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Detrusormyoplastik bei akontraktiler Harnblase mittels freier neurovaskulärer Transplantation des M. latissimus dorsi — Experimentelle Studien

Dynamic detrusor myoplasty for the acontractile bladder — experimental studies

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Acta chirurgica Austriaca Aims and scope Submit manuscript

Zusammenfassung

Grundlagen: In tierexperimentellen Studien wurde die mögliche Anwendbarkeit eines freien Transfers des M. latissimus dorsi (LDM) zur Harnblase untersucht. Wir entwickelten Techniken, um die Entleerung eines der Harnblase entsprechenden Reservoirs durch einen quergestreiften Muskel zu verbessern. Durch diese Untersuchungen sollten Grundlagen für die funktionelle Verwendung des reinnervierten freien LDM-Lappens an der Blase geschaffen werden. Zusätzlich liegen erste klinische Erfahrungen bereits vor.

Methodik: Ein sogenanntes „Tensions-Torsions-Modell“ mit rekonfiguriertem LDM (spezielle sprialförmige Umhüllung eines am Rücken implantierten Silikonreservoirs) wurde über einen Zeitraum von 6 Monaten an 4 Hunden getestet. In einer 2. Serie wurde bei 4 Hunden ein an der Blasenkuppel durch Entfernung des Blasendetrusors gesetzter Defekt durch einen mikrochirurgisch zur Blase transferierten und reinnervierten LDM gedeckt. Urodynamische und bildgebende Studien erfolgten nach 6 und 9 Monaten.

Ergebnisse: Die nervale Stimulation des geometrisch rekonfigurierten LDM-Reservoirs nach 6 Monaten führte zu intraluminalen Drucken bis zu 190 cm H2O bei maximaler Kapazität (50 cm3, 100 cm3 bzw. 150 cm3) und 35 cm H2O bei einer Restkapazität derselben Reservoire von 10 ml (Korrelation zwischen Zeit der Stimulation, Füllungsvolumen und intraluminalem Druck). In der anderen Gruppe fÜhrte nach 9 Monaten die Stimulation des zur Blase transferierten LDM proximal der Nerv-Koaptierungsstelle zu einer sichtbaren und meßbaren Kontraktion des quergestreiften Muskels. Im Zystogramm waren keine Divertikel oder Fisteln erkennbar. Histochemische und elektronenmikroskopische Untersuchungen zeigten einen reinnervierten und vitalen quergestreiften Muskel.

Schlußfolgerungen: Ein mikrochirurgisch durchgeführter, freier Transfer des LDM an die Blase führt zu einem funktionell brauchbaren, reinnervierten Muskellappen, der sich zur Behandlung der denervierten, akontraktilen Blase eignen könnte. Durch Rekonfiguration des Muskels im Sinne des Tensions-Torsions-Modells kann die Entleerung von Reservoiren durch quergestreifte Muskeln verbessert werden.

Summary

Background: In this study we investigated the ability of the latissimus dorsi muscle (LDM) to evacuate a bladder reservoir in situ. Functional, anatomical, and histopathological data from partial or subtotal bladder reconstruction with innervated free LDM in mongrel dogs should be the basis for further clinical studies.

Methods: Group I (4 dogs): The LDM was dissected and tailored in situ, leaving the neurovascular bundle intact. To form a bladder-like reservoir, this pedicled LDM flap was wrapped around tissue expanders of varying sizes (a volume of 50 cm3, 100 cm3, and 150 cm3, respectively). At the time of surgery and 6 months thereafter standard Electromyography (EMG) and intraluminal pressure measurements were done using a Dantec urodynamic unit. Group II (4 dogs): In this group the bladder wall was removed up to 50% at the dome with the mucosal layer left intact. The resulting defect was covered with a free innervated LDM flap. The thoracodorsal vessels were anastomosed to pelvic branches of the hypogastric vessels and the thoracodorsal nerve was coapted to a pelvic motor nerve which was selected by use of a nerve stimulator. Taking particular care of the resting tension the transferred LDM was shaped and wrapped around the bladder in a spiral form.

Urodynamic studies and cystography were performed after 3, 6, and 9 months. EMG was done after 9 months prior to sacrification of the animals. Additionally, regular histological and electron microscopic examinations were done.

Results: After 6 months, stimulation of the thoracodorsal nerve of the reconfigurated LDM reservoirs in situ yielded average intraluminar pressures of 190 cm H2O at maximum capacity, and 35 cm H2O at a minimum capacity of 10 to 15 cm3 in group I. In group II, stimulation of the LDM which had been transferred to the bladder, resulted in a visible and measurable contraction of the transplanted muscle after 9 months. Urodynamic values pre- and postoperatively were basically unchanged. As revealed by cystography the bladder outline was smooth both during filling and voiding. Light and electron microscopic examination confirmed viable, reinnervated muscle.

Conclusions: After nerve stimulation the reconfigurated pedicled LDM has the ability to evacuate a bladder-like reservoir. A detrusor function of the bladder can be induced through the contractility of reinnervated free LDM which was wrapped around the bladder. An innervated free LDM flap does not undergo severe muscle fibrosis, contracture, and atrophy which occur after transfer of completely or partially denervated, pedicled muscle. This means that a functional bladder reconstruction/ augmentation can be achieved by microneurovascular transfer of a free LDM flap.

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Authors and Affiliations

  1. Universitätsklinik für Plastische und Wiederherstellungschirurgie, Anichstraße 35, A-6020, Innsbruck, Austria

    M. Ninković, A. Schwabegger & H. Anderl

  2. Universitätsklinik für Urologie, Austria

    A. Stenzl, K. Colleselli & G. Bartsch

  3. Institut für Histologie und Embryologie der Universität Innsbruck, Austria

    M. Hess

  4. Institut für Pathologische Anatomie der Universität Innsbruck, Austria

    H. Feichtinger

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  1. M. Ninković
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  2. A. Stenzl
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  3. M. Hess
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  4. H. Feichtinger
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  5. A. Schwabegger
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  6. K. Colleselli
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  7. G. Bartsch
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  8. H. Anderl
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Correspondence to M. Ninković.

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Die Arbeitsgruppe erhielt den „Billroth-Preis der Österreichischen Gesellschaft für Chirurgie 1997”.

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Ninković, M., Stenzl, A., Hess, M. et al. Detrusormyoplastik bei akontraktiler Harnblase mittels freier neurovaskulärer Transplantation des M. latissimus dorsi — Experimentelle Studien. Acta Chir Austriaca 30, 29–34 (1998). https://doi.org/10.1007/BF02619847

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