Der Urologe, Ausgabe A

, Volume 42, Issue 12, pp 1569–1575 | Cite as

Blasendysfunktion und Operationen im kleinen Becken

Therapiemöglichkeiten
Leitthema

Zusammenfassung

Je ausgedehnter ein operativer Eingriff im kleinen Becken, desto stärker ist der untere Harntrakt mit seinen versorgenden Nerven und Nervenplexus gefährdet. Blasenentleerungsstörungen und Blasenspeicherstörungen müssen urodynamisch abgeklärt werden, und Verlaufskontrollen tragen zur Differenzierung temporärer von persistierenden Störungen bei. Die postoperative Blasenentleerungsstörung sollte zunächst durch suprapubische Harnableitung, möglichst bald aber durch intermittierenden Selbstkatheterismus behandelt werden, um Blasenüberdehnung, rezidivierende Harnwegsinfekte und eine Schädigung des oberen Harntraktes zu vermeiden. Eine wiedereinsetzende Spontanmiktion kann bei vertretbaren Blasendruck- und Restharnwerten durch Parasympathikomimetika und/oder α-Blocker unterstützt werden. Für die Elektrostimulation einer Miktion eignen sich die intravesikale Therapieform (großer zeitlicher Aufwand) oder die bilaterale sakrale Neuromodulation (aufwendig und teuer). Bei Eingriffen zur Senkung des Auslasswiderstandes der Blase besteht wegen der oft gleichzeitigen Sphinkterstörung die Gefahr der postoperativen Inkontinenz. Die persistierende Blasenspeicherstörung beruht oft auf einer Inkontinenz bei Harnretention (Überlaufinkontinenz). Hier kann intermittierender Selbstkatheterismus zur sozialen Kontinenz führen. Verminderung von Blasencompliance und Urethraverschlussdruck bedingen Belastungs- und Dranginkontinenz, die üblicherweise physio- und verhaltenstherapeutisch, medikamentös und nur in Ausnahmefällen operativ behandelt werden sollen. Die Prävention postoperativer Blasenfunktionsstörungen ist durch eine gewebe- und nervenschonende Operationstechnik möglich. Sie wird aber immer durch onkologische Gesichtspunkte begrenzt.

Schlüsselwörter

Postoperative Blasendysfunktion Beckenchirurgie und Urodynamik Parasympathische Dezentralisation Komplikationen nach radikaler Beckenchirurgie  

Abstract

The more extensive a surgical procedure in a small pelvis, the higher the risk for the lower urinary tract with its nerve supply and nerve plexus. This concerns mainly the sympathetic chains, the parasympathetic structures and, rarely, the visceral supply of the pelvic floor. Direct trauma to the bladder and its vascular supply as well as indirect injury by displacement of the bladder need to be seriously considered. Problems with micturition and impaired storage capacity of the bladder are the result. Complete urodynamic examination and follow-up can help in differentiating between temporary and persisting disturbances and in taking therapeutical decisions. The most evident postoperative complication is disturbed micturition, managed initially by suprapubic urinary diversion, followed as soon as possible by intermittent self-catheterisation. This is the only way to avoid overstretching of the bladder, recurring urinary tract infection and damage to the upper urinary tract. Restoration of spontaneous micturition can be supported by drug treatment with parasympatholytics and/or alpha-blockers if the measured bladder pressure and residual urine are within tolerable limits. For electrostimulation of micturition, intravesical therapy, although timeconsuming, is best suited because it can easily be done on an outpatient basis. More promising seems bilateral sacral neuromodulation, which, however, is a rather complicated and expensive procedure. Surgical procedures to reduce the voiding resistance of the bladder involve the risk of postoperative incontinence because the sphincter function in those patients is often disturbed too. Persisting problems with bladder storage capacity as a result of tumor surgery in the small pelvis are frequently secondary to retention of urine (overflow incontinence). In these cases, regular evacuation of the bladder by intermittent self-catheterisation can lead to social acceptance. Reduced bladder compliance and lowering of the urethral leak pressure point may result in stress and urge incontinence, which, according to the established rules, should be managed by physiotherapy and behaviour therapy as well as drug therapy and only in exceptional cases by surgical measures. Prevention of postoperative bladder dysfunction can be tried by tissue- and nerve-sparing surgical techniques, but is always determined by oncological aspects.

Keywords

Postoperative bladder dysfunction  Pelvic surgery and urodynamic examination Parasympathetic detrusor muscle decentralisation Radical pelvic surgery complications  

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Copyright information

© Springer-Verlag 2003

Authors and Affiliations

  1. 1.Klinik für UrologieUniversitätsklinikum Charité, Campus MitteBerlin
  2. 2.Klinik für UrologieUniversitätsklinikum Charité, Campus MitteBerlin

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