Peripheral NervesNeuromodulation of the superior hypogastric plexus: a new option to treat bladder atonia secondary to radical pelvic surgery?
Introduction
It is well documented that radical pelvic surgery can lead to postoperative dysfunction of the lower urinary and intestinal tracts, such as loss of bladder and rectum sensation and impairment in the command to spontaneously void the bladder or rectum [2], [8]. For this reason, “nerve-sparing” techniques have been developed. They mainly consist of identifying and sparing the different bands of neural tissue involved in micturition and defecation [5], [6], [9], [14], [19]. Even in cases where a radical resection of the parametria is required, it is possible to selectively spare the parasympathetic pelvic nerves [13]. Therefore, postoperative functional morbidity should not be accepted as a routine side effect of radical pelvic surgery. Despite this, the incidence of bladder atonia secondary to the destruction of the pelvic autonomous motoric nerves during pelvic surgery remains high. Management of bladder atonia is based on the need to empty the bladder before overflow, leakage, or stretching occurs, and most of the patients still use self-catheterization on a regular basis. Several therapies for recovery bladder voiding function in patients with bladder atonia have been evaluated in the past, but none permit effective recovery of bladder function when atonia is secondary to radical pelvic surgery. In this study, we report on 1 technique never reported before, the neuromodulation of the superior hypogastric plexus.
Section snippets
Methods
We report on 4 patients who have bladder atonia secondary to pelvic surgery. Diagnosis was secured by previous neurourologic reports and urodynamic testing, and all 4 patients managed their bladder atonia by intermittent self-catheterization.
The first patient is a 30-year-old woman who had chronic pelvic pain and bladder atonia following pelveoperitonitis secondary to a postpartal hysterectomy in 2005, performed after a uterine rupture. The patient underwent 3 further laparoscopies with
Results
In the first patient, we had planned a neuromodulation of the superior hypogastric plexus in an attempt to control her pelvic visceral pain. The LION procedure on the superior hypogastric plexus was uneventful and took 55 minutes. On the third postoperative day, the patient defecated normally, and all analgesics were stopped. The test phase to prove efficacy of the neuromodulation was then started. The external stimulation was alternately switched on and off for a period of 5 hours. The patient
Discussion
The more extensive a surgical procedure in the pelvis is, the higher the risk of damage to the lower urinary tract will be. The most common postoperative complication is the an- or hypocontractility of the detrusor secondary to injury of the vesical motoric innervation. To avoid overstretching of the bladder and damage to the upper urinary tract, bladder atonia is mostly managed by intermittent self-catheterization. Medical treatment with α-blockers can reduce hypertonia of the dorsal urethra
Conclusion
We report in our small series on the neuromodulation of the superior hypogastric plexus as a therapy option to control visceral pelvic pain and to recover micturition with bladder atonia secondary to pelvic surgery. It is clear that these results need to be confirmed on a larger number of patients and with a longer follow-up. The technique of neuromodulation of the superior hypogastric plexus is a completely new surgical procedure that has never been performed or reported on before.
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