Vol. 115, February
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
UROLOGIC COMPLICATIONS FOLLOWING ABDOMINOPERINEAL RESECTION HANS-UDO EICKENBERG, MOHAMMAD AMIN, WILLIAM KLOMPUS
AND
ROBERT LICH, JR.
From the Section of Urology, Department of Surgery and the Price Institute of Surgical Research, University of Louisville School of Medicine, Health Sciences Center, Louisville and the Departments of Surgery and Urology, Trover Clinic, Madisonville, Kentucky
ABSTRACT
In a retrospective study we analyzed the high incidence of 75 urological complications after abdominoperineal resection in 52 patients. A prospective study was done also to anticipate as well as to minimize or eliminate these highly significant complications. Direct injury leading to obstruction and fistullf formation was avoided. Obstructive uropathy in 10 of 25 male patients was found as a direct result of preoperative evaluation. Same day prostatectomies in 5 patients made no appreciable difference in the urological management, complication rate or end results. Neurogenic bladder dysfunction of various degrees was found in 50 per cent of all patients but represented a long-term problem in only 10 per cent. Abdominoperineal resection has been a major but standard operative procedure since it was popularized by Miles in 1908. 1 Reported rates of urological complications after this procedure are as high as 80 per cent. 2 - 12 In a retrospective review a high incidence of urological complications was discovered following abdominoperineal resection. A prospective study has been done in an attempt to anticipate and, possibly, to minimize these highly significant complications. RETROSPECTIVE STUDY
Materials and method. To evaluate the problem at our hospitals we studied the records of 100 consecutive patients who underwent abdominoperineal resections of the rectum for various pathological processes between 1963 and 1973. Approximately 90 per cent of the resections were for invasive cancer and the remainder were for inflammatory disease (table 1). The disparate proportion of women (16) to men (84) is a result of the larger number of men at our Veterans Hospital. More than 80 per cent of the men were in the prostatic age group. There were 75 urological complications encountered in 52 patients (table 2). Urinary retention of some degree was the most common complication after abdominoperineal resection and was noted in 39 patients. Urologic investigations included excretory urography (IVP), cystoscopy and cystometry. Prostatic obstruction was thought to be the causative factor in 20 patients and 13 of these were managed by prostatectomy. Adenocarcinoma of the prostate was noted in 2 patients and urethral strictures were found in 5. Of the latter 5 patients 3 needed intermittent urethral dilatation and 1 underwent internal urethrotomy. The fifth patient required ilea! conduit urinary diversion because of upper urinary tract dilatation. Neurogenic bladder dysfunction was believed to be the cause of retention in 14 patients, 3 of whom were women. All of these patients were treated conservatively with prolonged catheter drainage, treatment of infection and bethanechol chloride therapy. There were 6 men who underwent transurethral resection to decrease resistance to urinary flow. All of the patients in this group, whether treated conservatively or by transurethral resection, required prolonged and close followup care. Permanent catheter drainage was necessary in 6 patients. Accepted for publication June 6, 1975. Read at annual meeting of Society of University Urology Residents, Lake of the Ozarks, Missouri, May 15-18, 197 4. 180
Bladder injury is another category of urological complications following abdominoperineal resection. In our series vesicoperineal and vesicovaginal fistulas developed in 2 patients. Undoubtedly, the bladder was entered more commonly but the primary repair resulted in healing and not in further complication. These 2 fistulas resulted either from unrecognized bladder perforation or ischemic damage to the bladder wall. Ureteral obstruction occurred 10 times in the series. Of 3 patients with bilateral obstruction 1 required ileal conduit urinary diversion. Left nephrostomy was performed in another but this patient died postoperatively. Bilateral obstruction in the third patient was relieved after incision and drainage of a large pelvic abscess. A patient with a ureteroperineal fistula was treated with prolonged ureteral catheter drainage but required nephrectomy because of persistence of the fistula. In 2 patients unilateral non-functioning kidneys were found in postoperative IVPs but no further treatment was done. Neither patient had clinical evidence of urological injury at the time of operation. A cutaneous ureterostomy relieved the obstruction in another patient. The etiologies of these ureteral obstructions varied from patient to patient. Since preoperative and postoperative IVPs were not available in all of the cases it was difficult to distinguish whether recurrent malignancy, fibrosis or direct surgical interference was the definite etiologic factor. Posterior urethral injury is probably not uncommon during the perinea! portion of the dissection but, because of the universal catheter drainage in these patients, it does not pose any major problems. After a time urethral stricture may result possibly from urethral injury or prolonged catheter drainage. Urethroperineal fistula was observed in 2 patients and urethral strictures symptomatic enough to require urological care were noted in 5 patients. Sexual morbidity among our patients could not be completely evaluated because of lack of information in our records. Some researchers consider impotence a universal complaint following abdominoperineal resection of the rectosigmoid. 1 •- 1 • In our series only 2 men returned to the hospital complaining of loss of sexual function. Impotence may be attributable to loss of nerve supply to the vessels and muscles controlling erection. An interesting aspect was pointed out by Devlin and associates who reviewed their experience with this procedure in Britain and found 2 homosexual male subjects who had undergone operation for anorectal cancer. One committed suicide and the other, when interviewed, commented, "You should not do it to us gay people".•
181
UROLOGlC COMPLICATIONS AFTER ABDOMINOPERINEAL RESECTION
1. Disease processes requiring abdominoperineal resection
TABLE
No. Pts. Adenocarcinoma of the rectum Squamous cell carcinoma of the rectum Ulcerative colitis Villous adenoma Others Total
79 6
5 3
7
100
TABLE
2. Urological complications No.
Urinary retention: Prostatic obstruction Neurogenic bladder Urethral stricture Severe urinary tract infection Urinary incontinence Ureteral obstruction: Bilateral Unilateral Fistulas: Ureteroperineal Vesicoperineal Vesicovaginal Urethroperineal Impotence Total
20 14 5 15 1
1 2
2
69 PROSPECTIVE STUDY
In an attempt to anticipate and possibly mm1mize the seemingly inevitable urological complications after abdominoperineal operations a preoperative protocol was established in 1967. Before April 1973, 40 abdominoperineal resections were done following this protocol. A basic urological evaluation was to precede all operations. Included in this evaluation were a complete urological history, urinalysis, urine culture and sensitivity, IVPs with a post-voiding film, cystopanendoscopy and 1 or more cystometrograms. The presence of residual urine on the immediate post-voiding film in the IVP series was considered a valuable indication of vesical outlet obstruction or detrusor hypotonicity. Cystoscopic inspection served to rule out malignant extension to the bladder and to establish the presence or absence of outlet obstruction (for example benign prostatic hyperplasia or urethral stenosis) and the concomitant degree of detrusor trabeculation. Cystometrographic studies attested to the preoperative status of the bladder reflex mechanism. Patients. Of the 16 women who underwent abdominoperineal resection 1 death occurred within 6 months of the operation. Postmortem examination of this 77-year-old woman showed bilateral hydronephrosis from retroperitoneal fibrosis with no evidence of recurrence of malignancy. A 73-year-old patient died 15 months after an operation for recurrent malignancy. Eight of the female patients had no significant urological complications, while 6 had short-term difficulties (that is less than 6 months). Of the 6 patients with short-term complications 1 had pyelonephritis secondary to vesicoureteral reflux, which responded to appropriate antibiotics based on preoperative and postoperative cultures and sensitivity studies. The remaining 5 women had flaccid neurogenic bladders manifested by persisting pyuria and residual volumes more than 60 cc. None had bouts of urosepsis. Three had normal bladder function with normal cystometrograms within 6 months. The remaining 2 patients continued to have difficulty. One patient had normal findings within 6 months after resection but bacilluria developed and 140 cc residual urine was noted 15 months after the operation. with bethanechol chlo-
ride and appropriate antibiotics normal urinary status returned and it has remained normal on urological followup 5 years after the abdominoperineal resection. The other patient has required suprapubic catheter drainage for the 8 months since the operation. She is a diabetic and has an atonic sensory and motor neurogenic bladder. Of the 25 men undergoing abdominoperineal resection 20 had urological complications. Of these, 17 had complications lasting less than 6 months and consisting of flaccid bladders in 15 cases, urosepsis with reversible renal failure in 1 and unresponsive urinary tract infection lasting about 4 months in the remaining patient. There were 3 additional patients who manifested flaccid neurogenic bladders 6 months after their original operations. Surgical treatment. Of the 25 male patients in the study 12 underwent prostatectomy (table 3). Ten of these were direct results of preoperative evaluation. There were 5 patients who underwent prostatic operations the of abdominoperineal resection. In 2 retropubic prostatectomy was done during the abdominal portion of the colon procedure. In the third a suprapubic prostatectomy was similarly timed. The suprapubic (transvesical) route was selected because of the presence of a rather large bladder tumor that was excised by segmental vesical resection. Transurethral prostatic resections were done on 2 men under the same anesthesia as colon resection. One was performed before abdominoperineal resection and the other was accomplished immediately after. There was no appreciable difference in the urological management, complication rate or end results in the 5 cases of same day prostatectomy. The main disadvantage of performing transurethral resection is the loss of access to the prostatic capsule by rectal palpation. However, this problem is not a serious handicap in accomplishing an adequate prostatic resection. Retropubic adenectomy during the abdominal phase of the colon resection seemed the least complicated approach to prostatectomy in the patient requiring correction of vesical neck obstruction. If prostatic bleeding becomes a significant factor after enucleation of the gland, the hypogastric arteries can be ligated with relative impunity before completion of the abdominal portion of the colon procedure. Delayed transurethral resection offers the disadvantage of increased blood loss during and after a prostatic operation. This may be caused by prostatic engorgement and collateralization resulting from prior ligation of the rectal vasculature. Transurethral prostatectomies were done in 7 patients subsequent to abdominoperineal resection. Of these procedures 3 were performed within a month of the colon operation and 4 other patients underwent prostatic resection 4 months, 1, 2 1/2 and 6 years later, respectively. Suprapubic catheters. The need for continuing an intravesical catheter is not a significant disadvantage because suprapubic catheters are used routinely until vesical tone and satisfactory bladder emptying have been established. Avoiding the urethral catheter has practically eliminated postoperative urethritis and prostatitis. The suprapubic catheter has the obvious advantage of allowing trials of voiding and determination of residual urine without removal of the catheter itself. The cystotomy also TABLE
3. Prostatic operations No. (%)
Total patients Prostatectomy Same day procedure: Transurethral resection Retropubic Suprapubic Later transurethral resection
25 (100) 12 (48) 5
2 2 1 7
(20) (8) (8) (4) (24)
182
EICKENBERG AND ASSOCIATES
serves as a point of fixation of the bladder to the anterior abdominal wall. Although this is not an essential factor, cystopexy is occasionally used when vesical descensus appears significant after removal of the colonic specimen. Postoperative urological care. Immediate postoperative urological care is minimal even when concomitant prostatectomy has been performed. The suprapubic catheter is irrigated twice daily with a 10 per cent furacin solution and a cystometrogram is obtained within the first week postoperatively. The sensory component is also tested using iced and heated sterile saline instillations. When the patient is taking oral medication, bethanechol chloride is started if the cystometrogram confirms the usual flaccid pattern. A trial of voiding is best performed during supra pubic instillation rather than by clamping the catheter. If indicated by culture or febrile response urinary antiseptics or antibiotics are started, although this is by no means routinely necessary. With resumption or institution of voiding (usually indicated by readings in excess of 40 cm. water on the cystometrogram) the residual urine should be determined after each act of bladder emptying. If residual urine less than 30 cc is consistently demonstrated and there is no clinical x-ray evidence of reflux, the catheter can be removed. The presence of persisting residual urine makes the eradication of pyuria and bacilluria virtually impossible. A useful maneuver when there is persisting urine residual despite adequate amounts of bethanechol chloride (50 mg. 4 times daily) consists of introducing sterile mineral oil into the bladder in volume equal to or slightly in excess of the determined amount of residual urine. The sterile mineral oil is relatively inert and does not support bacterial growth. The dead space within the bladder is no longer occupied by stagnant urine and as a result the patient voids under the oil with a remarkably clear specimen. As bladder tone returns the oil is gradually eliminated until complete vesical emptying is resumed. DISCUSSION
After institution of the prospective study in which the basic urological examination preceded all abdominoperineal operations, new information about urological complications was obtained. The serious problems of ureteral obstruction and fistula formation can be avoided. Urinary retention resulting from prostatic obstruction can be anticipated and prevented by prostatectomy the same day of the abdominoperineal resection or postoperatively without problems. The incidence of urethral strictures can be decreased by avoiding an indwelling urethral catheter. The incidence of bladder dysfunction in patients without any obstructive uropathy was much higher in the prospective study than in the retrospective one, probably because bladder dysfunction of a milder degree may not cause any symptoms and may, therefore, have passed unobserved in the first group. Approximately 50 per cent of all patients in our prospective study had a flaccid neurogenic bladder. This is in agreement with previous reports. 12 Three theories explaining the vesical dysfunction after abdominoperineal resection have been suggested. 1) Direct injury to the vesical nerve supply may be a cause of this complication. The bladder is supplied by parasympathetic (82 to 84) as well as sympathetic (presacral) nerves. Bladder function may be dependent upon the coordinated action of the sympathetic and parasympathetic nerves. After numerous abdominoperineal resections in cadavers,
Simmons found that some degree of injury to the parasympathetic supply to the bladder is inevitable. 15 Injury to the sympathetic nerves is unlikely because of their position. Simmons concluded that bladder dysfunction after abdominoperineal resection is attributable to this imbalance of innervation and advocated presacral neurectomy to wipe out the sympathetic side of the balance. Although good results were obtained in a few clinical cases the validity of this hypothesis has not been proved. 2) Loss of support produces sagging of the bladder after abdominoperineal resection. This anatomic derangement also has been implicated in bladder dysfunction. Some surgeons routinely fix the bladder to the anterior abdominal wall by suprapubic cystotomy or simple sutures, claiming a diminished incidence of bladder dysfunction. 3) Traumatic aseptic pericystitis had been suggested as a cause of postoperative vesical dysfunction. Campbell found marked edema and fibrosis of perivesical space in 4 patients who underwent suprapubic cystotomy up to 4 weeks after the abdominoperineal resection. 3 This pericystitis caused the bladder wall to be rigid and unable to contract effectively. Fortunately this bladder dysfunction is only transient in most patients and in less than 10 per cent of our patients did it represent a long-term problem. By anticipating this complication and understanding its mechanism the patient can be guided through the postoperative course until he resumes complete and functional vesical emptying. REFERENCES
1. Miles, W. E.: A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet, 2: 1812, 1908. 2. Baumrucker, G. 0. and Shaw, J. W.: Urological complications following abdominoperineal resection of the rectum. Arch. Surg., 67: 502, 1953. 3. Campbell, M. F .: Urologic complications of anorectal and colon surgery. Amer. J. Proctol., 12: 43, 1961. 4. Tank, E. S., Ernst, C. B., Woolson, S. T. and Lapides, J.: Urinary tract complications of anorectal surgery. Amer. J. Surg., 123: 118, 1972. 5. Ward, J. N. and Nay, H. R.: Immediate and delayed urologic complications associated with abdominoperineal resection. Amer. J. Surg., 123: 642, 1972. 6. Levin, I. A. and Tarantino, M. J.: Complications of abdominal perinea! resection. South. Med. J., 65: 33, 1972. 7. Campbell, E. W.: Pericystitis: a cause for the retention of urine following abdominoperineal proctosigmoidectomy. J. Urol., 61: 550, 1949. 8. Burdette, W. J.: The continuing challenge of colorectal carcinoma. Hosp. Prac., p. 146, May 1973. 9. Devlin, H. B., Plant, J. A. and Griffin, M.: Aftermath of surgery for anorectal cancer. Brit. Med. J., 3: 413, 1971. 10. Stahlgren, L. H. and Ferguson, L. K.: Influence on sexual function of abdominoperineal resection for ulcerative colitis. New Engl. J. Med., 259: 873, 1958. 11. Donovan, M. J. and O'Hara, E. T.: Sexual function following surgery for ulcerative colitis. New Engl. J. Med., 262: 719, 1960. 12. Kontturi, M., Larmi, T. K. and Tuononen, S.: Bladder dysfunction and its manifestations following abdominoperineal extirpation of the rectum. Ann. Surg., 179: 179, 1974. 13. Mullen, T. F. and Lestrohan, P.: Urologic complications of cancer of the rectum. Ann. Surg., 116: 6, 1942. 14. Barnes, R.: Discussion of paper by Bisquertt T., J.E. and Emmett, J. L.: Transurethral resection to relieve urinary retention following operations on the rectum and sigmoid. J. Urol., 57: 771, 1947. 15. Simmons, H. T.: Retention of urine after excision of the rectum. Brit. Med. J., 1: 171, 1938. 16. Rankin, F. W.: What can we expect from radical surgery for rectal and rectosigmoidal cancer? South. Surg., 5: 192, 1936.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
UROLOGIC COMPLICATIONS FOLLOWING ABDOMINOPERINEAL RESECTION HANS-UDO EICKENBERG, MOHAMMAD AMIN, WILLIAM KLOMPUS
AND
ROBERT LICH, JR.
From the Section of Urology, Department of Surgery and the Price Institute of Surgical Research, University of Louisville School of Medicine, Health Sciences Center, Louisville and the Departments of Surgery and Urology, Trover Clinic, Madisonville, Kentucky
ABSTRACT
In a retrospective study we analyzed the high incidence of 75 urological complications after abdominoperineal resection in 52 patients. A prospective study was done also to anticipate as well as to minimize or eliminate these highly significant complications. Direct injury leading to obstruction and fistullf formation was avoided. Obstructive uropathy in 10 of 25 male patients was found as a direct result of preoperative evaluation. Same day prostatectomies in 5 patients made no appreciable difference in the urological management, complication rate or end results. Neurogenic bladder dysfunction of various degrees was found in 50 per cent of all patients but represented a long-term problem in only 10 per cent. Abdominoperineal resection has been a major but standard operative procedure since it was popularized by Miles in 1908. 1 Reported rates of urological complications after this procedure are as high as 80 per cent. 2 - 12 In a retrospective review a high incidence of urological complications was discovered following abdominoperineal resection. A prospective study has been done in an attempt to anticipate and, possibly, to minimize these highly significant complications. RETROSPECTIVE STUDY
Materials and method. To evaluate the problem at our hospitals we studied the records of 100 consecutive patients who underwent abdominoperineal resections of the rectum for various pathological processes between 1963 and 1973. Approximately 90 per cent of the resections were for invasive cancer and the remainder were for inflammatory disease (table 1). The disparate proportion of women (16) to men (84) is a result of the larger number of men at our Veterans Hospital. More than 80 per cent of the men were in the prostatic age group. There were 75 urological complications encountered in 52 patients (table 2). Urinary retention of some degree was the most common complication after abdominoperineal resection and was noted in 39 patients. Urologic investigations included excretory urography (IVP), cystoscopy and cystometry. Prostatic obstruction was thought to be the causative factor in 20 patients and 13 of these were managed by prostatectomy. Adenocarcinoma of the prostate was noted in 2 patients and urethral strictures were found in 5. Of the latter 5 patients 3 needed intermittent urethral dilatation and 1 underwent internal urethrotomy. The fifth patient required ilea! conduit urinary diversion because of upper urinary tract dilatation. Neurogenic bladder dysfunction was believed to be the cause of retention in 14 patients, 3 of whom were women. All of these patients were treated conservatively with prolonged catheter drainage, treatment of infection and bethanechol chloride therapy. There were 6 men who underwent transurethral resection to decrease resistance to urinary flow. All of the patients in this group, whether treated conservatively or by transurethral resection, required prolonged and close followup care. Permanent catheter drainage was necessary in 6 patients. Accepted for publication June 6, 1975. Read at annual meeting of Society of University Urology Residents, Lake of the Ozarks, Missouri, May 15-18, 197 4. 180
Bladder injury is another category of urological complications following abdominoperineal resection. In our series vesicoperineal and vesicovaginal fistulas developed in 2 patients. Undoubtedly, the bladder was entered more commonly but the primary repair resulted in healing and not in further complication. These 2 fistulas resulted either from unrecognized bladder perforation or ischemic damage to the bladder wall. Ureteral obstruction occurred 10 times in the series. Of 3 patients with bilateral obstruction 1 required ileal conduit urinary diversion. Left nephrostomy was performed in another but this patient died postoperatively. Bilateral obstruction in the third patient was relieved after incision and drainage of a large pelvic abscess. A patient with a ureteroperineal fistula was treated with prolonged ureteral catheter drainage but required nephrectomy because of persistence of the fistula. In 2 patients unilateral non-functioning kidneys were found in postoperative IVPs but no further treatment was done. Neither patient had clinical evidence of urological injury at the time of operation. A cutaneous ureterostomy relieved the obstruction in another patient. The etiologies of these ureteral obstructions varied from patient to patient. Since preoperative and postoperative IVPs were not available in all of the cases it was difficult to distinguish whether recurrent malignancy, fibrosis or direct surgical interference was the definite etiologic factor. Posterior urethral injury is probably not uncommon during the perinea! portion of the dissection but, because of the universal catheter drainage in these patients, it does not pose any major problems. After a time urethral stricture may result possibly from urethral injury or prolonged catheter drainage. Urethroperineal fistula was observed in 2 patients and urethral strictures symptomatic enough to require urological care were noted in 5 patients. Sexual morbidity among our patients could not be completely evaluated because of lack of information in our records. Some researchers consider impotence a universal complaint following abdominoperineal resection of the rectosigmoid. 1 •- 1 • In our series only 2 men returned to the hospital complaining of loss of sexual function. Impotence may be attributable to loss of nerve supply to the vessels and muscles controlling erection. An interesting aspect was pointed out by Devlin and associates who reviewed their experience with this procedure in Britain and found 2 homosexual male subjects who had undergone operation for anorectal cancer. One committed suicide and the other, when interviewed, commented, "You should not do it to us gay people".•
181
UROLOGlC COMPLICATIONS AFTER ABDOMINOPERINEAL RESECTION
1. Disease processes requiring abdominoperineal resection
TABLE
No. Pts. Adenocarcinoma of the rectum Squamous cell carcinoma of the rectum Ulcerative colitis Villous adenoma Others Total
79 6
5 3
7
100
TABLE
2. Urological complications No.
Urinary retention: Prostatic obstruction Neurogenic bladder Urethral stricture Severe urinary tract infection Urinary incontinence Ureteral obstruction: Bilateral Unilateral Fistulas: Ureteroperineal Vesicoperineal Vesicovaginal Urethroperineal Impotence Total
20 14 5 15 1
1 2
2
69 PROSPECTIVE STUDY
In an attempt to anticipate and possibly mm1mize the seemingly inevitable urological complications after abdominoperineal operations a preoperative protocol was established in 1967. Before April 1973, 40 abdominoperineal resections were done following this protocol. A basic urological evaluation was to precede all operations. Included in this evaluation were a complete urological history, urinalysis, urine culture and sensitivity, IVPs with a post-voiding film, cystopanendoscopy and 1 or more cystometrograms. The presence of residual urine on the immediate post-voiding film in the IVP series was considered a valuable indication of vesical outlet obstruction or detrusor hypotonicity. Cystoscopic inspection served to rule out malignant extension to the bladder and to establish the presence or absence of outlet obstruction (for example benign prostatic hyperplasia or urethral stenosis) and the concomitant degree of detrusor trabeculation. Cystometrographic studies attested to the preoperative status of the bladder reflex mechanism. Patients. Of the 16 women who underwent abdominoperineal resection 1 death occurred within 6 months of the operation. Postmortem examination of this 77-year-old woman showed bilateral hydronephrosis from retroperitoneal fibrosis with no evidence of recurrence of malignancy. A 73-year-old patient died 15 months after an operation for recurrent malignancy. Eight of the female patients had no significant urological complications, while 6 had short-term difficulties (that is less than 6 months). Of the 6 patients with short-term complications 1 had pyelonephritis secondary to vesicoureteral reflux, which responded to appropriate antibiotics based on preoperative and postoperative cultures and sensitivity studies. The remaining 5 women had flaccid neurogenic bladders manifested by persisting pyuria and residual volumes more than 60 cc. None had bouts of urosepsis. Three had normal bladder function with normal cystometrograms within 6 months. The remaining 2 patients continued to have difficulty. One patient had normal findings within 6 months after resection but bacilluria developed and 140 cc residual urine was noted 15 months after the operation. with bethanechol chlo-
ride and appropriate antibiotics normal urinary status returned and it has remained normal on urological followup 5 years after the abdominoperineal resection. The other patient has required suprapubic catheter drainage for the 8 months since the operation. She is a diabetic and has an atonic sensory and motor neurogenic bladder. Of the 25 men undergoing abdominoperineal resection 20 had urological complications. Of these, 17 had complications lasting less than 6 months and consisting of flaccid bladders in 15 cases, urosepsis with reversible renal failure in 1 and unresponsive urinary tract infection lasting about 4 months in the remaining patient. There were 3 additional patients who manifested flaccid neurogenic bladders 6 months after their original operations. Surgical treatment. Of the 25 male patients in the study 12 underwent prostatectomy (table 3). Ten of these were direct results of preoperative evaluation. There were 5 patients who underwent prostatic operations the of abdominoperineal resection. In 2 retropubic prostatectomy was done during the abdominal portion of the colon procedure. In the third a suprapubic prostatectomy was similarly timed. The suprapubic (transvesical) route was selected because of the presence of a rather large bladder tumor that was excised by segmental vesical resection. Transurethral prostatic resections were done on 2 men under the same anesthesia as colon resection. One was performed before abdominoperineal resection and the other was accomplished immediately after. There was no appreciable difference in the urological management, complication rate or end results in the 5 cases of same day prostatectomy. The main disadvantage of performing transurethral resection is the loss of access to the prostatic capsule by rectal palpation. However, this problem is not a serious handicap in accomplishing an adequate prostatic resection. Retropubic adenectomy during the abdominal phase of the colon resection seemed the least complicated approach to prostatectomy in the patient requiring correction of vesical neck obstruction. If prostatic bleeding becomes a significant factor after enucleation of the gland, the hypogastric arteries can be ligated with relative impunity before completion of the abdominal portion of the colon procedure. Delayed transurethral resection offers the disadvantage of increased blood loss during and after a prostatic operation. This may be caused by prostatic engorgement and collateralization resulting from prior ligation of the rectal vasculature. Transurethral prostatectomies were done in 7 patients subsequent to abdominoperineal resection. Of these procedures 3 were performed within a month of the colon operation and 4 other patients underwent prostatic resection 4 months, 1, 2 1/2 and 6 years later, respectively. Suprapubic catheters. The need for continuing an intravesical catheter is not a significant disadvantage because suprapubic catheters are used routinely until vesical tone and satisfactory bladder emptying have been established. Avoiding the urethral catheter has practically eliminated postoperative urethritis and prostatitis. The suprapubic catheter has the obvious advantage of allowing trials of voiding and determination of residual urine without removal of the catheter itself. The cystotomy also TABLE
3. Prostatic operations No. (%)
Total patients Prostatectomy Same day procedure: Transurethral resection Retropubic Suprapubic Later transurethral resection
25 (100) 12 (48) 5
2 2 1 7
(20) (8) (8) (4) (24)
182
EICKENBERG AND ASSOCIATES
serves as a point of fixation of the bladder to the anterior abdominal wall. Although this is not an essential factor, cystopexy is occasionally used when vesical descensus appears significant after removal of the colonic specimen. Postoperative urological care. Immediate postoperative urological care is minimal even when concomitant prostatectomy has been performed. The suprapubic catheter is irrigated twice daily with a 10 per cent furacin solution and a cystometrogram is obtained within the first week postoperatively. The sensory component is also tested using iced and heated sterile saline instillations. When the patient is taking oral medication, bethanechol chloride is started if the cystometrogram confirms the usual flaccid pattern. A trial of voiding is best performed during supra pubic instillation rather than by clamping the catheter. If indicated by culture or febrile response urinary antiseptics or antibiotics are started, although this is by no means routinely necessary. With resumption or institution of voiding (usually indicated by readings in excess of 40 cm. water on the cystometrogram) the residual urine should be determined after each act of bladder emptying. If residual urine less than 30 cc is consistently demonstrated and there is no clinical x-ray evidence of reflux, the catheter can be removed. The presence of persisting residual urine makes the eradication of pyuria and bacilluria virtually impossible. A useful maneuver when there is persisting urine residual despite adequate amounts of bethanechol chloride (50 mg. 4 times daily) consists of introducing sterile mineral oil into the bladder in volume equal to or slightly in excess of the determined amount of residual urine. The sterile mineral oil is relatively inert and does not support bacterial growth. The dead space within the bladder is no longer occupied by stagnant urine and as a result the patient voids under the oil with a remarkably clear specimen. As bladder tone returns the oil is gradually eliminated until complete vesical emptying is resumed. DISCUSSION
After institution of the prospective study in which the basic urological examination preceded all abdominoperineal operations, new information about urological complications was obtained. The serious problems of ureteral obstruction and fistula formation can be avoided. Urinary retention resulting from prostatic obstruction can be anticipated and prevented by prostatectomy the same day of the abdominoperineal resection or postoperatively without problems. The incidence of urethral strictures can be decreased by avoiding an indwelling urethral catheter. The incidence of bladder dysfunction in patients without any obstructive uropathy was much higher in the prospective study than in the retrospective one, probably because bladder dysfunction of a milder degree may not cause any symptoms and may, therefore, have passed unobserved in the first group. Approximately 50 per cent of all patients in our prospective study had a flaccid neurogenic bladder. This is in agreement with previous reports. 12 Three theories explaining the vesical dysfunction after abdominoperineal resection have been suggested. 1) Direct injury to the vesical nerve supply may be a cause of this complication. The bladder is supplied by parasympathetic (82 to 84) as well as sympathetic (presacral) nerves. Bladder function may be dependent upon the coordinated action of the sympathetic and parasympathetic nerves. After numerous abdominoperineal resections in cadavers,
Simmons found that some degree of injury to the parasympathetic supply to the bladder is inevitable. 15 Injury to the sympathetic nerves is unlikely because of their position. Simmons concluded that bladder dysfunction after abdominoperineal resection is attributable to this imbalance of innervation and advocated presacral neurectomy to wipe out the sympathetic side of the balance. Although good results were obtained in a few clinical cases the validity of this hypothesis has not been proved. 2) Loss of support produces sagging of the bladder after abdominoperineal resection. This anatomic derangement also has been implicated in bladder dysfunction. Some surgeons routinely fix the bladder to the anterior abdominal wall by suprapubic cystotomy or simple sutures, claiming a diminished incidence of bladder dysfunction. 3) Traumatic aseptic pericystitis had been suggested as a cause of postoperative vesical dysfunction. Campbell found marked edema and fibrosis of perivesical space in 4 patients who underwent suprapubic cystotomy up to 4 weeks after the abdominoperineal resection. 3 This pericystitis caused the bladder wall to be rigid and unable to contract effectively. Fortunately this bladder dysfunction is only transient in most patients and in less than 10 per cent of our patients did it represent a long-term problem. By anticipating this complication and understanding its mechanism the patient can be guided through the postoperative course until he resumes complete and functional vesical emptying. REFERENCES
1. Miles, W. E.: A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet, 2: 1812, 1908. 2. Baumrucker, G. 0. and Shaw, J. W.: Urological complications following abdominoperineal resection of the rectum. Arch. Surg., 67: 502, 1953. 3. Campbell, M. F .: Urologic complications of anorectal and colon surgery. Amer. J. Proctol., 12: 43, 1961. 4. Tank, E. S., Ernst, C. B., Woolson, S. T. and Lapides, J.: Urinary tract complications of anorectal surgery. Amer. J. Surg., 123: 118, 1972. 5. Ward, J. N. and Nay, H. R.: Immediate and delayed urologic complications associated with abdominoperineal resection. Amer. J. Surg., 123: 642, 1972. 6. Levin, I. A. and Tarantino, M. J.: Complications of abdominal perinea! resection. South. Med. J., 65: 33, 1972. 7. Campbell, E. W.: Pericystitis: a cause for the retention of urine following abdominoperineal proctosigmoidectomy. J. Urol., 61: 550, 1949. 8. Burdette, W. J.: The continuing challenge of colorectal carcinoma. Hosp. Prac., p. 146, May 1973. 9. Devlin, H. B., Plant, J. A. and Griffin, M.: Aftermath of surgery for anorectal cancer. Brit. Med. J., 3: 413, 1971. 10. Stahlgren, L. H. and Ferguson, L. K.: Influence on sexual function of abdominoperineal resection for ulcerative colitis. New Engl. J. Med., 259: 873, 1958. 11. Donovan, M. J. and O'Hara, E. T.: Sexual function following surgery for ulcerative colitis. New Engl. J. Med., 262: 719, 1960. 12. Kontturi, M., Larmi, T. K. and Tuononen, S.: Bladder dysfunction and its manifestations following abdominoperineal extirpation of the rectum. Ann. Surg., 179: 179, 1974. 13. Mullen, T. F. and Lestrohan, P.: Urologic complications of cancer of the rectum. Ann. Surg., 116: 6, 1942. 14. Barnes, R.: Discussion of paper by Bisquertt T., J.E. and Emmett, J. L.: Transurethral resection to relieve urinary retention following operations on the rectum and sigmoid. J. Urol., 57: 771, 1947. 15. Simmons, H. T.: Retention of urine after excision of the rectum. Brit. Med. J., 1: 171, 1938. 16. Rankin, F. W.: What can we expect from radical surgery for rectal and rectosigmoidal cancer? South. Surg., 5: 192, 1936.
