- Email: [email protected]
Production of a Collateral Blood Supply to the Urinary Bladder
THE JOURNAL OF UROLOGY
Vol. 83, No. 3, March 1960 Printed in U.S.A.
PRODUCTION OF A COLLATERAL BLOOD SUPPLY TO THE URINARY BLADDER HERBERT L. WARRES From the Thompson-Brumm-Knepper Clinic, St. Joseph, Mo.
It was previously ascertained that following ileo- and colocystoplasty the lymphatic flow from the urinary bladder followed not only the original lymphatic channels of the bladder but also those of new pathways brought by the graft. 1 Ileocystoplasty was more effective in this respect than colocystoplasty. It was decided to learn if there would be a difference between these two procedures in producing a collateral blood supply to the urinary bladder. METHODS AND RESULTS
In 11 dogs the blood supply to the urinary bladder was clamped, cut and ligated leaving the bladder attached by the ureters and urethra stripped of adventitia. Eight were females, three males. In the male animals the blood supply to the prostate was also interrupted. Seven dogs died of gangrene of the bladder in two to seven days. All of the four surviving animals were found to have undergone spontaneous omentopexy. In one of these, 7 days after the initial procedure, the wound was reopened. The bladder appeared viable. Brisk bleeding occurred in trying to separate the adherent omentum from the bladder. The omentum was clamped, cut and ligated. The animal expired 2 days later of a gangrenous bladder. The remaining 3 animals were sacrificed at 5, 8, and 48 day intervals. Collateral blood supply could be found from the omentum to the bladder both by gross anatomical and microscopic inspection. In one animal, there was also marked adherence of the bladder to the anterior abdominal wall. In a second group of 7 dogs the blood supply to the urinary bladder was interrupted as above. The bladder was then briskly rubbed with a gauze sponge and the omentum sutured to the back, sides, and front of the bladder almost completely investing it. Two of these animals died Accepted for publication September 4, 1959. This investigation was aided by a grant from the F. G. Thompson, Sr. Research Foundation. 1 Warres, H. L.: Lymphatic flow following ileo-neo-cystotomy and colo-neo-cystotomy. J. Urol., 83: 286, 1960.
in four and seven days from gangrene of the bladder. The remainder were sacrificed in three to nine weeks. All had good collateral circulation by both gross anatomical inspection and microscopic examination. In one dog, the same procedure was carried out omitting rubbing the bladder with a gauze sponge. This animal expired in 3 days of gangrene of the bladder. There was a purulent exudate between the bladder and omentum with no apparent organization. In a group of 6 dogs, the blood supply to the bladder was interrupted as outlined above. Ileocystoplasty was then done, isolating a segment of ileum two to three inches in length, opening it at its antimesenteric border, and suturing it to the urinary bladder which had been opened by a two to three inch transverse incision in its dome. One dog expired on the third postoperative day of pneumonia. The bladder with its ileal segment appeared viable. Microscopically, it showed acute inflammation but no more at the anastomotic line than would be expected on the third postoperative day. Two dogs died on the fifth and seventh postoperative day of gangrene of the bladder. The remaining animals were sacrificed in one to two months. Microscopically a good anastomotic capillary network was present. One dog showed an area of ossification at the anastomotic line. In a fourth group of 5 dogs, the blood supply to the bladder was interrupted and colocystoplasty done in a fashion similar to that as outlined for ileocystoplasty above. All of these dogs expired in two to five days of gangrene of the bladder. In one dog, the blood supply to the bladder was interrupted and colocystoplasty done. The omentum was then sutured over the anastomotic line. This animal survived and was sacrificed after three weeks. Good collateral blood supply was present, but the bladder was filled with inspissated mucus. In one dog, ileocyatoplasty was done to the normal bladder. Four months later the blood supply to the urinary bladder was clamped, cut,
290
LYMPI-L\TIC FLOW
Pm. 1. Xine weelrn after oment.opcxy and int.errnption of blood supply to bladder.,{, X78. There good anastomotic network between omentnm and bladder wall B, X330. Capillaric,s forming coliater:il circulation are shown.
Fm. 2. Eight weeks after ileoc)·stoplasty and interruption of blood supply to bladder. There is goud anastomotic snbmucosal cnpillary network. Xi8.
ancl tiecl ,1·it.hout interrupting the blood suppl_,.
from tlw ilea! segment. This clog ma
The clen,Jopnwnt of a collatrml circulation usually means the clilata tion and increased
physiological function of collateral bloocl ,-1,.ssds normally present. 2 • 3 l;nckr tlw crmditions of our experiment, the only remaining blood to the urinary bladder ,nts through the nrnscu lari~ 2 Nash, .J.: Snrgical Physiolog_1·. Springfield Ill.: Charles C Thomas, 1950, pp. 405-407 3 vVinblad, J. N., H.eemtsma., IC, Vernlwl,, J. L., La.ville, L. P. and Creech, 0., Jr.: l1;tio logical mechanisms in the development of col lateral circulation. Surgery, 45: 105, Hl5\J.
292
H. L. WARRES
Fm. 3. Two days after colocystoplasty and interruption of blood supply to bladder. Infarction of bladder involves anastomotic line with colon. X78.
Fm. 4. Eight weeks after ileocystoplasty and interruption of blood supply to bladder. A, X21. Good capillary collateral circulation is present. Area of ossification is seen at suture line. B, X78. Shows bone is present in involved area. and submucosa of the ureters and urethra, was minimal in degree, and was constant for all the various groups and procedures. The efficacy of the addition of a new blood supply is dependent upon the caliber and number of new blood vessels brought to the site, neurogenic and humoral factors, the distance from the
heart, and the tissues involved. 4- 6 The more complex and differentiated the tissue, the less readily 4 Quiring, D. P.: Collateral Circulation. Philadelphia: Lea & Febiger, 1949, pp. 23-38. 5 Edwards, E. A.: The anatomy of collateral circulation. Surg., Gynec. & Obst., 107: 183, 1958. 6 Rosenberg, M. Z. and Liebow, A. A.: Effects of age, growth hormone, cortisone, and other
LYMPHATIC FLOW
it will tolerate acute occlusion of the blood supply. The presPncc of infection or potentially pathogenic organisms will adversely affect the production of a collateral blood supply The colon having a lesser blood supply, being farther from the heart, a complex, highly differentiated t~'PG of tissue, and containing numerous bacteria, consistently gave poor results. The omentum, while having no large blood vcss0ls, has many small mws. It, is an uncomplicated form of tissu<' readily becoming adherent to and forming a capillary network with other tissues. Omentopexy was facilitated by our animals having little fat in the omentum, and because the urinary bladder is an intraperitoneal organ in dogs, enabling us to almost completely cover the blaclrkr with omentum. \Ve believe that the good results of ileocystoplasty and the other uses made of ileum for urological purposes are only partially due to the mechanical enlargement of the bladder or as a conduit for urine. In large measure, it is also clue to the increased vascularity afforded by this organ. 7 It lwhooves us to consider the use of this procedure earlier, before irrevcrnible fibrosis has taken place. Our preliminary studies in experimental interntitial cystitis indicate that treatnwnt wch as lavage with increasing strengths of sih-er nitrate 01· chlorpactin solution, overdistension of the bladder, and wry light electrofactors on collateral circulation. A. JVI. A. Arch. Path., 57: 80, 1954. 7 Prrn,t. F. W. and Campbell, R. B.: Viable intestinal segments for plastic repair of the urinary bladder. Harper Hosp. Bull., 12: 160, 1954.
coagulation produce their beneficial results part, by c:ausing hyperemia of the musrnlttri:o layer of the bladder. The use of ilrnm, through vascularity and re-absorptive abilities. :il,;o creates new problems, limiting the length of ileum utilizable and opening potential for the spread of disease and malignancy, Fatty connective tissue about the site of ao extensive ureterotomy incision permit~ more normal healing. 8 • 9 -Use of omentopexy as a snp plement to uretera1 repair, nreteroncocystostomy and possibly in other t:vpr:s of bladder surgcr,: should be considered. YVe wish to acknowledge our indebtedness Dr. Richard V. Riddell, pathologi,t, for assistance in preparing and interpreting the microscopic: sections and photomicrogrnphs 1-4). SUMMARY AND CONCLUSIOK
l'Vhen the blood supply to the urinary bladdc:r was interrupted, most dogs expired of gangn·rn: of the bladder. Those that survived had under, gone spontaneous omcntopcxy. When om,·n· topexy was done at the time of ligation of the blood supply to the bladder, gangrene was pre vented in most animals. Ileocystoplast? afao prevented gangrern\ under similar conditioHs. Colocystoplasty did not prevent massive tnfare tion of the bladder. 8 Lapiues, J. and Caffery, E. L.: Observa1.ionY on healing of ureteral muscle: tc,. intubated urcterotomy. J. Urol., 73: 47, 9 Hinman, F., Jr. and Oppenheimer, R. Ureternl regeneration IV. Fascia[ pared with fatt:v connective tissue ..J 720, 1956.
Vol. 83, No. 3, March 1960 Printed in U.S.A.
PRODUCTION OF A COLLATERAL BLOOD SUPPLY TO THE URINARY BLADDER HERBERT L. WARRES From the Thompson-Brumm-Knepper Clinic, St. Joseph, Mo.
It was previously ascertained that following ileo- and colocystoplasty the lymphatic flow from the urinary bladder followed not only the original lymphatic channels of the bladder but also those of new pathways brought by the graft. 1 Ileocystoplasty was more effective in this respect than colocystoplasty. It was decided to learn if there would be a difference between these two procedures in producing a collateral blood supply to the urinary bladder. METHODS AND RESULTS
In 11 dogs the blood supply to the urinary bladder was clamped, cut and ligated leaving the bladder attached by the ureters and urethra stripped of adventitia. Eight were females, three males. In the male animals the blood supply to the prostate was also interrupted. Seven dogs died of gangrene of the bladder in two to seven days. All of the four surviving animals were found to have undergone spontaneous omentopexy. In one of these, 7 days after the initial procedure, the wound was reopened. The bladder appeared viable. Brisk bleeding occurred in trying to separate the adherent omentum from the bladder. The omentum was clamped, cut and ligated. The animal expired 2 days later of a gangrenous bladder. The remaining 3 animals were sacrificed at 5, 8, and 48 day intervals. Collateral blood supply could be found from the omentum to the bladder both by gross anatomical and microscopic inspection. In one animal, there was also marked adherence of the bladder to the anterior abdominal wall. In a second group of 7 dogs the blood supply to the urinary bladder was interrupted as above. The bladder was then briskly rubbed with a gauze sponge and the omentum sutured to the back, sides, and front of the bladder almost completely investing it. Two of these animals died Accepted for publication September 4, 1959. This investigation was aided by a grant from the F. G. Thompson, Sr. Research Foundation. 1 Warres, H. L.: Lymphatic flow following ileo-neo-cystotomy and colo-neo-cystotomy. J. Urol., 83: 286, 1960.
in four and seven days from gangrene of the bladder. The remainder were sacrificed in three to nine weeks. All had good collateral circulation by both gross anatomical inspection and microscopic examination. In one dog, the same procedure was carried out omitting rubbing the bladder with a gauze sponge. This animal expired in 3 days of gangrene of the bladder. There was a purulent exudate between the bladder and omentum with no apparent organization. In a group of 6 dogs, the blood supply to the bladder was interrupted as outlined above. Ileocystoplasty was then done, isolating a segment of ileum two to three inches in length, opening it at its antimesenteric border, and suturing it to the urinary bladder which had been opened by a two to three inch transverse incision in its dome. One dog expired on the third postoperative day of pneumonia. The bladder with its ileal segment appeared viable. Microscopically, it showed acute inflammation but no more at the anastomotic line than would be expected on the third postoperative day. Two dogs died on the fifth and seventh postoperative day of gangrene of the bladder. The remaining animals were sacrificed in one to two months. Microscopically a good anastomotic capillary network was present. One dog showed an area of ossification at the anastomotic line. In a fourth group of 5 dogs, the blood supply to the bladder was interrupted and colocystoplasty done in a fashion similar to that as outlined for ileocystoplasty above. All of these dogs expired in two to five days of gangrene of the bladder. In one dog, the blood supply to the bladder was interrupted and colocystoplasty done. The omentum was then sutured over the anastomotic line. This animal survived and was sacrificed after three weeks. Good collateral blood supply was present, but the bladder was filled with inspissated mucus. In one dog, ileocyatoplasty was done to the normal bladder. Four months later the blood supply to the urinary bladder was clamped, cut,
290
LYMPI-L\TIC FLOW
Pm. 1. Xine weelrn after oment.opcxy and int.errnption of blood supply to bladder.,{, X78. There good anastomotic network between omentnm and bladder wall B, X330. Capillaric,s forming coliater:il circulation are shown.
Fm. 2. Eight weeks after ileoc)·stoplasty and interruption of blood supply to bladder. There is goud anastomotic snbmucosal cnpillary network. Xi8.
ancl tiecl ,1·it.hout interrupting the blood suppl_,.
from tlw ilea! segment. This clog ma
The clen,Jopnwnt of a collatrml circulation usually means the clilata tion and increased
physiological function of collateral bloocl ,-1,.ssds normally present. 2 • 3 l;nckr tlw crmditions of our experiment, the only remaining blood to the urinary bladder ,nts through the nrnscu lari~ 2 Nash, .J.: Snrgical Physiolog_1·. Springfield Ill.: Charles C Thomas, 1950, pp. 405-407 3 vVinblad, J. N., H.eemtsma., IC, Vernlwl,, J. L., La.ville, L. P. and Creech, 0., Jr.: l1;tio logical mechanisms in the development of col lateral circulation. Surgery, 45: 105, Hl5\J.
292
H. L. WARRES
Fm. 3. Two days after colocystoplasty and interruption of blood supply to bladder. Infarction of bladder involves anastomotic line with colon. X78.
Fm. 4. Eight weeks after ileocystoplasty and interruption of blood supply to bladder. A, X21. Good capillary collateral circulation is present. Area of ossification is seen at suture line. B, X78. Shows bone is present in involved area. and submucosa of the ureters and urethra, was minimal in degree, and was constant for all the various groups and procedures. The efficacy of the addition of a new blood supply is dependent upon the caliber and number of new blood vessels brought to the site, neurogenic and humoral factors, the distance from the
heart, and the tissues involved. 4- 6 The more complex and differentiated the tissue, the less readily 4 Quiring, D. P.: Collateral Circulation. Philadelphia: Lea & Febiger, 1949, pp. 23-38. 5 Edwards, E. A.: The anatomy of collateral circulation. Surg., Gynec. & Obst., 107: 183, 1958. 6 Rosenberg, M. Z. and Liebow, A. A.: Effects of age, growth hormone, cortisone, and other
LYMPHATIC FLOW
it will tolerate acute occlusion of the blood supply. The presPncc of infection or potentially pathogenic organisms will adversely affect the production of a collateral blood supply The colon having a lesser blood supply, being farther from the heart, a complex, highly differentiated t~'PG of tissue, and containing numerous bacteria, consistently gave poor results. The omentum, while having no large blood vcss0ls, has many small mws. It, is an uncomplicated form of tissu<' readily becoming adherent to and forming a capillary network with other tissues. Omentopexy was facilitated by our animals having little fat in the omentum, and because the urinary bladder is an intraperitoneal organ in dogs, enabling us to almost completely cover the blaclrkr with omentum. \Ve believe that the good results of ileocystoplasty and the other uses made of ileum for urological purposes are only partially due to the mechanical enlargement of the bladder or as a conduit for urine. In large measure, it is also clue to the increased vascularity afforded by this organ. 7 It lwhooves us to consider the use of this procedure earlier, before irrevcrnible fibrosis has taken place. Our preliminary studies in experimental interntitial cystitis indicate that treatnwnt wch as lavage with increasing strengths of sih-er nitrate 01· chlorpactin solution, overdistension of the bladder, and wry light electrofactors on collateral circulation. A. JVI. A. Arch. Path., 57: 80, 1954. 7 Prrn,t. F. W. and Campbell, R. B.: Viable intestinal segments for plastic repair of the urinary bladder. Harper Hosp. Bull., 12: 160, 1954.
coagulation produce their beneficial results part, by c:ausing hyperemia of the musrnlttri:o layer of the bladder. The use of ilrnm, through vascularity and re-absorptive abilities. :il,;o creates new problems, limiting the length of ileum utilizable and opening potential for the spread of disease and malignancy, Fatty connective tissue about the site of ao extensive ureterotomy incision permit~ more normal healing. 8 • 9 -Use of omentopexy as a snp plement to uretera1 repair, nreteroncocystostomy and possibly in other t:vpr:s of bladder surgcr,: should be considered. YVe wish to acknowledge our indebtedness Dr. Richard V. Riddell, pathologi,t, for assistance in preparing and interpreting the microscopic: sections and photomicrogrnphs 1-4). SUMMARY AND CONCLUSIOK
l'Vhen the blood supply to the urinary bladdc:r was interrupted, most dogs expired of gangn·rn: of the bladder. Those that survived had under, gone spontaneous omcntopcxy. When om,·n· topexy was done at the time of ligation of the blood supply to the bladder, gangrene was pre vented in most animals. Ileocystoplast? afao prevented gangrern\ under similar conditioHs. Colocystoplasty did not prevent massive tnfare tion of the bladder. 8 Lapiues, J. and Caffery, E. L.: Observa1.ionY on healing of ureteral muscle: tc,. intubated urcterotomy. J. Urol., 73: 47, 9 Hinman, F., Jr. and Oppenheimer, R. Ureternl regeneration IV. Fascia[ pared with fatt:v connective tissue ..J 720, 1956.