PRELIMINARY
URINARY
INCONTINENCE:
A CHALLENGE III.
COMMUNICATION
AND A SOLUTICb’+;
Plication of Muscles of Deep Pe:t--iI-lea1Pouc.bh
M. ISLAM,
M.D.
From The Medical and Surgical Clinic, Peoria, Illinois
ABSTRACT - A new operation, very simple to perform under local anesthesia., is describedfor urinary incontinence caused by operations on the prostate gland or the bladder neck; satisfact-oq results have been obtained, with no complications to date. The surgical procedure ccnsists essentially of plication of the external urethral sphincter and other muscles in the deep perineal pouch thereby increasing their tone, which appears to assist the smooth muscle sphincter for urinary continence. ____--
Urinary incontinence which occasionally follows surgery of the prostate gland or bladder neck is a frustration to the patient and a challenge to his physician. Various procedures, including a new operative technique, vesiconeosphincteroplasty, have been described and successfully performed, but they are either too extensive or too complicated. l-4 The purpose of this article is to describe a simpler procedure of plication of muscles of the deep perineal pouch performed under local anesthesia, with satisfactory results.
An assistant holds the sound in place. Turo 5mm. incisions are made, one on each side and slightly posterior to the bulbous urethra (Fig. 1A). Using 0 Mercelin on a large curved atraumatic: needle, a stitch is placed by entering from one skin incision deeply aiming to the external urethral sphincter and coming out from the opposite incision (Fig. 1). Continuing the same suture, it is reversed entering from the second incision and coming out the first. The sound is removed from the urethra, incontinence is observed, and the suture tightened just enough to control it. If necessary, one or two more such sutures are inserted to achieve full continence. As the sutures are tied they go beneath the skin; usually, therefore, it is not necessary to close the skin incisions. This operation can be repeated with impunity if necessary. It has been performed in 3 cases which follow.
Surgical Technique The patient is placed in the dorsal lithotomy position. His external genitalia and perineal region are prepared and draped in the customary manner. The bladder is filled with approximately 250 cc. of water via an inlying uretheral catheter which is then removed. If severely incontinent, the patient will dribble freely; otherwise only on stress (for example, coughing or sneezing). After incontinence is confirmed, local anesthesia is administered in the perineal region around the bulbous urethra and the largest acceptable Van Buren sound is inserted all the way to the bulbous urethra. Inlying sound would make the bulbous urethra easily palpable and visible as a bulge. The membranous urethra is just above the bulbous urethra around which the operation takes place.
UROLOGY
/ FEBRUARY
1975 / VOLUME
V, NUMBER
Case Reports Case 1 This patient had a transurethral resection of the bladder neck and prostate on February 6, 1973, following which he became completely and unexplainably incontinent. On May 29, this operation was performed, and he has been completely continent for more than fifteen months without any dysuria, frequency, or residual urine. This is considered a very satisfactory result.
2
257
SUTURE URETHRAL
IN
EXTERNAL SPHINCTER
FIGURE 1. (A) Patient in lithotomy position, showing bulbous urethra, small incisions,‘and suture. (B) Muscles of deep perineal pouch mainly external urethral sphincter and deep transverse muscles of perineum, and site of plicatiflg suture.
Case 2
A transurethral resection of the prostate gland was performed on July 8, 1971,following which this patient gradually became incontinent. The usual conservative measures, such as exercises of the perineal muscles, did not help. On September 26, 1973, the operation described was performed, resulting in almost complete continence; however, approximately three months later he started dribbling. On April 1, 1974, the same operation was repeated, and the patient has been completely continent since. He is extremely satisfied because with improvement of continence, his erectile potency has also improved. Case 3 In, this case a transurethral resection of the prostate gland was done on March 3,1972, following whichthe patient had three or four episodes of bleeding, requiring repeated instrumentation, fulguration, and secondary resection of the prostate. He became completely incontinent. On August 3, 1973, this operation was performed, with almost complete continence except on extreme stress. The patient appears satisfied.
principles are applied in this operation of plication of the striated muscle sphincter and other muscles in the deep perineal pouch, thereby improving their basal tone and function. It is reasonable to state that the tone of the striated muscle sphincter does assist smooth muscle sphincter in maintaining urinary continence for a prolonged period. The loss of the tone resulting from OverstretchingJor damage to the striated muscle sphincter during surgery may be the cause of incontinence which cannot be explained otherwise. The Keyes’ operation successfully perfcrmed for urinary incontinence following perineal prostatectomy and the satisfactory results obtained in 3 consecutive cases described here, of urinary incontinence following either transurethral resection of the prostate gland or the bladder neck, substantiate this concept. 100
References
1. ISLAM,M:, and BOYD, P. F.: 2.
Comment All striated muscles have a certain degree of basal tone which is maintained even at rest. The basal tone can be increased or decreased by changing the length of the muscle as is seen and utilized in the correction: ‘of imbalance of the external ocular muscles:. ‘I Also, according to Starling’s law of cardiac muscle, which is applicable to the striated muscle also, increasing the length of the muscle increases its’ tone and force of contraction vvjthin certain limits. 5 These same
258
Northeast Randolph Peoria, Illinois 61606
3.
4.
5. 6.
Urinary incontinence: a challenge and a solution, Sci. Bull. Huron Road Hosp. 15: 11 (1969). ,ISLAM, M., BOYD, P. F., and LAUGHLIN,C. V.: Urinary incontinence: a challenge and a solution, J. Urol. 106: 872 (1971). TANAGIIO,E. A.,and SMITH, D. R.:’ Clinical evaluation of surgical technique for correction of complete urinary incontinence, ibid. 10.7: 402 (1972). FLOCKS,R. H., and BOLDUS: R.: The surgical treatment and prevention of urinary incontinence associated with disturbance of the internal urethral sphincter+ mechanism, ibid. 109: 279 (1973). KEELE, C. A., and NEIL,E.: Samson Wright’s Applied Physiology, 11th ed!, London, Oxford University Press, 1965,p. 119. KEYES, E. L.: Keyes: operation for incontinence of urine,~S’urg. Gynecol: Obstet. 42: 423 (1926).
UBOLOGY /
FEBRUARY 1975 / VOLUME V, NUMBER 2
URINARY
INCONTINENCE:
A CHALLENGE III.
COMMUNICATION
AND A SOLUTICb’+;
Plication of Muscles of Deep Pe:t--iI-lea1Pouc.bh
M. ISLAM,
M.D.
From The Medical and Surgical Clinic, Peoria, Illinois
ABSTRACT - A new operation, very simple to perform under local anesthesia., is describedfor urinary incontinence caused by operations on the prostate gland or the bladder neck; satisfact-oq results have been obtained, with no complications to date. The surgical procedure ccnsists essentially of plication of the external urethral sphincter and other muscles in the deep perineal pouch thereby increasing their tone, which appears to assist the smooth muscle sphincter for urinary continence. ____--
Urinary incontinence which occasionally follows surgery of the prostate gland or bladder neck is a frustration to the patient and a challenge to his physician. Various procedures, including a new operative technique, vesiconeosphincteroplasty, have been described and successfully performed, but they are either too extensive or too complicated. l-4 The purpose of this article is to describe a simpler procedure of plication of muscles of the deep perineal pouch performed under local anesthesia, with satisfactory results.
An assistant holds the sound in place. Turo 5mm. incisions are made, one on each side and slightly posterior to the bulbous urethra (Fig. 1A). Using 0 Mercelin on a large curved atraumatic: needle, a stitch is placed by entering from one skin incision deeply aiming to the external urethral sphincter and coming out from the opposite incision (Fig. 1). Continuing the same suture, it is reversed entering from the second incision and coming out the first. The sound is removed from the urethra, incontinence is observed, and the suture tightened just enough to control it. If necessary, one or two more such sutures are inserted to achieve full continence. As the sutures are tied they go beneath the skin; usually, therefore, it is not necessary to close the skin incisions. This operation can be repeated with impunity if necessary. It has been performed in 3 cases which follow.
Surgical Technique The patient is placed in the dorsal lithotomy position. His external genitalia and perineal region are prepared and draped in the customary manner. The bladder is filled with approximately 250 cc. of water via an inlying uretheral catheter which is then removed. If severely incontinent, the patient will dribble freely; otherwise only on stress (for example, coughing or sneezing). After incontinence is confirmed, local anesthesia is administered in the perineal region around the bulbous urethra and the largest acceptable Van Buren sound is inserted all the way to the bulbous urethra. Inlying sound would make the bulbous urethra easily palpable and visible as a bulge. The membranous urethra is just above the bulbous urethra around which the operation takes place.
UROLOGY
/ FEBRUARY
1975 / VOLUME
V, NUMBER
Case Reports Case 1 This patient had a transurethral resection of the bladder neck and prostate on February 6, 1973, following which he became completely and unexplainably incontinent. On May 29, this operation was performed, and he has been completely continent for more than fifteen months without any dysuria, frequency, or residual urine. This is considered a very satisfactory result.
2
257
SUTURE URETHRAL
IN
EXTERNAL SPHINCTER
FIGURE 1. (A) Patient in lithotomy position, showing bulbous urethra, small incisions,‘and suture. (B) Muscles of deep perineal pouch mainly external urethral sphincter and deep transverse muscles of perineum, and site of plicatiflg suture.
Case 2
A transurethral resection of the prostate gland was performed on July 8, 1971,following which this patient gradually became incontinent. The usual conservative measures, such as exercises of the perineal muscles, did not help. On September 26, 1973, the operation described was performed, resulting in almost complete continence; however, approximately three months later he started dribbling. On April 1, 1974, the same operation was repeated, and the patient has been completely continent since. He is extremely satisfied because with improvement of continence, his erectile potency has also improved. Case 3 In, this case a transurethral resection of the prostate gland was done on March 3,1972, following whichthe patient had three or four episodes of bleeding, requiring repeated instrumentation, fulguration, and secondary resection of the prostate. He became completely incontinent. On August 3, 1973, this operation was performed, with almost complete continence except on extreme stress. The patient appears satisfied.
principles are applied in this operation of plication of the striated muscle sphincter and other muscles in the deep perineal pouch, thereby improving their basal tone and function. It is reasonable to state that the tone of the striated muscle sphincter does assist smooth muscle sphincter in maintaining urinary continence for a prolonged period. The loss of the tone resulting from OverstretchingJor damage to the striated muscle sphincter during surgery may be the cause of incontinence which cannot be explained otherwise. The Keyes’ operation successfully perfcrmed for urinary incontinence following perineal prostatectomy and the satisfactory results obtained in 3 consecutive cases described here, of urinary incontinence following either transurethral resection of the prostate gland or the bladder neck, substantiate this concept. 100
References
1. ISLAM,M:, and BOYD, P. F.: 2.
Comment All striated muscles have a certain degree of basal tone which is maintained even at rest. The basal tone can be increased or decreased by changing the length of the muscle as is seen and utilized in the correction: ‘of imbalance of the external ocular muscles:. ‘I Also, according to Starling’s law of cardiac muscle, which is applicable to the striated muscle also, increasing the length of the muscle increases its’ tone and force of contraction vvjthin certain limits. 5 These same
258
Northeast Randolph Peoria, Illinois 61606
3.
4.
5. 6.
Urinary incontinence: a challenge and a solution, Sci. Bull. Huron Road Hosp. 15: 11 (1969). ,ISLAM, M., BOYD, P. F., and LAUGHLIN,C. V.: Urinary incontinence: a challenge and a solution, J. Urol. 106: 872 (1971). TANAGIIO,E. A.,and SMITH, D. R.:’ Clinical evaluation of surgical technique for correction of complete urinary incontinence, ibid. 10.7: 402 (1972). FLOCKS,R. H., and BOLDUS: R.: The surgical treatment and prevention of urinary incontinence associated with disturbance of the internal urethral sphincter+ mechanism, ibid. 109: 279 (1973). KEELE, C. A., and NEIL,E.: Samson Wright’s Applied Physiology, 11th ed!, London, Oxford University Press, 1965,p. 119. KEYES, E. L.: Keyes: operation for incontinence of urine,~S’urg. Gynecol: Obstet. 42: 423 (1926).
UBOLOGY /
FEBRUARY 1975 / VOLUME V, NUMBER 2
