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.
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.
Literatur
Bakke A, Malt U (1991) Quality of life and discomfort in patients treated with clean intermittent catheterization. Neurourol Urodyn 10: 305–306
Braun PM, Seif C, Scheepe JR et al. (2002) Chronische sakrale bilaterale Neuromodulation. Urologe A 41: 44–47
Bross S, Braun PM, Weiß J et al. (2003) Sakrale Neuromodulation bei nichtobstruktiver, chronischer Harnretention: Die Wertigkeit des Carbacholtests und der Einfluss der assoziierten Nervenläsion. Akt Urol 34: 157–161
Blandy JP, Fowler CG (1999) Urological considerations in colorectal surgery. In: Keighley MRB, Williams NS (eds) Surgery of the anus, rectum and colon, 2nd edn, vol II. WB Saunders, London
Buchsbaum HJ, Plaxe SC (1993) The urinary tract and radical hysterectomy. In: Buchsbaum HJ, Schmidt JD (eds) Gynecologic and obstetric urology, 3rd edn. WB Saunders, Philadelphia
Decter RM (2000) Intravesical electrical stimulation of the bladder: Urology 56: 5–8
Dwyer PL, O’Callaghan D (1993) Urinary dysfunction following radical hysterectomy; is there spontaneous inprovement with time? Neurourol Urodyn 12: 429–430
Farquharson DIM, Shingleton HM, Orr JW Jr et al. (1987) The short-term effect of radical hysterctomy on urethral and bladder function. Br J Obstet Gynec 94: 351–357
Ghoniem G (1994) Disorders of bladder compliance. In: Kursh ED, McGuire EJ (eds) Female urology. JB Lippincott, Philadelphia
Kemp B, Kitschke HJ, Goetz M, Heyl W (1997) Prophylaxis and treatment of bladder dysfunction after Wertheim-Meigs Operation: the positive effect of early postoperative detrusor stimulation using the cholinergic drug Betanecholchloride. Int Urogynecol J 8: 138–141
Madersbacher H, Kiss G, Kölle D, Mayr D (1995) Intravesikale Elektrostimulation zur Rehabilitation von Blasenfunktionsstörungen nach gynäkologischen Operationen. Urologe A 34 (Suppl 1): 46
Milani R, Maggioni A, Scalambrino S et al. (1991) Bladder function following randomization to two different radical hysterectomy procedure: a prospective study. Int Urogynecol J 2: 77–80
Miyai K, Usuda K, Takahashi T, Kitami K (1992) Intermittent catheterization on the patients following radical surgery in carcinoma of the rectum. Neurourol Urodyn 11: 415–416
Miyai K, Asakura T, Takahashi T (2002) Urinary incontinence following radical surgery in rectal cancer. Neurourol Urodyn 21: 331
Pavlakis AJ (1991) Cauda equina and pelvic plexus injury. In: Krane RJ, Siroky MB (eds) Clinical neurourology 2nd edn. Little, Brown & Comp, Boston
Petri E (1996) Bladder dysfunction after intraabdominal or vaginal surgery. In: Ostergard DR, Bent AE (eds) Urogynecology and urodynamics: Theory and practice, 4th edn. Williams & Wilkins, Baltimore
Primus G, Kramer G, Pummer K (1996) Restoration of micturition in patients with acontractile and hypocontractile detrusor by transurethral electrical bladder stimulation. Neurourol Urodyn 15: 489–497
Ralph G (1995) Dysfunktionen nach Radikaloperationen. In: Fischer W, Kölbl H (Hrsg) Urogynäkologie in Praxis und Klinik. Walter de Gruyter, Berlin
Riedl C, Daha L, Knoll M, Pfueger H (2002) Betanechol in the restitution of acontractile detrusor: a prospective, randomized, double-blind, placebo-controlled study. Neurourol Urodyn21: 376
Stöhrer M, Sauerwein D (2001) Der intermittierende Katheterismus bei neurogener Blasenfunktionsstörung. Urologe B 41: 362–368
Thomas PJ (1994) Pelvic plexus injury. In: Mundy AR, Stephenson TP, Wein AJ: Urodynamics, principles, practice and application. Churchill Livingstone, Edinburgh
Vervest H (1993) Changes in the function of the lower urinary tract after hysterectomy. Int Urogynecol J 4: 350–355
Wein AJ (2002) Neuromuscular dysfunction of the lower urinary tract and its management. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds) Campell’s urology, 8th edn. WB Saunders, Philadelphia
Zimmern PE (1996) Bladder dysfunction after radiation and radical pelvic surgery. In: Raz S: Femals urology, 2nd. edn. WB Saunders, Philadelphia
Zinner N, Dmochowski R, Miklos J et al. (2002) Duloxetine versus placebo in treatment of stress urinary incontinence (SUI). Neurourol Urodyn 21: 383–384
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Schönberger, B. Blasendysfunktion und Operationen im kleinen Becken. Urologe [A] 42, 1569–1575 (2003). https://doi.org/10.1007/s00120-003-0467-4
Issue Date:
DOI: https://doi.org/10.1007/s00120-003-0467-4
Schlüsselwörter
- Postoperative Blasendysfunktion
- Beckenchirurgie und Urodynamik
- Parasympathische Dezentralisation
- Komplikationen nach radikaler Beckenchirurgie