neurogenic bladders renal failure remains the leading cause of death in these patients. Attempts to decrease intravesical pressure and to provide better bladder emptying by rhizotomy did not become popular until after World War 2. Munro noted occasional improvement in bladder function after anterior rhizotomy. 3 Heimburger and associates determined cystometrographic improvement in bladder capacity after injection of procaine hydrochloride into the sacral foramina in 12 patients and found this useful in determining which roots would be appropriate for anterior rhizotomy. 4 A similar approach was taken by Meirowsky and associates who used local anesthetic block of the sacral nerve and determined the improvement in bladder capacity with cystometrographic studies before nerve section via an open surgical procedure. 5 Misak and associates reported their experience with 28 surgical sacral rhizotomies and conectomies and 31 cases of subarachnoid alcohol injection. 6 The rhizotomy group seemed to fare better with an improvement rate in the range of 80 per cent, as compared to about 60 per cent in the alcohol injection group. Various other reports followed these, relating the authors' experience with the effort of sacral rhizotomy on bladder function. 1-1o The results have been variable but no long-term followup has been given for a number of years. In a recent study Rockswold and associates used air cystometry to determine the effect of local sacral nerve block on detrusor hyperreflexia in 50 patients, most of whom had

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Results of percutaneous radiofrequency sacral rhizotomy Pt. -Sex-Age

Disease Process

Vesical Volume Pre-

Nerve Roots Electrocoagulated

omy

Vesical Volume PostRhizotomy

175

350

S2, S3, S4-bilat.

225 80 50 150 70

325 300 200 300 75

25

100

S2, S3- bilat. S4-bilat. S2-lt. S3-bilat. S2, S3, S4-bilat. S2-lt., S3, S4bilat.

Rhizot-

FS- F- 31 SG- FMC-FBA- MLC- FDR- M-

30 26 22 17 22

FL- F- 57

Central nervous systern degenerative disease T12 cord transection T9 cord transection C6 cord transection TlO cord transection Multiple sclerosis Cerebrovascular accident

multiple sclerosis. 11 They found that the detrusor reflex was abolished with unilateral block in more than half of the patients. The same authors performed partial rhizotomy, achieving good results in 3 of 6 patients with multiple sclerosis. 12 By section of only part of the nerve bladder capacity may be increased with preservation of the detrusor reflex and sphincter function. McGuire also noted preservation of urinary continence and an unchanged urethral pressure profile after sacral denervation. 13 Spinal anesthesia altered both of these parameters and the author concluded that thoracolumbar sympathetic outflow maintained vesical neck tone after sacral denervation. In 1975 Toczek and associates concluded that non-selective rhizotomy was not practical. 14 There was too much variability of predominant nerve roots with overlapping of vesical, rectal and perineal innervation. They exposed the sacral roots surgically and noted changes on the cystometrogram on the operating table with stimulation of individual nerves. The bundles were dissected and only those nerves affecting the bladder were sectioned. Five cases were followed carefully and 4 of the 5 regained spasticity within 2 years. The development of alternate reflex pathways was offered as an explanation. A year later Torrens and Griffith reported that 7 of 9 patients with incontinence owing to an uninhibited bladder were cured or improved with selective sacral neurectomy. 15 Selective sacral nerves were blocked with anesthetic followed by routine urodynamic assessment. When the desired augmentation of bladder capacity was achieved the appropriate nerves were exposed extradurally by a limited sacral laminectomy and sectioned. In most of these reports the largest increases in bladder capacity occurred after bilateral sacral root section, usually S3. Loss of potency was variable and the use oflocal anesthetic before permanent section of the nerves would determine whether erections would still be possible. In some series return of spasticity seemed to occur, usually within 2 years of the nerve section. Either regrowth of nerve roots or the development of alternative reflex pathways could explain this phenomenon. Followup in our series of percutaneous rhizotomies has been less than 1 year. If time proves that bladder spasticity returns in these patients repeat percutaneous rhizotomy or electrocoagulation of alternative pathways would seem to be as easily performed as the original nerve ablation.

Repeat thermal destruction at the same or at additional sacral levels could be performed. REFERENCES

1. Lapides, J., Diokno, A. C., Gould, F. R. and Lowe, B. S.: Further observations on self-catheterization. J. Urol., 116: 169, 1976. 2. Sweet, W. H. and Wepsic, J. G.: Controlled thermocoagulation oftrigeminal ganglion and rootlets for differential destruction of pain fibers. 1. Trigeminal neuralgia. J. Neurosurg., 39: 143, 1974. 3. Munro, D.: Rehabilitation of patients totally paralyzed below the waist, with special reference to making them ambulatory and capable of earning their living; anterior rhizotomy for spastic paraplegia. New Engl. J. Med., 233: 453, 1945. 4. Heimburger, R. F., Freeman, L. W. and Wilde, N. J.: Sacral nerve innervation of the human bladder. J. Neurosurg., 5: 154, 1948. 5. Meirowsky, A. M., Scheibert, C. D. and Rose, D. K.: Indications for neurosurgical establishment of bladder automaticity in paraplegia. J. Urol., 67: 192, 1952. 6. Misak, S. J., Bunts, R. C., Ulmer, J. L. and Eagles, W. M.: Nerve interruption procedures in the urologic management of paraplegic patients. J. Urol., 88: 392, 1962. 7. Brendler, H., Krueger, E. G., Lerman, P., Harper, J. G. M., Bradley, D., Berman, M. M., Hertzberg, A. D., Lerman, F. and Dean, A. L.: Spinal root section in the treatment of advanced paraplegic bladder. J. Urol., 70: 223, 1953. 8. Hutch, J. A.: The treatment of hydronephrosis by sacral rhizotomy in paraplegics. J. Urol., 77: 123, 1957. 9. Ambrose, S. S. and Swanson, H. S.: The hypertonic neurogenic bladder in children: its sequelae and management. J. Urol., 83: 672, 1960. 10. Manfredi, R. A. and Leal, J. F.: Selective sacral rhizotomy for the spastic bladder syndrome in patients with spinal cord injuries. J. Urol., 100: 17, 1968. 11. Rockswold, G. L., Bradley, W. E. and Chou, S. N.: Effect of sacral nerve block on the function of the urinary bladder in humans. J. Neurosurg., 40: 83, 1974. 12. Rockswold, G. L., Bradley, W. E. and Chou, S. N.: Differential sacral rhizotomy in the treatment of neurogenic bladder dysfunction. Preliminary report of six cases. J. Neurosurg., 38: 748, 1973. 13. McGuire, E. J.: The effects of sacral denervation on bladder and urethral function. Surg., Gynec. & Obst., 144: 343, 1977. 14. Toczek, S. K., McCullough, D. C., Gargour, G. W., Kachman, R., Baker, R. and Luessenhop, A. J.: Selective sacral rootlet rhizotomy for hypertonic neurogenic bladder. J. Neurosurg., 42: 567, 1975. 15. Torrens, M. J. and Griffith, H. B.: Management of the uninhibited bladder by selective sacral neurectomy. J. Neurosurg., 44: 176, 1976. EDITORIAL COMMENT Selective sacral rhizotomy is an effective method to ameliorate involuntary contractions of the bladder that are uncontrollable with drugs. The percutaneous technique seems to be simpler, less stressing and as effective as transection via lumbosacral laminectomy. It is well to remember that most patients with detrusor hyperreflexia can be treated quite nicely with anticholinergic medication. Jack Lapides and Ananias C. Diokno Department of Urology University of Michigan Medical Center Ann Arbor, Michigan