ANTERIOR BLADDER TUBE FOR CONTINENCE IN NEUROGENIC
BLADDER*
Experimental Study HARRY W. SCHOENBERG,
M.D.
MARK P. SCHOENBERG JOHN G. GREGORY, M.D.
From the Section of Urology, Department St. Louis University School of Medicine, St. Louis, Missouri
of Surgery,
ABSTRACT - Experimental studies oksigned to evaluate the anterior bluoYer tube as a method of muintaining continence in the neurologically deprived bluddm achieved a 50 to 60 per cent success rate. This success rate is not sufficient to warrant its clinical use.
Reconstruction or lengthening of the urethra by means of tubes of detrusor muscle has been accomplished by a number of investigators for many years. In 1953 Flocks and Culpl described the use of an anterior bladder tube to reconstruct the urethra after radical retropubic prostatectomy. Lapide? formed the entire urethra out of bladder muscle anda brought this neourethra to the abdominal wall. Leadbetter3 described the use of a posterior bladder tube for construction and elongation of the urethra in vesical extrophy. More recently, Tanagho and Smith4 and co-workers5 used the anterior bladder tube to provide continence in patients whose incontinence was related to surgical procedures on the prostate and urethra, to congenital problems such as epispadias, and in 3 patients with neurogenic bladder of different varieties. Al1 3 patients with neurogenic bladder were failures, whereas there were 7 successes in the remaining 12 patients. Tanagho and associates4 state in this report that they believe neurogenic bladder is a contraindication to the use of this procedure. During the period reports from Tanagho and coworkers were appearing, Lapides and associate+’ were promoting interest in the use of intermittent catheterization and self-catheteriza*Supported in part by United States Public Service, Grant Rol, AM 16312-01.
UROLOGY
/
JUNE 1975
/
Health
VOLUME V, NUMBER 6
tion for the management of bladder failure related to a variety of lesions. Our interest in these two procedures was occasioned by a large number of meningomyelocele patients in whom urinary incontinence was one of the major reasons for supravesical urinary diversion. In seeking alternatives to urinary diversion, we were attracted to the use of intermittent catheterization, but on the other hand, a number of our patients were suflìciently incontinent that even intermittent catheterization would not keep them dry. It was considered worthwhile to try experimentally the use of the anterior bladder tube to maintain continence in the neurogenic bladder so that intermittent catheterization might then become a satisfactory method of bladder emptying. For detrusor muscle to fimction as a competent urethra it was necessary to have sustained tone within this muscle tube over an adequate length. This tube would then provide resistance to flow. There is an extensive neurologie, physiologic, and urologie literature that states that bladder tone is independent of neurologie control or reflex activity.8-14 Many authors, including Denny-Brown, Sabetian, Dees, Nesbit, Tang, and Ross, have done both clinical and laboratory experiments to demonstrate this property of detrusor muscle. Some have stated that atonicity in the neurogenic bladder follows
759
FICURE 1. Anterior bladder tube (A) anastomosed to distal urethra, and (B) brought out to abdominal wall. overdistention and is not related to the neurologie condition. We believed, therefore, that a group of experiments could be structured that would determine whether or not tone in the neurologically deprived detrusor would be adequate to maintain continence when a bladder tube of this muscle was constructed. Material and Methods Three groups of female, mongrel dogs were used in this experiment. In the first group of 7 animals, an anterior bladder tube 3 cm. in length was constructed. The diameter of the tube was sufficient to accommodate a 12 F plastic catheter. The tube was formed around the catheter using chromic catgut, and the bladder was closed with chromic catgut. The proximal 1.5 cm. of urethra beginning at the bladder neck was excised and the bladder tube anastomosed to the distal urethra by interrupted sutures of fine chromic catcatheter was gut (Fig. 1A). A n indwelling sutured in place and cut off flush with the urethral meatus in the perineum so that it could not be removed by the animal. This catheter was left in place for a period of ten days to two weeks. At the time of surgery, the large ganglia lying on the rectal wal1 with branches extending onto the bladder were removed bilaterally, and the nerve tissue found crossing the ureterovesical junction was also divided. A personal communication from Bradley l5 states that we might expect this type of nerve section to produce an autonomous bladder. At the end of two weeks, the catheter was removed, replaced with a Foley catheter, and cystometric studies were carried out as wel1 as multiple observations for 760
continence in association with intermittent catheterization. The second group of 8 animals was treated in identical fàshion, except that the bladder tube was brought out onto the anterior abdominal wal1 rather than heing anastomosed to the urethra (Fig. 1B). This had the advantage of allowing US to be certain that there was no urethral element in whatever continence might persist; its disadvantage was that tone in the abdominal muscles might contribute to continence. A third group of 4 animals served as a control for the nerve section. These animals underwent nerve section without constructing the bladder tube. Following this procedure al1 voided or dribbled smal1 amounts of urine frequently or continuously with residual urine of at least 75 cc. Cystometric evaluation suggested an autonomous neurogenic bladder. Results One animal from each experimental group died from urinary extravasation and sepsis. Cystometric studies of the remaining animals while awake and anesthetized had the characteristic curves of an autonomous bladder (Fig. 2). Two of the remaining 6 animals from group 1 and 3 of the remaining 7 animals from group 11 were incontinent to the extent that they held less than 20 cc. of urine in the bladder (Table 1). The remaining animals in both groups were al1able to remain continent with intravesical volumes of not less than 75 cc. When their critical volume TABLE 1. Volume at which animal
remuins continent
Animal
Volume
(Cubic Centimeters)
GROWP1 1 2 3
125* 1W 5 100 w 20
5 6 GROUP 11 1 2 3 4 5 6 7
12w 130 15 150* 75 10 10
* Subsequent spinal cord section.
UROLOGY
/ JUNE1975 / VOLUMEV,
NUMBERG
50 45 40 35 30 25 20 15
FIGURE2. Cysmelrogmm lowing (A) neme section,
10
fol-
(B) construction of anterior bladder tube anastomosed to urethra1 tube plus nerve section, (C) brought to abdominal wall plus nerve section, and (D) anBstomosed to urethra1 tube plus spinal cord sectin.
5
0
50 100 150 200 250 300
was reached, about half of them began to dribble continuously while some squatted and voided smal1 amounts. Of the animals that voided, none had a residual urine of less than 50 cc. Half of the animals in each group were subjected to postoperative excretory urography, and no upper urinary changes were noted during the course of the experiment. Five animals considered to have successful results, 3 fkom group 1 and 2 from group 11, were subjected to spinal cord transection at the lumbar level. Following cord transection there was no change in the degree of continence. Comment Tanagho reported an almost 100 per cent success rate using intact animals as opposed to those having neurogenic bladders. Our success rate was significantly diminished in neurogenic bladders. The fact that a reasonable percentage of our animals achieved continence tends to substantiate the presence of tone in the detrusor muscle that has had interference with its innervation.
UROLOCY / JUNE 1975 / VOLUME V, NUMBER 6
At this time we would have to agree with Tanagho that there is no clinical applicability for this procedure in neurogenic bladder and incontinence, particularly since the mechanica1 sphincter of Bradley and Scott appears to be achieving a reasonably high success rate. 1325
South Grand Boulevard St. Louis, Missouri 63104 (DR. SCHOENBERG)
References 1. FLOCKS, Ft. H., and CULP, D. A.: Modification of technique for anastomosing membranous urethra and bladder neck following total prostatectomy, J. Urol. 69: 411(1953). 2. LAPIDES, J. : The abdominal neourethra, ibid. 95:
350 (1966).
3. LEADBE’ITw, G. W., JR.: Surgical correction of total urinary incontinence, ibtd. 91: 261(1964). 4. TANACHO, E. A., and S~TH, D. R.: Chnical evaluation of a surgical technique for tbe correction of complete urinary incontinence, &d. 197: 409 (1972). 5. TANAGHO, E. A., S~TH, D. Ft., MEYERS, F. H., and FISHER, R.: Mechanisms of urinary continence. 11.
761
6.
7.
8.
9. 10.
762
Technique for surgical correction of incontinence, ibid. 101:305 (1969). LAPIDES, J., DIOKNO, A., SILBER, S. J., and LOWE, B. S.: Clean, intermittent self-catheterixation in the treatment of urinary tract disease, ibid. 107:458(1972). LAPIDES, J., DIOKNO, A. C., LOWE, B. S., and KALISH, M.D.: Follow-up on unsterile, intermittent self-catheterization, ibid. 111: 184(1974). DENNY-BROWN, D., and ROBERTSON, E. C.: On the physiology of micturition, Brain 56: 149 (1933). SABETIAN, M.: The genesis of bladder tone, Br. J. Urol. 37: 424 (1965). DEES, J. E., and LANGWORTHY, 0. R.: Experimental study of bladder disturbances analogous to those of tabes dorsalis, J. Urol. 34: 359 (1935).
11. NESBIT, R. M., and LAPIDES, J.:
Tonus of the bladder during spinal “shock,” Arch. Surg. 56: 138 (1948). 12. TANG, P. C., and RUCH, T. C.: Non-neurogenic basis of bladder tonus, Am. J. Physiol. 191: 248 (1955). 13. Ross, J. C.: Treatment of the bladder in paraplegia, Br. J. Urol. 28: 14 (1956). 14. BORS, E., COMARFI, A. E., and MOULTON, S. H.: ‘I’he role of nerve blocks in management of traumatic cord bladders: spinal anesthesia, subarachnoid alcohol injections, pudendal nerve anesthesia and vesical neck anesthesia, J. Urol. 63: 853 (1950). 15. BRADLEY,W. F.: Personal communication, 1974.
UROLGGY / JUNE 1975 / VOLUME V, NUMBER 6
BLADDER*
Experimental Study HARRY W. SCHOENBERG,
M.D.
MARK P. SCHOENBERG JOHN G. GREGORY, M.D.
From the Section of Urology, Department St. Louis University School of Medicine, St. Louis, Missouri
of Surgery,
ABSTRACT - Experimental studies oksigned to evaluate the anterior bluoYer tube as a method of muintaining continence in the neurologically deprived bluddm achieved a 50 to 60 per cent success rate. This success rate is not sufficient to warrant its clinical use.
Reconstruction or lengthening of the urethra by means of tubes of detrusor muscle has been accomplished by a number of investigators for many years. In 1953 Flocks and Culpl described the use of an anterior bladder tube to reconstruct the urethra after radical retropubic prostatectomy. Lapide? formed the entire urethra out of bladder muscle anda brought this neourethra to the abdominal wall. Leadbetter3 described the use of a posterior bladder tube for construction and elongation of the urethra in vesical extrophy. More recently, Tanagho and Smith4 and co-workers5 used the anterior bladder tube to provide continence in patients whose incontinence was related to surgical procedures on the prostate and urethra, to congenital problems such as epispadias, and in 3 patients with neurogenic bladder of different varieties. Al1 3 patients with neurogenic bladder were failures, whereas there were 7 successes in the remaining 12 patients. Tanagho and associates4 state in this report that they believe neurogenic bladder is a contraindication to the use of this procedure. During the period reports from Tanagho and coworkers were appearing, Lapides and associate+’ were promoting interest in the use of intermittent catheterization and self-catheteriza*Supported in part by United States Public Service, Grant Rol, AM 16312-01.
UROLOGY
/
JUNE 1975
/
Health
VOLUME V, NUMBER 6
tion for the management of bladder failure related to a variety of lesions. Our interest in these two procedures was occasioned by a large number of meningomyelocele patients in whom urinary incontinence was one of the major reasons for supravesical urinary diversion. In seeking alternatives to urinary diversion, we were attracted to the use of intermittent catheterization, but on the other hand, a number of our patients were suflìciently incontinent that even intermittent catheterization would not keep them dry. It was considered worthwhile to try experimentally the use of the anterior bladder tube to maintain continence in the neurogenic bladder so that intermittent catheterization might then become a satisfactory method of bladder emptying. For detrusor muscle to fimction as a competent urethra it was necessary to have sustained tone within this muscle tube over an adequate length. This tube would then provide resistance to flow. There is an extensive neurologie, physiologic, and urologie literature that states that bladder tone is independent of neurologie control or reflex activity.8-14 Many authors, including Denny-Brown, Sabetian, Dees, Nesbit, Tang, and Ross, have done both clinical and laboratory experiments to demonstrate this property of detrusor muscle. Some have stated that atonicity in the neurogenic bladder follows
759
FICURE 1. Anterior bladder tube (A) anastomosed to distal urethra, and (B) brought out to abdominal wall. overdistention and is not related to the neurologie condition. We believed, therefore, that a group of experiments could be structured that would determine whether or not tone in the neurologically deprived detrusor would be adequate to maintain continence when a bladder tube of this muscle was constructed. Material and Methods Three groups of female, mongrel dogs were used in this experiment. In the first group of 7 animals, an anterior bladder tube 3 cm. in length was constructed. The diameter of the tube was sufficient to accommodate a 12 F plastic catheter. The tube was formed around the catheter using chromic catgut, and the bladder was closed with chromic catgut. The proximal 1.5 cm. of urethra beginning at the bladder neck was excised and the bladder tube anastomosed to the distal urethra by interrupted sutures of fine chromic catcatheter was gut (Fig. 1A). A n indwelling sutured in place and cut off flush with the urethral meatus in the perineum so that it could not be removed by the animal. This catheter was left in place for a period of ten days to two weeks. At the time of surgery, the large ganglia lying on the rectal wal1 with branches extending onto the bladder were removed bilaterally, and the nerve tissue found crossing the ureterovesical junction was also divided. A personal communication from Bradley l5 states that we might expect this type of nerve section to produce an autonomous bladder. At the end of two weeks, the catheter was removed, replaced with a Foley catheter, and cystometric studies were carried out as wel1 as multiple observations for 760
continence in association with intermittent catheterization. The second group of 8 animals was treated in identical fàshion, except that the bladder tube was brought out onto the anterior abdominal wal1 rather than heing anastomosed to the urethra (Fig. 1B). This had the advantage of allowing US to be certain that there was no urethral element in whatever continence might persist; its disadvantage was that tone in the abdominal muscles might contribute to continence. A third group of 4 animals served as a control for the nerve section. These animals underwent nerve section without constructing the bladder tube. Following this procedure al1 voided or dribbled smal1 amounts of urine frequently or continuously with residual urine of at least 75 cc. Cystometric evaluation suggested an autonomous neurogenic bladder. Results One animal from each experimental group died from urinary extravasation and sepsis. Cystometric studies of the remaining animals while awake and anesthetized had the characteristic curves of an autonomous bladder (Fig. 2). Two of the remaining 6 animals from group 1 and 3 of the remaining 7 animals from group 11 were incontinent to the extent that they held less than 20 cc. of urine in the bladder (Table 1). The remaining animals in both groups were al1able to remain continent with intravesical volumes of not less than 75 cc. When their critical volume TABLE 1. Volume at which animal
remuins continent
Animal
Volume
(Cubic Centimeters)
GROWP1 1 2 3
125* 1W 5 100 w 20
5 6 GROUP 11 1 2 3 4 5 6 7
12w 130 15 150* 75 10 10
* Subsequent spinal cord section.
UROLOGY
/ JUNE1975 / VOLUMEV,
NUMBERG
50 45 40 35 30 25 20 15
FIGURE2. Cysmelrogmm lowing (A) neme section,
10
fol-
(B) construction of anterior bladder tube anastomosed to urethra1 tube plus nerve section, (C) brought to abdominal wall plus nerve section, and (D) anBstomosed to urethra1 tube plus spinal cord sectin.
5
0
50 100 150 200 250 300
was reached, about half of them began to dribble continuously while some squatted and voided smal1 amounts. Of the animals that voided, none had a residual urine of less than 50 cc. Half of the animals in each group were subjected to postoperative excretory urography, and no upper urinary changes were noted during the course of the experiment. Five animals considered to have successful results, 3 fkom group 1 and 2 from group 11, were subjected to spinal cord transection at the lumbar level. Following cord transection there was no change in the degree of continence. Comment Tanagho reported an almost 100 per cent success rate using intact animals as opposed to those having neurogenic bladders. Our success rate was significantly diminished in neurogenic bladders. The fact that a reasonable percentage of our animals achieved continence tends to substantiate the presence of tone in the detrusor muscle that has had interference with its innervation.
UROLOCY / JUNE 1975 / VOLUME V, NUMBER 6
At this time we would have to agree with Tanagho that there is no clinical applicability for this procedure in neurogenic bladder and incontinence, particularly since the mechanica1 sphincter of Bradley and Scott appears to be achieving a reasonably high success rate. 1325
South Grand Boulevard St. Louis, Missouri 63104 (DR. SCHOENBERG)
References 1. FLOCKS, Ft. H., and CULP, D. A.: Modification of technique for anastomosing membranous urethra and bladder neck following total prostatectomy, J. Urol. 69: 411(1953). 2. LAPIDES, J. : The abdominal neourethra, ibid. 95:
350 (1966).
3. LEADBE’ITw, G. W., JR.: Surgical correction of total urinary incontinence, ibtd. 91: 261(1964). 4. TANACHO, E. A., and S~TH, D. R.: Chnical evaluation of a surgical technique for tbe correction of complete urinary incontinence, &d. 197: 409 (1972). 5. TANAGHO, E. A., S~TH, D. Ft., MEYERS, F. H., and FISHER, R.: Mechanisms of urinary continence. 11.
761
6.
7.
8.
9. 10.
762
Technique for surgical correction of incontinence, ibid. 101:305 (1969). LAPIDES, J., DIOKNO, A., SILBER, S. J., and LOWE, B. S.: Clean, intermittent self-catheterixation in the treatment of urinary tract disease, ibid. 107:458(1972). LAPIDES, J., DIOKNO, A. C., LOWE, B. S., and KALISH, M.D.: Follow-up on unsterile, intermittent self-catheterization, ibid. 111: 184(1974). DENNY-BROWN, D., and ROBERTSON, E. C.: On the physiology of micturition, Brain 56: 149 (1933). SABETIAN, M.: The genesis of bladder tone, Br. J. Urol. 37: 424 (1965). DEES, J. E., and LANGWORTHY, 0. R.: Experimental study of bladder disturbances analogous to those of tabes dorsalis, J. Urol. 34: 359 (1935).
11. NESBIT, R. M., and LAPIDES, J.:
Tonus of the bladder during spinal “shock,” Arch. Surg. 56: 138 (1948). 12. TANG, P. C., and RUCH, T. C.: Non-neurogenic basis of bladder tonus, Am. J. Physiol. 191: 248 (1955). 13. Ross, J. C.: Treatment of the bladder in paraplegia, Br. J. Urol. 28: 14 (1956). 14. BORS, E., COMARFI, A. E., and MOULTON, S. H.: ‘I’he role of nerve blocks in management of traumatic cord bladders: spinal anesthesia, subarachnoid alcohol injections, pudendal nerve anesthesia and vesical neck anesthesia, J. Urol. 63: 853 (1950). 15. BRADLEY,W. F.: Personal communication, 1974.
UROLGGY / JUNE 1975 / VOLUME V, NUMBER 6
