British Journal of Urology (1977), 49, 121-724
0
Choice of Operation to promote Micturition after Spinal Cord Injury G . J. FELLOWS, I. NUSEIBEH
and
J. J. WALSH
National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbuvy, Bucks
Following injury to the spinal cord, retention of urine is the rule, necessitating some form of catheter drainage. Micturition is re-established in the majority of patients within the first 3 months after injury. Parasympathominietic and alpha-adrenergic blocking drugs may help to initiate micturition. There remains a group of patients who fail to void and require either permanent catheters or surgery to lower the resistance of the bladder outflow tract. The operations most frequently employed are internal membranous urethrotomy (external sphincterotomy, IMU), bladder neck resection (BNR) or a combination of the two (BNR+ IMU). An inappropriate operation will be ineffective and may lead to undesirable complications. Bladder neck resection is followed by retrograde ejaculation (most patients with cord injury are young men) and internal membranous urethrotomy occasionally causes erectile impotence (Schoenfeld, Carrion and Politano, 1974; Thomas, 1976). This paper sets out to determine whether the result of surgery can be predicted in the individual patient, thus enabling the correct operation to be chosen. Patients and Methods From June 1974 to September 1976 61 male patients who had not established satisfactory micturition after injury had one of the following operations: IMU (15), BNR (22), BNR+IMU (24). 31 had complete urinary retention and 30 could pass a little urine with difficulty, leaving residual urine volumes in excess of 150 ml. Cord injury was traumatic in 54 and due to benign lesions with or without surgery to the spine in 7. One-quarter had incomplete lesions. The following factors which might influence the outcome of surgery were studied : age, level of lesion, sacral cord reflexes, cystometry, urethral pressure profile and the appearance of the bladder neck on cystourethrography. All patients had full neurological examinations, intravenous urograms and cystourethrograms preoperatively. 30 patients had preoperative cystometrograms. Bladders were filled through an 8 Ch urethral catheter at 50 ml per min to a capacity not exceeding 500 ml. Total bladder, rectal and subtracted pressures were recorded. Detrusor contractions were triggered if possible by coughing, suprapubic tapping and other manoeuvres, such as anal stimulation. Urethral pressure profiles were obtained in most patients who had cystometrograms. Bladder neck resection was usually from 3 to 9 o’clock using a loop electrode, occasionally the resection was continued around the whole circumference of the bladder neck. Internal membranous urethrotomy was performed with a Collings Knife Electrode at 3 and 9 o’clock from the level of the verumontanum distally not less than 2.5 cm. The operation was termed successful if micturition occurred with a residual volume less than 100 ml. In most patients it was much less and in many was nil. Results
+
The overall results after each operation are shown in Table I. The superiority of BNR IMU over BNR alone falls just short of statistical significance. A second operation was carried out in all Read at the 33rd Annual Meeting of the British Association of Urological Surgeons in Aberdeen, June 1977. 72 1
722
BRITISH JOURNAL OF UROLOGY
but 3 of the failures and there was only 1 patient who failed to void after a second operation. Thus 4 patients out of the original 61 were finally assigned to catheter drainage. Younger patients fared neither better nor worse after surgery than older patients (Table 11). 3 tetraplegic patients had BNRs and all failed to void (Table 111). When the upper sensory level was L1 or below, all patients passed urine whatever operation was employed. The remaining patients had lesions in the thoracic segments. The three failures after IMU all occurred in patients with lesions above T6 (above the sympathetic outflow to the bladder). There were failures above and below this level following BNR and the combined operation. The integrity of sacral cord segments S2, 3, 4 was tested by the anal and bulbo-cavernosus reflexes and confirmed by penile erections. The overall results of surgery were better in those with absent sacral reflexes (P < 0.05) (Table IV). The combined operation was superior to BNR alone in those with intact sacral reflexes (P < 0.05) but not significantly better than IMU. The strength of detrusor contractions did not correlate with the outcome of surgery after any of the three operatioiis (Table V). Maximum closure pressure on the urethral pressure profile varied from 36 to 140 cm of water (Table VI). The 3 patients with the highest pressures (1 11, 123, 140 cm of water) all failed to void after bladder neck resection alone. Cystograms with films during attempted micturition were obtained in all patients. In 19 the bladder neck appeared normal. In 33 patients it remained closed. In the remaining 9 a thin trickle of contrast entered the urethra with no funnelling of the bladder neck. These patients are classified with the “closed” group in Table VII. The appearance of the bladder neck was no guide to the outcome of surgery. Discussion During the period of this survey, approximately 30% of men with new lesions admitted to the National Spinal Injuries Centre had surgery to their bladder outflow tracts. This is similar to the proportion reported by O’Flynn (1974). When surgery is necessary there are no agreed criteria for resecting the bladder neck, incising the membranous urethra or combining the 2 operations as advocated by Smith, Cook and Arrowsmith (197 1). Gibbon (1974) states that the bladder neck should open if detrusor contractions exceed 30 cm of water. Rossier and Ott (1974) add bladder neck resection to internal membranous urethrotomy if detrusor pressure is low. We have failed to confirm this relationship between detrusor pressure and the result of IMU although our numbers are small. There were, however, 3 unexpected failures after IMU in patients with strong detrusor contractions ( > 3 0 cm HA)). It may be significant that the 3 patients with the highest maximum urethral closure pressures failed to void after BNR alone. A high pressure in the membranous urethra may be an indication for IMU. Electromyography of the external sphincter has not been performed in this series. Detrusor sphincter dys-synergism demonstrated by synchronous cystometry and sphincter electromyography may be an indication for IMU (Thomas, Smallwood and Graham, 1975). However, patients may have significant resistance in the membranous urethra without external sphincter spasm and also require “sphlncterotomy” (Abel et al., 1974). Sphincterotomy (IMU) was first used in patients whose sacral cord reflexes had been abolished by alcohol block (Ross, Gibbon and Damanski, 1958). It might be expected that the voiding cystourethrogram would be a sound guide to the choice of operation, those with closed bladder necks responding well to BNR and those with wide bladder necks to IMU. The present study, however, shows that the appearance of the bladder neck is no help in the choice of operation. Others have also found cystourethrography unreliable (Shopfner, 1967; Scher, 1977). The opinion that younger men are more likely to pass urine after surgery than older men was not confirmed.
723
OPERATION TO PROMOTE MICTURITION AFTER SPINAL CORD INJURY
Table I
Table I1
Result of First Operation after Cord Injury
Age in Relation to Result of Procedure ~
IMU BNR BNR+ IMU IMU-Internal BNR-Bladder
Total
Success
Failure
15
10 12 19
5 10 5
22 24
IMU BNR BNR+IMU
membranous urethrotomy neck resection
Success
Failure
31 (18-46) 44 (20-69) 37 (17-56)
31 (17-65) 43 (21 -62) 41 (17-59)
Mean age in years with range in parenthesis.
Table I11 Upper Level of Neuro!ogical Lesion Cervical
IMU BNR BNR IMU
+
Thoracic
Lumbo-sacral
Success
Failure
Success
Failure
Success
Failure
4 0 2
2 3 2
5 6 14
3 7 3
1 6 3
0 0
0
Table IV Integrity of Cord Segments S2, 3 and 4 ~~
Intact
IMU BNR BNRfIMU
~
Disrupted
Success
Failure
Success
Failure
6 7 17
5 9 5
4 5
0 1 0
2
The overall failure rate after BNR alone is unacceptably high. It is probably an inappropriate operation in patients with cervical lesions and in patients with maximum urethral closure pressure in excess of 100 cm of water, but may be suitable in patients with low lesions and low pressure in the membranous urethra. Bladder neck resection should be avoided if the patient is able to ejaculate. Internal membranous urethrotomy appears to be a suitable operation for patients with lesions at all levels of the spinal cord. If this operation fails, the completeness of the IMU can be checked by repeating the urethral pressure profile (Abel et al., 1975). IMU can be repeated or, if necessary, a bladder neck resection can then be performed. The combined operation under one anaesthetic carries the greatest chance of success, and should be performed if no attempt is to be made to preserve sexual function.
Summary 61 male patients who had resection of the bladder neck alone, internal membranous urethrotomy alone or a combination of the 2 procedures to establish micturition after cord injury are reviewed.
724
BRITISH JOURNAL OF UROLOGY
Table V Detrusor Contractions on Cystometrograms More than 20 cm water ~~
~
Less than 20 cm water
Success
Failure
Success
Failure
2 3 2
3 2
2 4 6
0
~
IMU BNR BNR+IMU
0
4 2
Table VI
Table VII
Mean Maximum Urethral Closure Pressures
Bladder Neck on Cystography
IMU BNR BNR+ IMU
Success
Failure
60 (4) 66 (6) 78 (6)
67 (2) 125 (3) 84 (3)
Wide
Figures in parentheses are numbers in each group.
IMU BNR BNR+IMU
Narrow/closed
Success
Failure
Success
Failure
4
3 2
5
1
6 8 14
2
4
8 4
The combined operation has the greatest chance of initial success and should be performed if no attempt is to be made to preserve sexual function. Internal membranous urethrotomy is appropriate for lesions at all levels of the cord. Cystometry and cystourethrography are not helpful in the choice of operation.
References ABEL,B. J., GIBBON, N. 0. K., JAMESON, R. M. and KNSHNAN, K. R. (1974). The neuropathic urethra. Lancet, 2, 1229-1230. ABEL,B. J., Ross, J. C., GIBBON,N. 0. K. and JAMESON,R. M. (1975). Urethral pressure measurement after division of the external sphincter. Paraplegia, 13, 37-41. GIBBON,N. 0. K. (1974). Later management of the paraplegic bladder. Paraplegia, 12,87-91. O'FLYNN,J. D. (1974). Early management of neuropathic bladder in spinal cord injuries. PurapIegia, 12, 83-86. Ross, J. C., GIBBON, N. 0. K. and DAMANSKI, M. (1958). Division of the external urethral sphincter in the treatment of the paraplegic bladder. British Journal of Urology, 30, 204-212. ROSIER,A. B. and Om, R. (1974). Urinary manometry in spinal cord injury: a follow-up study. British Journal of Urology, 46,439-448. SCHER, A. T. (1977). Problems in the radiological interpretation of the X-ray appearance of the bladder wall and bladder neck obtained on micturating cystourethrography in patients with neurogenic bladders. paraplegia, 15, 15-20. SCHOENFELD, L., CARRION, H. M. and POLITANO, V. A. (1974). Erectile impotence: complication of external sphincterotomy. Urology, 4, 681-685. SHOPFNER, C. E. (1967). Roentgenological evaluation of bladder neck obstruction. American Journal of Roentgenofogy, 100,162-176. SMITH,P. H., COOK,J. B. and ARROWSMITH, W. A. (1971). Transurethral resection of the bladder neck and external sphincter after spinal injury. Proceedings Veterans Administration Spinal Cord Injuries Conference,18,166-169. D. G. (1976). The effect of trans-urethral surgery on penile erections in spinal cord injury patients. THOMAS, Paraplegia, 13, 286-289. THOMAS, D. G., SMALLWOOD, R. and GRAHAM, D. (1975). Urodynamic observations following spinal trauma. British Journal of Urology, 47, 161-175.
The Authors G. J. Fellows, MS, FRCS, Consultant Urologist. I. Nuseibeh, FRCS, Consultant Surgeon. J. 3. Walsh, MD, FRCS, FRCP, Director of National Spinal Injuries Centre.
0
Choice of Operation to promote Micturition after Spinal Cord Injury G . J. FELLOWS, I. NUSEIBEH
and
J. J. WALSH
National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbuvy, Bucks
Following injury to the spinal cord, retention of urine is the rule, necessitating some form of catheter drainage. Micturition is re-established in the majority of patients within the first 3 months after injury. Parasympathominietic and alpha-adrenergic blocking drugs may help to initiate micturition. There remains a group of patients who fail to void and require either permanent catheters or surgery to lower the resistance of the bladder outflow tract. The operations most frequently employed are internal membranous urethrotomy (external sphincterotomy, IMU), bladder neck resection (BNR) or a combination of the two (BNR+ IMU). An inappropriate operation will be ineffective and may lead to undesirable complications. Bladder neck resection is followed by retrograde ejaculation (most patients with cord injury are young men) and internal membranous urethrotomy occasionally causes erectile impotence (Schoenfeld, Carrion and Politano, 1974; Thomas, 1976). This paper sets out to determine whether the result of surgery can be predicted in the individual patient, thus enabling the correct operation to be chosen. Patients and Methods From June 1974 to September 1976 61 male patients who had not established satisfactory micturition after injury had one of the following operations: IMU (15), BNR (22), BNR+IMU (24). 31 had complete urinary retention and 30 could pass a little urine with difficulty, leaving residual urine volumes in excess of 150 ml. Cord injury was traumatic in 54 and due to benign lesions with or without surgery to the spine in 7. One-quarter had incomplete lesions. The following factors which might influence the outcome of surgery were studied : age, level of lesion, sacral cord reflexes, cystometry, urethral pressure profile and the appearance of the bladder neck on cystourethrography. All patients had full neurological examinations, intravenous urograms and cystourethrograms preoperatively. 30 patients had preoperative cystometrograms. Bladders were filled through an 8 Ch urethral catheter at 50 ml per min to a capacity not exceeding 500 ml. Total bladder, rectal and subtracted pressures were recorded. Detrusor contractions were triggered if possible by coughing, suprapubic tapping and other manoeuvres, such as anal stimulation. Urethral pressure profiles were obtained in most patients who had cystometrograms. Bladder neck resection was usually from 3 to 9 o’clock using a loop electrode, occasionally the resection was continued around the whole circumference of the bladder neck. Internal membranous urethrotomy was performed with a Collings Knife Electrode at 3 and 9 o’clock from the level of the verumontanum distally not less than 2.5 cm. The operation was termed successful if micturition occurred with a residual volume less than 100 ml. In most patients it was much less and in many was nil. Results
+
The overall results after each operation are shown in Table I. The superiority of BNR IMU over BNR alone falls just short of statistical significance. A second operation was carried out in all Read at the 33rd Annual Meeting of the British Association of Urological Surgeons in Aberdeen, June 1977. 72 1
722
BRITISH JOURNAL OF UROLOGY
but 3 of the failures and there was only 1 patient who failed to void after a second operation. Thus 4 patients out of the original 61 were finally assigned to catheter drainage. Younger patients fared neither better nor worse after surgery than older patients (Table 11). 3 tetraplegic patients had BNRs and all failed to void (Table 111). When the upper sensory level was L1 or below, all patients passed urine whatever operation was employed. The remaining patients had lesions in the thoracic segments. The three failures after IMU all occurred in patients with lesions above T6 (above the sympathetic outflow to the bladder). There were failures above and below this level following BNR and the combined operation. The integrity of sacral cord segments S2, 3, 4 was tested by the anal and bulbo-cavernosus reflexes and confirmed by penile erections. The overall results of surgery were better in those with absent sacral reflexes (P < 0.05) (Table IV). The combined operation was superior to BNR alone in those with intact sacral reflexes (P < 0.05) but not significantly better than IMU. The strength of detrusor contractions did not correlate with the outcome of surgery after any of the three operatioiis (Table V). Maximum closure pressure on the urethral pressure profile varied from 36 to 140 cm of water (Table VI). The 3 patients with the highest pressures (1 11, 123, 140 cm of water) all failed to void after bladder neck resection alone. Cystograms with films during attempted micturition were obtained in all patients. In 19 the bladder neck appeared normal. In 33 patients it remained closed. In the remaining 9 a thin trickle of contrast entered the urethra with no funnelling of the bladder neck. These patients are classified with the “closed” group in Table VII. The appearance of the bladder neck was no guide to the outcome of surgery. Discussion During the period of this survey, approximately 30% of men with new lesions admitted to the National Spinal Injuries Centre had surgery to their bladder outflow tracts. This is similar to the proportion reported by O’Flynn (1974). When surgery is necessary there are no agreed criteria for resecting the bladder neck, incising the membranous urethra or combining the 2 operations as advocated by Smith, Cook and Arrowsmith (197 1). Gibbon (1974) states that the bladder neck should open if detrusor contractions exceed 30 cm of water. Rossier and Ott (1974) add bladder neck resection to internal membranous urethrotomy if detrusor pressure is low. We have failed to confirm this relationship between detrusor pressure and the result of IMU although our numbers are small. There were, however, 3 unexpected failures after IMU in patients with strong detrusor contractions ( > 3 0 cm HA)). It may be significant that the 3 patients with the highest maximum urethral closure pressures failed to void after BNR alone. A high pressure in the membranous urethra may be an indication for IMU. Electromyography of the external sphincter has not been performed in this series. Detrusor sphincter dys-synergism demonstrated by synchronous cystometry and sphincter electromyography may be an indication for IMU (Thomas, Smallwood and Graham, 1975). However, patients may have significant resistance in the membranous urethra without external sphincter spasm and also require “sphlncterotomy” (Abel et al., 1974). Sphincterotomy (IMU) was first used in patients whose sacral cord reflexes had been abolished by alcohol block (Ross, Gibbon and Damanski, 1958). It might be expected that the voiding cystourethrogram would be a sound guide to the choice of operation, those with closed bladder necks responding well to BNR and those with wide bladder necks to IMU. The present study, however, shows that the appearance of the bladder neck is no help in the choice of operation. Others have also found cystourethrography unreliable (Shopfner, 1967; Scher, 1977). The opinion that younger men are more likely to pass urine after surgery than older men was not confirmed.
723
OPERATION TO PROMOTE MICTURITION AFTER SPINAL CORD INJURY
Table I
Table I1
Result of First Operation after Cord Injury
Age in Relation to Result of Procedure ~
IMU BNR BNR+ IMU IMU-Internal BNR-Bladder
Total
Success
Failure
15
10 12 19
5 10 5
22 24
IMU BNR BNR+IMU
membranous urethrotomy neck resection
Success
Failure
31 (18-46) 44 (20-69) 37 (17-56)
31 (17-65) 43 (21 -62) 41 (17-59)
Mean age in years with range in parenthesis.
Table I11 Upper Level of Neuro!ogical Lesion Cervical
IMU BNR BNR IMU
+
Thoracic
Lumbo-sacral
Success
Failure
Success
Failure
Success
Failure
4 0 2
2 3 2
5 6 14
3 7 3
1 6 3
0 0
0
Table IV Integrity of Cord Segments S2, 3 and 4 ~~
Intact
IMU BNR BNRfIMU
~
Disrupted
Success
Failure
Success
Failure
6 7 17
5 9 5
4 5
0 1 0
2
The overall failure rate after BNR alone is unacceptably high. It is probably an inappropriate operation in patients with cervical lesions and in patients with maximum urethral closure pressure in excess of 100 cm of water, but may be suitable in patients with low lesions and low pressure in the membranous urethra. Bladder neck resection should be avoided if the patient is able to ejaculate. Internal membranous urethrotomy appears to be a suitable operation for patients with lesions at all levels of the spinal cord. If this operation fails, the completeness of the IMU can be checked by repeating the urethral pressure profile (Abel et al., 1975). IMU can be repeated or, if necessary, a bladder neck resection can then be performed. The combined operation under one anaesthetic carries the greatest chance of success, and should be performed if no attempt is to be made to preserve sexual function.
Summary 61 male patients who had resection of the bladder neck alone, internal membranous urethrotomy alone or a combination of the 2 procedures to establish micturition after cord injury are reviewed.
724
BRITISH JOURNAL OF UROLOGY
Table V Detrusor Contractions on Cystometrograms More than 20 cm water ~~
~
Less than 20 cm water
Success
Failure
Success
Failure
2 3 2
3 2
2 4 6
0
~
IMU BNR BNR+IMU
0
4 2
Table VI
Table VII
Mean Maximum Urethral Closure Pressures
Bladder Neck on Cystography
IMU BNR BNR+ IMU
Success
Failure
60 (4) 66 (6) 78 (6)
67 (2) 125 (3) 84 (3)
Wide
Figures in parentheses are numbers in each group.
IMU BNR BNR+IMU
Narrow/closed
Success
Failure
Success
Failure
4
3 2
5
1
6 8 14
2
4
8 4
The combined operation has the greatest chance of initial success and should be performed if no attempt is to be made to preserve sexual function. Internal membranous urethrotomy is appropriate for lesions at all levels of the cord. Cystometry and cystourethrography are not helpful in the choice of operation.
References ABEL,B. J., GIBBON, N. 0. K., JAMESON, R. M. and KNSHNAN, K. R. (1974). The neuropathic urethra. Lancet, 2, 1229-1230. ABEL,B. J., Ross, J. C., GIBBON,N. 0. K. and JAMESON,R. M. (1975). Urethral pressure measurement after division of the external sphincter. Paraplegia, 13, 37-41. GIBBON,N. 0. K. (1974). Later management of the paraplegic bladder. Paraplegia, 12,87-91. O'FLYNN,J. D. (1974). Early management of neuropathic bladder in spinal cord injuries. PurapIegia, 12, 83-86. Ross, J. C., GIBBON, N. 0. K. and DAMANSKI, M. (1958). Division of the external urethral sphincter in the treatment of the paraplegic bladder. British Journal of Urology, 30, 204-212. ROSIER,A. B. and Om, R. (1974). Urinary manometry in spinal cord injury: a follow-up study. British Journal of Urology, 46,439-448. SCHER, A. T. (1977). Problems in the radiological interpretation of the X-ray appearance of the bladder wall and bladder neck obtained on micturating cystourethrography in patients with neurogenic bladders. paraplegia, 15, 15-20. SCHOENFELD, L., CARRION, H. M. and POLITANO, V. A. (1974). Erectile impotence: complication of external sphincterotomy. Urology, 4, 681-685. SHOPFNER, C. E. (1967). Roentgenological evaluation of bladder neck obstruction. American Journal of Roentgenofogy, 100,162-176. SMITH,P. H., COOK,J. B. and ARROWSMITH, W. A. (1971). Transurethral resection of the bladder neck and external sphincter after spinal injury. Proceedings Veterans Administration Spinal Cord Injuries Conference,18,166-169. D. G. (1976). The effect of trans-urethral surgery on penile erections in spinal cord injury patients. THOMAS, Paraplegia, 13, 286-289. THOMAS, D. G., SMALLWOOD, R. and GRAHAM, D. (1975). Urodynamic observations following spinal trauma. British Journal of Urology, 47, 161-175.
The Authors G. J. Fellows, MS, FRCS, Consultant Urologist. I. Nuseibeh, FRCS, Consultant Surgeon. J. 3. Walsh, MD, FRCS, FRCP, Director of National Spinal Injuries Centre.
