British Journal of Urology (1992), 70,382-386 1992 British Journal of Urology
Is There Still a Place for Prolonged Bladder Distension? S. N. LLOYD, S. M. LLOYD, K. ROGERS, R. F. DEANE, D. KIRK and K. F. KYLE Departments of Urology and Anaesthesia, Western Infirmary, Glasgow
Summary-Over a 2-year period, 3 1 patients underwent prolonged hydrostatic bladder distension for benign and malignant bladder disease in this unit. Of these, 2 9 patients had benign functional disorders or bladder contracture, and in 2 patients hydrodistension was performed for complications of treatment for bladder neoplasia. Of the 2 9 patients with benign disease, 6 observed marked improvement and 8 some improvement in their symptoms, and 12 received no benefit. Patients with detrusor hypersensitivity fared better than those with detrusor instability or interstitial cystitis. A patient with malignant bladder disease died soon after the procedure as a result of a myocardial infarction. Problems attributed to the hydrostatic balloon catheter were responsible for 2 failures. The regional anaesthetic technique failed to provide adequate anaesthesia for hydrodistension in 9 procedures and limited the duration to 2 h in 1 3 others. Following recall of the perished balloon catheters by the manufacturer, and the introduction of continuous spinal anaesthesia, the number of technical failures has been reduced. This technique still has an important role to play in the relief of severe symptoms unresponsive to medical treatment, but it is important that ideal conditions are provided for hydrodistension in order to ensure maximum success, particularly when the alternative is major surgery.
The management of patients with symptoms of frequency, urgency and urge incontinence of urine remains a common problem. Therapeutic options include medical management (Abrams, 1988), transvesical injection of phenol (Blackford et al., 1984), presacral selective sacral neurectomy (Lucas et al., 1988), prolonged bladder distension (Dunn et al., 1974), bladder transection (Hindmarsh et al., 1977) and enterocytoplasty (Bramble, 1982). Prolonged bladder distension was first introduced by Helmstein (1972) for the treatment of bladder cancer, and has been subsequently popularised for the management of benign disease with encouraging long-term results (Ramsden et al., 1976). The exact mechanism by which prolonged distension works remains unclear. It has been proposed that the distension may produce ischaemic or physical damage of the mucosa, nervous tissue or detrusor muscle (Dunn et al., 1974). The problems associated with prolonged bladder distension and the outcome of patients treated over Accepted for publication 22 October 1991
a 2-year period are presented. Recently we have been using continuous spinal anaesthesia for these procedures; our experience with the technique is described and discussed. Patients and Methods
During a 2-year period (1989-1990), 31 patients (21 women, 10 men) with a mean age 52 years (range 18-76) were treated by prolonged bladder distension (Table 1). One patient had severe frequency and urgency following instillation of Bacillus CalmetteGutrin (BCG) for carcinoma in situ of the bladder and another had haematuria from widespread superficial bladder carcinoma uncontrolled by endoscopic resection. The remaining 29 patients suffered from benign conditions (15 detrusor hypersensitivity, 6 detrusor instability, 6 interstitial cystitis, 2 iatrogenic disease) associated with severe irritative symptoms (frequency, nocturia, urgency and occasionally urge incontinence), and pain in the patients with interstitial cystitis. Prolonged bladder distension was used after failure of treat-
382
383
ROLE OF PROLONGED BLADDER DISTENSION
ment with anticholinergic drugs or other medical measures. Three patients (2 with detrusor hypersensitivity and 1 with interstitial cystitis) had previously undergone prolonged distension with some benefit. Hydrodistension technique Two patients underwent 2 separate hydrodistensions ; 3 1 anaesthetic procedures were required for 3 1 hydrodistensions. The patients were catheterised with a 12F Foley catheter prior to insertion of a 16F hydrodistension catheter (Rusch UK Ltd). Continuous hydrodistension was planned for approximately 3 h in all patients receiving regional anaesthesia. The volume of saline within the balloon was determined by gravity, but was not allowed to exceed 1 L. The height of the saline was fixed at a level of 1 m above the patient's umbilicus. Initial experience of trying to control the intravesical pressure as described by Ramsden et al. (1976) proved complicated and was abandoned for the above method. Following the period of distension, the balloon was deflated and the hydrodistension catheter replaced with a 16F Foley catheter left on free drainage overnight and removed the following morning. Anaesthetic techniques In all but 1 case a regional anaesthetic technique was attempted primarily (Table 2). In this patient, general anaesthesia had already been administered for the purpose of cystoscopy before the decision was made to perform hydrostatic distension of an hour-glass deformity following previous caecocystoplasty. In 1 patient, 2 epidurals had failed to provide adequate anaesthesia and general anaesthesia was therefore used. The remaining patients received either single dose spinal (15) or epidural anaesthesia (20) via a catheter with either bolus doses or a continuous infusion.
Results The outcome for patients undergoing prolonged bladder distension can be seen in Table 1. In 2 patients the hydrostatic balloon catheter failed to distend and the procedure was abandoned. Three patients had previously undergone prolonged bladder distension; 1 patient with interstitial cystitis received benefit from further distension but the other 2 patients with detrusor hypersensitivity obtained no symptomatic benefit from further bladder distension (1 underwent 2 separate procedures). Another patient with detrusor hypersensitivity underwent 2 separate distensions before symptomatic benefit was achieved. Overall, for those patients with benign disease, 6 (21%) have had marked continued benefit from the treatment, 8 (28%) have experienced some improvement in their symptoms, and 12 (41%) received no benefit from the procedure. A further 2 patients have been lost to follow-up. The patient who had previously received intravesical BCG for carcinoma in situ and subsequently developed severe irritative symptoms, developed haemorrhage around the hydrodistension catheter and the procedure was abandoned. The patient with widespread superficial disease developed acute cardiovascular complications during hydrodistension, culminating in a myocardial infarction from which he died. Subsequent procedures Seven of the 12 patients with benign conditions who failed to benefit from hydrostatic distension have subsequently proceeded to surgery. A further 6 have undergone ileocystoplasty and 1 prostatectomy (destrusor instability was considered secondary to bladder outflow obstruction). Two patients with interstitial cystitis and 1 with post-radiotherapy cystitis have undergone repeat hydrodistension
Table 1 Indications for Prolonged Bladder Distension and the Early Results Response Aetiology (no.ofpatients)
Good
Detrusor hypersensitivity (15) 4 Detrusor instability ( 6 ) Interstitial cystitis ( 6 ) Bladder carcinoma (1) Post-caecocystoplasty (1) Post-BCG (1) Post-DXT (1)
2
Fair
Poor
4 2 1
6 3 2
Procedure abandoned
Lost to follow-up 1 1
Comment 2 patients, 2 distensions
1 1
Balloon failure Myocardial infarction
1 1
Haemorrhage Balloon failure
1
384
BRITISH JOURNAL OF UROLOGY
Table 2 Anaesthetic Techniques
-
Anaesthetic result
-
Anaesthetic technique (no,)
Partial
Failed
Failed distension
Mean distension time (min) *
Complications
Good
Epidural (20)
12
2
4
2
184
Spinal (15) General (2)
13 2
1
1
Dural puncture (1) Hypotension** ( 5 ) Hypotension** (4) None
119 20
(no.)
* Only relates to procedures with good anaesthetic result ** Hypotension requiring treatment with vasopressors
during cystoscopy under general anaesthesia with some benefit. The patient with severe irritative symptoms following BCG therapy has had spontaneous resolution of his symptoms. Discussion Outcome The results of prolonged bladder distension for functional bladder disturbance have to be seen in the context of the alternatives available. Ileocystoplasty is associated with occasional mortality and significant morbidity, e.g. difficulty in emptying the bladder; this may require clean intermittent selfcatheterisation (Bramble, 1990) and there may be an increased risk of malignancy. Many urologists would subject patients with an essentially benign condition to such major surgery only after all alternatives had been exhausted, even if these procedures have a relatively low success rate. Prolonged bladder distension is one of these alternatives; it is simple and associated with a low morbidity rate. Symptomatic relief was achieved in approximately 49% of patients undergoing this procedure in this series. Possible reasons for failure in the remaining 5 1% will be considered separately. Hydrodistension technique The ideal duration of distension and the volume required for each condition and each patient remain uncertain. Initial reports recommended intermittent distension (Dunn et al., 1974) but subsequent series have used continued distension with varying success (Pengelly et al., 1978; Wolk and Bishop, 1981). It has been our intention to use continuous distension for 3 h (provided anaesthesia is adequate), but there is no recognised standard distension time and some have used distension for up to 6 h (Wolk and Bishop, 1981). It is possible that 3 h
are insufficient and some patients may require more than one procedure before benefit is achieved. Case selection Another possible reason for poor response is case selection. From this series it appears that patients with detrusor hypersensitivity and those with interstitial cystitis are more likely to respond than are patients with detrusor instability. There is no way of predicting the likelihood of success in each individual patient and so it is our policy to offer this form of treatment to all patients in whom major surgery is considered. The only fatality in this series was a patient who was regarded as unfit for cystectomy; hydrodistension was considered the only feasible means of controlling the haemorrhage from his widespread superficial disease. Balloon failure It became apparent that technical faults were sometimes responsible for failure of the procedure, as in 2 cases where the hydrodistension catheter burst. Several other catheters were found to have perished. The manufacturer (Rusch UK Ltd) has recalled all hydrodistension catheters, acknowledging a fault in the production which resulted in premature perishing of the balloon. The new catheters have stronger balloons. We used to monitor the intravesical pressure routinely (Ramsden et al., 1976), but found it increasingly difficult to correlate the measured pressure with the distension. Testing the balloons confirmed that considerable pressure was necessary simply to overcome the tension of the balloon wall, and this made it impossible to relate measured pressure to pressure within the active bladder. It may be that we are distending the bladder at too low a pressure for adequate results. The design of the balloons,
385
ROLE OF PROLONGED BLADDER DISTENSION
incorporating a balance between strength and distensibility, could probably be improved. Anaesthetic problems It was apparent that the anaesthetic techniques may have contributed significantly to failure of the procedure, either because of inadequate anaesthesia to permit distension or by limiting distension time. The distension time for both procedures under general anaesthesia was 20 min, with volumes of 220 and 500 ml respectively. Lasting symptomatic benefit from this procedure was experienced by 1 patient. The duration of hydrostatic distension was limited by the onset of pain in all patients who received single dose spinal anaesthesia, with a mean distension time for the 13 successful blocks of 2 h and with a mean distension volume of 592 ml (range 350-800). One spinal anaesthetic gave only a partial block and another failed completely; in both instances anaesthesia was considered inadequate for hydrodistension. Hypotension requiring vasopressor treatment was required for 4 patients during spinal anaesthesia. Epidural anaesthesia was used for 20 procedures and provided adequate anaesthesia for 12, with a mean hydrodistension time of 184 min and a mean distension volume of 562 ml for the successful blocks (range 300-1000). Failure to insert the epidural catheter or asymmetry of anaesthesia prevented adequate bladder distension in 4 patients and limited the duration of distension in 2. Hypotension requiring vasopressor treatment was required for 5 patients during epidural anaesthesia. Continuous spinal anaesthesia Following discussion with our anaesthetic colleagues, it was considered that the anaesthetic requirements for this procedure would be best provided by continuous spinal anaesthesia. This method of regional anaesthesia has received renewed interest following improvements in product development, permitting a microspinal technique (Hurley and Lambert, 1987). Continuous spinal anaesthesia is useful for prolonged procedures, providing a reliable dense symmetrical block and permitting titration of anaesthesia with relatively small doses of local anaesthetic agent, with no increase in complications over single-dose spinal anaesthesia (Denny et al., 1987). To date, 14 patients have undergone prolonged bladder distension under continuous spinal anaesthesia using the 28G CoSpan spinal catheter via a standard 22G spinal needle (The Kendall Company). In each case the technique provided suitable conditions for
3 hours hydrodistension. One patient required treatment with vasopressors for hypotension following the first dose of bupivacaine. One patient developed a mild headache associated with an upper respiratory tract infection following continuous spinal anaesthesia. This was not considered typical of post-dural puncture headache and it settled spontaneously. Another patient received a single dose spinal anaesthetic because introduction of the spinal catheter proved impossible. He subsequently developed a post-dural puncture headache, requiring an epidural blood patch. We advocate prolonged hydrostatic balloon distension of the bladder in all patients where the alternative is major surgery. Even under ideal conditions the procedure will fail to provide symptomatic benefit in some patients. In order to provide optimum conditions for success we recommend continuous spinal anaesthesia. It is too early to assess the clinical outcome of prolonged distension in this group of patients, but initial results look favourable. We also recommend that all old stocks of hydrodistension catheters should be returned to the manufacturers for replacement by new ones free of charge.
Acknowledgements We thank The Kendall Company Ltd for providing the CoSpan continuous spinal catheters for this study.
References Abrams, P. (1988). Drug therapy in the management of detrusor instability. In Update On Drugs and the Lower Urinary Tract, ed. Cardozo, L. Pp. 3-8. London: Royal Society of Medicine Services. Blackford, H. N., Murray, K., Stephenson, T. P. er al. (1984). Results of transvesical infiltration of pelvic plexuses with phenol in 116 patients. Br. J . Urol.,56,647-649. Bramble, F. J. (1982). The treatment of adult enuresis and urge incontinence by enterocystoplasty. Br. J . Urol.,54,693-696. Bramble, F. J. (1990). The clam cystoplasty. Br. J . Urol., 66, 337-341. Denny, N., Masters, R., Pearson, D. et uf. (1987). Postdural puncture headache after continuous spinal anaesthesia. Anesth. Analg., 66, 791-794. Dunn, M., Smith, J. C. and Ardran, G . M. (1974). Prolonged bladder distension as a treatment of urgency and urge incontinence of urine. Br. J . Urol., 46,645-652. Helmstein, K. (1972). Treatment of bladder carcinoma by a hydrostatic pressure technique. Br. J . Urol.,44,434450. Hindmarsb, J. R., Essenhigh, D. M. and Yeates, W. K. (1977). Bladder transection for adult enuresis. Br. J . Urol., 49, 515521. Hurley, R. J. and Lambert, D. (1987). Continuous spinal anaesthesia with a microcatheter techniaue. Rep. Anaesth.. 12,54.
-
386 Lucas, M. G., Thomas, D. G., Clarke, S. et ul. (1988). Long-term follow-up of selective sacral neurectomy. Br. J . Urol., 61, 218220. Pengelly, A. W., Stephenson, T. P., Milroy, E. J. G. et al. (1978). Results of prolonged bladder distension as treatment for detrusor instability. Br. J . Urol.,50, 243-245. Ramsden, P. D., Smith, J. C., Dunn, M. et ul. (1976). Distension therapy for the unstable bladder: later results including an assessment of repeat distensions. Br. J . Urol.,48, 623-629. Wolk, F. N. and Bishop, M. C. (1981). Effectivenessof prolonged hydrostatic dilatation of bladder. Urology, 18, 572-575.
BRITISH JOURNAL OF UROLOGY
The Authors S. N. Lloyd, FRCS, Research Fellow in Urology. S. M. Lloyd, FCAnaes, Registrar in Anaesthesia. K. Rogers, FFARCS, Consultant Anaesthetist. R. F. Deane, MSc, FRCS, Consultant Urologist. D. Kirk, DM, FRCS, Consultant Urologist. K. F. Kyle, MCh, FRCS, Consultant Urologist. Requests for reprints to: S. N. Lloyd, Department of Urology, Western Infirmary, Dumbarton Road, Glasgow G6 11NT.
Is There Still a Place for Prolonged Bladder Distension? S. N. LLOYD, S. M. LLOYD, K. ROGERS, R. F. DEANE, D. KIRK and K. F. KYLE Departments of Urology and Anaesthesia, Western Infirmary, Glasgow
Summary-Over a 2-year period, 3 1 patients underwent prolonged hydrostatic bladder distension for benign and malignant bladder disease in this unit. Of these, 2 9 patients had benign functional disorders or bladder contracture, and in 2 patients hydrodistension was performed for complications of treatment for bladder neoplasia. Of the 2 9 patients with benign disease, 6 observed marked improvement and 8 some improvement in their symptoms, and 12 received no benefit. Patients with detrusor hypersensitivity fared better than those with detrusor instability or interstitial cystitis. A patient with malignant bladder disease died soon after the procedure as a result of a myocardial infarction. Problems attributed to the hydrostatic balloon catheter were responsible for 2 failures. The regional anaesthetic technique failed to provide adequate anaesthesia for hydrodistension in 9 procedures and limited the duration to 2 h in 1 3 others. Following recall of the perished balloon catheters by the manufacturer, and the introduction of continuous spinal anaesthesia, the number of technical failures has been reduced. This technique still has an important role to play in the relief of severe symptoms unresponsive to medical treatment, but it is important that ideal conditions are provided for hydrodistension in order to ensure maximum success, particularly when the alternative is major surgery.
The management of patients with symptoms of frequency, urgency and urge incontinence of urine remains a common problem. Therapeutic options include medical management (Abrams, 1988), transvesical injection of phenol (Blackford et al., 1984), presacral selective sacral neurectomy (Lucas et al., 1988), prolonged bladder distension (Dunn et al., 1974), bladder transection (Hindmarsh et al., 1977) and enterocytoplasty (Bramble, 1982). Prolonged bladder distension was first introduced by Helmstein (1972) for the treatment of bladder cancer, and has been subsequently popularised for the management of benign disease with encouraging long-term results (Ramsden et al., 1976). The exact mechanism by which prolonged distension works remains unclear. It has been proposed that the distension may produce ischaemic or physical damage of the mucosa, nervous tissue or detrusor muscle (Dunn et al., 1974). The problems associated with prolonged bladder distension and the outcome of patients treated over Accepted for publication 22 October 1991
a 2-year period are presented. Recently we have been using continuous spinal anaesthesia for these procedures; our experience with the technique is described and discussed. Patients and Methods
During a 2-year period (1989-1990), 31 patients (21 women, 10 men) with a mean age 52 years (range 18-76) were treated by prolonged bladder distension (Table 1). One patient had severe frequency and urgency following instillation of Bacillus CalmetteGutrin (BCG) for carcinoma in situ of the bladder and another had haematuria from widespread superficial bladder carcinoma uncontrolled by endoscopic resection. The remaining 29 patients suffered from benign conditions (15 detrusor hypersensitivity, 6 detrusor instability, 6 interstitial cystitis, 2 iatrogenic disease) associated with severe irritative symptoms (frequency, nocturia, urgency and occasionally urge incontinence), and pain in the patients with interstitial cystitis. Prolonged bladder distension was used after failure of treat-
382
383
ROLE OF PROLONGED BLADDER DISTENSION
ment with anticholinergic drugs or other medical measures. Three patients (2 with detrusor hypersensitivity and 1 with interstitial cystitis) had previously undergone prolonged distension with some benefit. Hydrodistension technique Two patients underwent 2 separate hydrodistensions ; 3 1 anaesthetic procedures were required for 3 1 hydrodistensions. The patients were catheterised with a 12F Foley catheter prior to insertion of a 16F hydrodistension catheter (Rusch UK Ltd). Continuous hydrodistension was planned for approximately 3 h in all patients receiving regional anaesthesia. The volume of saline within the balloon was determined by gravity, but was not allowed to exceed 1 L. The height of the saline was fixed at a level of 1 m above the patient's umbilicus. Initial experience of trying to control the intravesical pressure as described by Ramsden et al. (1976) proved complicated and was abandoned for the above method. Following the period of distension, the balloon was deflated and the hydrodistension catheter replaced with a 16F Foley catheter left on free drainage overnight and removed the following morning. Anaesthetic techniques In all but 1 case a regional anaesthetic technique was attempted primarily (Table 2). In this patient, general anaesthesia had already been administered for the purpose of cystoscopy before the decision was made to perform hydrostatic distension of an hour-glass deformity following previous caecocystoplasty. In 1 patient, 2 epidurals had failed to provide adequate anaesthesia and general anaesthesia was therefore used. The remaining patients received either single dose spinal (15) or epidural anaesthesia (20) via a catheter with either bolus doses or a continuous infusion.
Results The outcome for patients undergoing prolonged bladder distension can be seen in Table 1. In 2 patients the hydrostatic balloon catheter failed to distend and the procedure was abandoned. Three patients had previously undergone prolonged bladder distension; 1 patient with interstitial cystitis received benefit from further distension but the other 2 patients with detrusor hypersensitivity obtained no symptomatic benefit from further bladder distension (1 underwent 2 separate procedures). Another patient with detrusor hypersensitivity underwent 2 separate distensions before symptomatic benefit was achieved. Overall, for those patients with benign disease, 6 (21%) have had marked continued benefit from the treatment, 8 (28%) have experienced some improvement in their symptoms, and 12 (41%) received no benefit from the procedure. A further 2 patients have been lost to follow-up. The patient who had previously received intravesical BCG for carcinoma in situ and subsequently developed severe irritative symptoms, developed haemorrhage around the hydrodistension catheter and the procedure was abandoned. The patient with widespread superficial disease developed acute cardiovascular complications during hydrodistension, culminating in a myocardial infarction from which he died. Subsequent procedures Seven of the 12 patients with benign conditions who failed to benefit from hydrostatic distension have subsequently proceeded to surgery. A further 6 have undergone ileocystoplasty and 1 prostatectomy (destrusor instability was considered secondary to bladder outflow obstruction). Two patients with interstitial cystitis and 1 with post-radiotherapy cystitis have undergone repeat hydrodistension
Table 1 Indications for Prolonged Bladder Distension and the Early Results Response Aetiology (no.ofpatients)
Good
Detrusor hypersensitivity (15) 4 Detrusor instability ( 6 ) Interstitial cystitis ( 6 ) Bladder carcinoma (1) Post-caecocystoplasty (1) Post-BCG (1) Post-DXT (1)
2
Fair
Poor
4 2 1
6 3 2
Procedure abandoned
Lost to follow-up 1 1
Comment 2 patients, 2 distensions
1 1
Balloon failure Myocardial infarction
1 1
Haemorrhage Balloon failure
1
384
BRITISH JOURNAL OF UROLOGY
Table 2 Anaesthetic Techniques
-
Anaesthetic result
-
Anaesthetic technique (no,)
Partial
Failed
Failed distension
Mean distension time (min) *
Complications
Good
Epidural (20)
12
2
4
2
184
Spinal (15) General (2)
13 2
1
1
Dural puncture (1) Hypotension** ( 5 ) Hypotension** (4) None
119 20
(no.)
* Only relates to procedures with good anaesthetic result ** Hypotension requiring treatment with vasopressors
during cystoscopy under general anaesthesia with some benefit. The patient with severe irritative symptoms following BCG therapy has had spontaneous resolution of his symptoms. Discussion Outcome The results of prolonged bladder distension for functional bladder disturbance have to be seen in the context of the alternatives available. Ileocystoplasty is associated with occasional mortality and significant morbidity, e.g. difficulty in emptying the bladder; this may require clean intermittent selfcatheterisation (Bramble, 1990) and there may be an increased risk of malignancy. Many urologists would subject patients with an essentially benign condition to such major surgery only after all alternatives had been exhausted, even if these procedures have a relatively low success rate. Prolonged bladder distension is one of these alternatives; it is simple and associated with a low morbidity rate. Symptomatic relief was achieved in approximately 49% of patients undergoing this procedure in this series. Possible reasons for failure in the remaining 5 1% will be considered separately. Hydrodistension technique The ideal duration of distension and the volume required for each condition and each patient remain uncertain. Initial reports recommended intermittent distension (Dunn et al., 1974) but subsequent series have used continued distension with varying success (Pengelly et al., 1978; Wolk and Bishop, 1981). It has been our intention to use continuous distension for 3 h (provided anaesthesia is adequate), but there is no recognised standard distension time and some have used distension for up to 6 h (Wolk and Bishop, 1981). It is possible that 3 h
are insufficient and some patients may require more than one procedure before benefit is achieved. Case selection Another possible reason for poor response is case selection. From this series it appears that patients with detrusor hypersensitivity and those with interstitial cystitis are more likely to respond than are patients with detrusor instability. There is no way of predicting the likelihood of success in each individual patient and so it is our policy to offer this form of treatment to all patients in whom major surgery is considered. The only fatality in this series was a patient who was regarded as unfit for cystectomy; hydrodistension was considered the only feasible means of controlling the haemorrhage from his widespread superficial disease. Balloon failure It became apparent that technical faults were sometimes responsible for failure of the procedure, as in 2 cases where the hydrodistension catheter burst. Several other catheters were found to have perished. The manufacturer (Rusch UK Ltd) has recalled all hydrodistension catheters, acknowledging a fault in the production which resulted in premature perishing of the balloon. The new catheters have stronger balloons. We used to monitor the intravesical pressure routinely (Ramsden et al., 1976), but found it increasingly difficult to correlate the measured pressure with the distension. Testing the balloons confirmed that considerable pressure was necessary simply to overcome the tension of the balloon wall, and this made it impossible to relate measured pressure to pressure within the active bladder. It may be that we are distending the bladder at too low a pressure for adequate results. The design of the balloons,
385
ROLE OF PROLONGED BLADDER DISTENSION
incorporating a balance between strength and distensibility, could probably be improved. Anaesthetic problems It was apparent that the anaesthetic techniques may have contributed significantly to failure of the procedure, either because of inadequate anaesthesia to permit distension or by limiting distension time. The distension time for both procedures under general anaesthesia was 20 min, with volumes of 220 and 500 ml respectively. Lasting symptomatic benefit from this procedure was experienced by 1 patient. The duration of hydrostatic distension was limited by the onset of pain in all patients who received single dose spinal anaesthesia, with a mean distension time for the 13 successful blocks of 2 h and with a mean distension volume of 592 ml (range 350-800). One spinal anaesthetic gave only a partial block and another failed completely; in both instances anaesthesia was considered inadequate for hydrodistension. Hypotension requiring vasopressor treatment was required for 4 patients during spinal anaesthesia. Epidural anaesthesia was used for 20 procedures and provided adequate anaesthesia for 12, with a mean hydrodistension time of 184 min and a mean distension volume of 562 ml for the successful blocks (range 300-1000). Failure to insert the epidural catheter or asymmetry of anaesthesia prevented adequate bladder distension in 4 patients and limited the duration of distension in 2. Hypotension requiring vasopressor treatment was required for 5 patients during epidural anaesthesia. Continuous spinal anaesthesia Following discussion with our anaesthetic colleagues, it was considered that the anaesthetic requirements for this procedure would be best provided by continuous spinal anaesthesia. This method of regional anaesthesia has received renewed interest following improvements in product development, permitting a microspinal technique (Hurley and Lambert, 1987). Continuous spinal anaesthesia is useful for prolonged procedures, providing a reliable dense symmetrical block and permitting titration of anaesthesia with relatively small doses of local anaesthetic agent, with no increase in complications over single-dose spinal anaesthesia (Denny et al., 1987). To date, 14 patients have undergone prolonged bladder distension under continuous spinal anaesthesia using the 28G CoSpan spinal catheter via a standard 22G spinal needle (The Kendall Company). In each case the technique provided suitable conditions for
3 hours hydrodistension. One patient required treatment with vasopressors for hypotension following the first dose of bupivacaine. One patient developed a mild headache associated with an upper respiratory tract infection following continuous spinal anaesthesia. This was not considered typical of post-dural puncture headache and it settled spontaneously. Another patient received a single dose spinal anaesthetic because introduction of the spinal catheter proved impossible. He subsequently developed a post-dural puncture headache, requiring an epidural blood patch. We advocate prolonged hydrostatic balloon distension of the bladder in all patients where the alternative is major surgery. Even under ideal conditions the procedure will fail to provide symptomatic benefit in some patients. In order to provide optimum conditions for success we recommend continuous spinal anaesthesia. It is too early to assess the clinical outcome of prolonged distension in this group of patients, but initial results look favourable. We also recommend that all old stocks of hydrodistension catheters should be returned to the manufacturers for replacement by new ones free of charge.
Acknowledgements We thank The Kendall Company Ltd for providing the CoSpan continuous spinal catheters for this study.
References Abrams, P. (1988). Drug therapy in the management of detrusor instability. In Update On Drugs and the Lower Urinary Tract, ed. Cardozo, L. Pp. 3-8. London: Royal Society of Medicine Services. Blackford, H. N., Murray, K., Stephenson, T. P. er al. (1984). Results of transvesical infiltration of pelvic plexuses with phenol in 116 patients. Br. J . Urol.,56,647-649. Bramble, F. J. (1982). The treatment of adult enuresis and urge incontinence by enterocystoplasty. Br. J . Urol.,54,693-696. Bramble, F. J. (1990). The clam cystoplasty. Br. J . Urol., 66, 337-341. Denny, N., Masters, R., Pearson, D. et uf. (1987). Postdural puncture headache after continuous spinal anaesthesia. Anesth. Analg., 66, 791-794. Dunn, M., Smith, J. C. and Ardran, G . M. (1974). Prolonged bladder distension as a treatment of urgency and urge incontinence of urine. Br. J . Urol., 46,645-652. Helmstein, K. (1972). Treatment of bladder carcinoma by a hydrostatic pressure technique. Br. J . Urol.,44,434450. Hindmarsb, J. R., Essenhigh, D. M. and Yeates, W. K. (1977). Bladder transection for adult enuresis. Br. J . Urol., 49, 515521. Hurley, R. J. and Lambert, D. (1987). Continuous spinal anaesthesia with a microcatheter techniaue. Rep. Anaesth.. 12,54.
-
386 Lucas, M. G., Thomas, D. G., Clarke, S. et ul. (1988). Long-term follow-up of selective sacral neurectomy. Br. J . Urol., 61, 218220. Pengelly, A. W., Stephenson, T. P., Milroy, E. J. G. et al. (1978). Results of prolonged bladder distension as treatment for detrusor instability. Br. J . Urol.,50, 243-245. Ramsden, P. D., Smith, J. C., Dunn, M. et ul. (1976). Distension therapy for the unstable bladder: later results including an assessment of repeat distensions. Br. J . Urol.,48, 623-629. Wolk, F. N. and Bishop, M. C. (1981). Effectivenessof prolonged hydrostatic dilatation of bladder. Urology, 18, 572-575.
BRITISH JOURNAL OF UROLOGY
The Authors S. N. Lloyd, FRCS, Research Fellow in Urology. S. M. Lloyd, FCAnaes, Registrar in Anaesthesia. K. Rogers, FFARCS, Consultant Anaesthetist. R. F. Deane, MSc, FRCS, Consultant Urologist. D. Kirk, DM, FRCS, Consultant Urologist. K. F. Kyle, MCh, FRCS, Consultant Urologist. Requests for reprints to: S. N. Lloyd, Department of Urology, Western Infirmary, Dumbarton Road, Glasgow G6 11NT.
