TECHNIQUE OF EXTERNAL SPHINCTER BALLOON DILATATION MICHAEL B. CHANCELLOR, M.D. IRVIN H. HIRSCH, M.D. PENTTI KIILHOLMA, M.D., PH.D. WILLIAM E. STAAS, M.D. From the Departments of Urology and Rehabilitation Medicine, Jefferson Medical College, Thomas Jefferson University, and Magee Rehabilitation Hospital, Philadelphia, Pennsylvania
ABSTRACT-We report on our technique and early experience with balloon dilatation of the external sphincter in 7 spinal cord-injured men with detrusor external sphincter dyssynergia and elevated voiding pressure. Following dilatation, bladder emptying into condom catheters was achieved in all patients without dribbling incontinence.
Balloon dilatation has emerged as a useful treatment modality in selective patients with bladder outlet obstruction secondary to benign prostate hypertrophy. lv2 And, while we have seen a cornucopia of alternative treatment options for other types of obstructive uropathy, such as benign prostatic hyperplasia, there are few alternatives for quadriplegics with detrusor external sphincter dyssynergia (DESD) . The complications associated with external sphincterotomy could be reduced if a simpler approach to sphincterotomy could be discovered. Complete division of the external sphincter is bloody and not easy, since it is difficult to ensure that the sphincter has been adequately divided. We wanted to develop a procedure that would create functional sphincterotomy without the associated complications. Because of the minimal risks associated with prostate balloon dilatation, we initiated a study of balloon dilatation of the external sphincter in spinal cord-injured men to determine the efficacy of this method in treating DESD. Material and Methods Balloon dilatation was performed in 7 spinal cord-injured men. Preoperative video-urodynamic study was done with simultaneous 308
bladder pressure, urethral pressure, and perineal electromyogram. DESD was demonstrated in all patients. Follow-up urodynamics were done at one month and four months postoperatively. Urodynamic parameters of bladder capacity, residual urine volume, and voiding pressure were compared pre- and post-operatively. Technique of balloon dilatation Cystourethroscopy is first carried out to evaluate the external sphincter and to rule out bladder abnormalities. A guide wire is then passed through the cystoscope and a well-lubricated prostate balloon dilatation catheter (OptiLume, American Medical Systems, Minnetonka, Minnesota) is advanced over the guide wire into the bladder. We have found it easier and more precise to perform the dilatation under fluoroscopic guidance than with cystoscopic visualization. We initially inflate the positioning balloon in the prostatic urethra. The positioning balloon is then pulled across the external sphincter under fluoroscopy. The balloon catheter is pulled down another 1 to 2 cm, and the dilatation balloon is gradually inflated with sterile radiographic contrast medium. The balloon ,is inflated with the external sphincter positioned at UROLOGYI OCTOBER 1992
/
VOLUME 40,NUMBER 4
FICURE~. External sphincter completely dilated to 9OF at 4 atm pressure and 35 mL in the balloon.
FIGURE 1. Fluoroscopic visualization during balloon dilatation of external sphincter showing “waist” forming at level of external sphincter at 15-mL balloon volume and 3 atm pressure.
its midpoint. With the balloon properly positioned across the external sphincter a “waist” can be seen forming (Fig. 1). The waist became more pronounced as the balloon is further inflated. At approximately 15 mL of fluid and 2 to 3 atm of pressure, the sphincter “pops” and the waist disappears on fluoroscopy. At this point there is a drop in the insufflation pressure. Subsequent inflation to 4 atm and 90F meets little resistance. Balloon repositioning is necessary on some of the patients because of proximal and distal migration. The balloon is inflated to its full diameter of 90F at 4 atm (60 pounds per square inch) pressure for ten minutes (Fig. 2). After the balloon is deflated a triple lumen 22F Foley catheter is inserted into the bladder, and a retrograde urethrogram is performed to assess for extravasation. Continuous bladder irrigation is needed for twenty-four hours in some patients. The patient is usually discharged after one to two days when the urine clears. The Foley catheter is generally removed after approximately seven days. Results Seven spinal cord-injured men mean age twenty-nine years (range 21 to 39 years)
UROLOGY
I OCTOBER1992
/ VOLUME40,NUMBER4
managed with indwelling Foley catheters were entered in the study. All the patients were voiding satisfactorily into condom catheters after balloon dilatation. In none of the patients did deterioration in renal function or erectile function develop. Autonomic dysreflexia improved in all 7 patients. Urodynamics
Detrusor external sphincter dyssynergia was demonstrated in all 7 patients none of whom had bladder neck/internal sphincter dyssynergia. The preoperative, and one-month and four-month postoperative voiding pressures were 99.3 f 13.6 cm water, 18.0 + 6.5 cm water, and 26.7 f 9.1 cm water, respectively. There was a statistically significant drop in voiding pressure from before to one and four months after dilatation (p < 0.005, paired ttest). There was no significant difference between the pressures at one and four months post dilatation. Bladder capacity and residual urine volume did not change before and after dilatation (Fig. 3). There were no urethral pressure changes or urine leakage when the 3-mL positioning balloon was inflated at or pulled across the external sphincter. Intraoperative stress incontinence was not demonstrated if dilatation stopped at 2 atm pressure or less than 15 mL of fluid was infused in the balloon. A small amount of extravasation from multiple tears at the level of the external sphincter was generally seen on retrograde urethrogram. In 1 patient delayed postoperative bleeding developed, requiring transfusion and coagulation to control the bleeding.
309
1 month
4 month
FIGURE 3. Voiding presure, bladder capacity, and residual urine volume before, and one and four months after balloon dilatation. *Statistically significant drop in voiding pressure between before and after balloon dilatation (p < 0.005).
Comment Accidental sphincter injury concerns urologists when doing a balloon dilatation of the prostate. We addressed this issue with our intentional disruption of external sphincter. There were no incidences of intraoperative stress incontinence or urethral pressure changes when the 3-mL positioning balloon was inflated or pulled across the external sphincter repeatedly. Additionally, no sphincter injury was noted when up to 2 atm pressure or less than 15 mL of fluid in the balloon was exerted to the external sphincter. We believe accidental injury to the external sphincter during routine prostate dilatation is unlikely. Balloons large enough to disrupt the sphincter cannot be pulled through the sphincter. We found fluoroscopy to be very helpful for proper positioning of the balloon. There was no evidence of a single commissurotomy of the external sphincter, as described of the prostatic capsule, with prostate balloon dilatation. Retrograde urethrogram after the dilatation showed extravasation from multiple tears at the level of the external sphincter. Cystoscopy after dilatation also demonstrated multi-
310
ple tears. The one case of delayed postoperative bleeding has modified our postoperative management to include indwelling catheter drainage for seven days and has resulted in no further such complication. We found that balloon dilatation of the external sphincter significantly lowered the voiding pressure without causing dribbling incontinence, Patients reported subjective improvement in autonomic dysreflexia symptoms, and no deleterious effects on renal function and erectile function were observed. All the patients were managed effectively with condom catheter drainage. Based on our preliminary results, balloon dilatation holds promise as an alternative to external sphincterotomy, however, with caution that longer follow-up is necessary to determine whether or not functional obstruction recurs. Encouraging preliminary results of using a permanent urethral prosthesis to keep the membranous urethra open has recently been reported.3 We are currently comparing external sphincter balloon dilatation and prosthesis placement in a prospective clinical trial at our spinal-cord center. Addendum Since the acceptance of this article, we have done balloon dilatation in an additional 10 patients, with follow-up ranging from three to eighteen months. Reobstruction has occurred in only 2 of the 17 patients, 1 at three months and the other at eight months post dilatation. Jefferson Medical College Suite 1112 College 1025 Walnut Street Philadelphia,Pennsylvania19107 (DR. CHANCELLOR) References 1. Reddy E Wasserman N, Castaneda F, and CastanedaZuniga WR: Balloon dilatation of the prostate for treatment of benign hyperplasia, Urol Clin North Am 15: 529 (1988). 2. Goldenberg SL, Perez-Marrero BA, Lee LM, and Emerson L: Endoscopic balloon dilation of the prostate: early experience, J Urol 144:83 (1999). 3. Shaw PJ, et ol: Permanent external striated sphincter prosthesis in patients with spinal injuries, Br J Uro166: 297 (1990).
UROLOGY
/
OCTOBER
1992
I VOLUME 40, NUMBER 4
ABSTRACT-We report on our technique and early experience with balloon dilatation of the external sphincter in 7 spinal cord-injured men with detrusor external sphincter dyssynergia and elevated voiding pressure. Following dilatation, bladder emptying into condom catheters was achieved in all patients without dribbling incontinence.
Balloon dilatation has emerged as a useful treatment modality in selective patients with bladder outlet obstruction secondary to benign prostate hypertrophy. lv2 And, while we have seen a cornucopia of alternative treatment options for other types of obstructive uropathy, such as benign prostatic hyperplasia, there are few alternatives for quadriplegics with detrusor external sphincter dyssynergia (DESD) . The complications associated with external sphincterotomy could be reduced if a simpler approach to sphincterotomy could be discovered. Complete division of the external sphincter is bloody and not easy, since it is difficult to ensure that the sphincter has been adequately divided. We wanted to develop a procedure that would create functional sphincterotomy without the associated complications. Because of the minimal risks associated with prostate balloon dilatation, we initiated a study of balloon dilatation of the external sphincter in spinal cord-injured men to determine the efficacy of this method in treating DESD. Material and Methods Balloon dilatation was performed in 7 spinal cord-injured men. Preoperative video-urodynamic study was done with simultaneous 308
bladder pressure, urethral pressure, and perineal electromyogram. DESD was demonstrated in all patients. Follow-up urodynamics were done at one month and four months postoperatively. Urodynamic parameters of bladder capacity, residual urine volume, and voiding pressure were compared pre- and post-operatively. Technique of balloon dilatation Cystourethroscopy is first carried out to evaluate the external sphincter and to rule out bladder abnormalities. A guide wire is then passed through the cystoscope and a well-lubricated prostate balloon dilatation catheter (OptiLume, American Medical Systems, Minnetonka, Minnesota) is advanced over the guide wire into the bladder. We have found it easier and more precise to perform the dilatation under fluoroscopic guidance than with cystoscopic visualization. We initially inflate the positioning balloon in the prostatic urethra. The positioning balloon is then pulled across the external sphincter under fluoroscopy. The balloon catheter is pulled down another 1 to 2 cm, and the dilatation balloon is gradually inflated with sterile radiographic contrast medium. The balloon ,is inflated with the external sphincter positioned at UROLOGYI OCTOBER 1992
/
VOLUME 40,NUMBER 4
FICURE~. External sphincter completely dilated to 9OF at 4 atm pressure and 35 mL in the balloon.
FIGURE 1. Fluoroscopic visualization during balloon dilatation of external sphincter showing “waist” forming at level of external sphincter at 15-mL balloon volume and 3 atm pressure.
its midpoint. With the balloon properly positioned across the external sphincter a “waist” can be seen forming (Fig. 1). The waist became more pronounced as the balloon is further inflated. At approximately 15 mL of fluid and 2 to 3 atm of pressure, the sphincter “pops” and the waist disappears on fluoroscopy. At this point there is a drop in the insufflation pressure. Subsequent inflation to 4 atm and 90F meets little resistance. Balloon repositioning is necessary on some of the patients because of proximal and distal migration. The balloon is inflated to its full diameter of 90F at 4 atm (60 pounds per square inch) pressure for ten minutes (Fig. 2). After the balloon is deflated a triple lumen 22F Foley catheter is inserted into the bladder, and a retrograde urethrogram is performed to assess for extravasation. Continuous bladder irrigation is needed for twenty-four hours in some patients. The patient is usually discharged after one to two days when the urine clears. The Foley catheter is generally removed after approximately seven days. Results Seven spinal cord-injured men mean age twenty-nine years (range 21 to 39 years)
UROLOGY
I OCTOBER1992
/ VOLUME40,NUMBER4
managed with indwelling Foley catheters were entered in the study. All the patients were voiding satisfactorily into condom catheters after balloon dilatation. In none of the patients did deterioration in renal function or erectile function develop. Autonomic dysreflexia improved in all 7 patients. Urodynamics
Detrusor external sphincter dyssynergia was demonstrated in all 7 patients none of whom had bladder neck/internal sphincter dyssynergia. The preoperative, and one-month and four-month postoperative voiding pressures were 99.3 f 13.6 cm water, 18.0 + 6.5 cm water, and 26.7 f 9.1 cm water, respectively. There was a statistically significant drop in voiding pressure from before to one and four months after dilatation (p < 0.005, paired ttest). There was no significant difference between the pressures at one and four months post dilatation. Bladder capacity and residual urine volume did not change before and after dilatation (Fig. 3). There were no urethral pressure changes or urine leakage when the 3-mL positioning balloon was inflated at or pulled across the external sphincter. Intraoperative stress incontinence was not demonstrated if dilatation stopped at 2 atm pressure or less than 15 mL of fluid was infused in the balloon. A small amount of extravasation from multiple tears at the level of the external sphincter was generally seen on retrograde urethrogram. In 1 patient delayed postoperative bleeding developed, requiring transfusion and coagulation to control the bleeding.
309
1 month
4 month
FIGURE 3. Voiding presure, bladder capacity, and residual urine volume before, and one and four months after balloon dilatation. *Statistically significant drop in voiding pressure between before and after balloon dilatation (p < 0.005).
Comment Accidental sphincter injury concerns urologists when doing a balloon dilatation of the prostate. We addressed this issue with our intentional disruption of external sphincter. There were no incidences of intraoperative stress incontinence or urethral pressure changes when the 3-mL positioning balloon was inflated or pulled across the external sphincter repeatedly. Additionally, no sphincter injury was noted when up to 2 atm pressure or less than 15 mL of fluid in the balloon was exerted to the external sphincter. We believe accidental injury to the external sphincter during routine prostate dilatation is unlikely. Balloons large enough to disrupt the sphincter cannot be pulled through the sphincter. We found fluoroscopy to be very helpful for proper positioning of the balloon. There was no evidence of a single commissurotomy of the external sphincter, as described of the prostatic capsule, with prostate balloon dilatation. Retrograde urethrogram after the dilatation showed extravasation from multiple tears at the level of the external sphincter. Cystoscopy after dilatation also demonstrated multi-
310
ple tears. The one case of delayed postoperative bleeding has modified our postoperative management to include indwelling catheter drainage for seven days and has resulted in no further such complication. We found that balloon dilatation of the external sphincter significantly lowered the voiding pressure without causing dribbling incontinence, Patients reported subjective improvement in autonomic dysreflexia symptoms, and no deleterious effects on renal function and erectile function were observed. All the patients were managed effectively with condom catheter drainage. Based on our preliminary results, balloon dilatation holds promise as an alternative to external sphincterotomy, however, with caution that longer follow-up is necessary to determine whether or not functional obstruction recurs. Encouraging preliminary results of using a permanent urethral prosthesis to keep the membranous urethra open has recently been reported.3 We are currently comparing external sphincter balloon dilatation and prosthesis placement in a prospective clinical trial at our spinal-cord center. Addendum Since the acceptance of this article, we have done balloon dilatation in an additional 10 patients, with follow-up ranging from three to eighteen months. Reobstruction has occurred in only 2 of the 17 patients, 1 at three months and the other at eight months post dilatation. Jefferson Medical College Suite 1112 College 1025 Walnut Street Philadelphia,Pennsylvania19107 (DR. CHANCELLOR) References 1. Reddy E Wasserman N, Castaneda F, and CastanedaZuniga WR: Balloon dilatation of the prostate for treatment of benign hyperplasia, Urol Clin North Am 15: 529 (1988). 2. Goldenberg SL, Perez-Marrero BA, Lee LM, and Emerson L: Endoscopic balloon dilation of the prostate: early experience, J Urol 144:83 (1999). 3. Shaw PJ, et ol: Permanent external striated sphincter prosthesis in patients with spinal injuries, Br J Uro166: 297 (1990).
UROLOGY
/
OCTOBER
1992
I VOLUME 40, NUMBER 4
