Reconstructive urology

Abstract

Purpose: Until now patients with bladder acontractility were destined to lifelong clean intermittent catheterization with all of its inherent risks. Previous experimental studies demonstrated that voluntary voiding can be restored by microneurovascular free transfer of a carefully selected muscle flap. We present the selection criteria, modifications in technique, follow-up schedule and long-term results in 20 patients treated with transplantation of latissimus dorsi muscle to the bladder.Materials and Methods: In 20 patients with bladder acontractility requiring intermittent catheterization for at least 2 years we performed latissimus dorsi detrusor myoplasty. Preoperative evaluation included urodynamic assessment, cystoscopy, upper tract imaging and electromyography of the rectus muscle. The procedure involves transfer of a free neurovascular latissimus dorsi muscle flap to the pelvis where it is anastomosed to the lowest motor branches of the intercostal nerve and deep inferior epigastric vessels. Patients were instructed to attempt voluntary voiding 3 months postoperatively. Follow-up included urodynamic evaluation, biannual Doppler ultrasonography and annual dynamic computerized tomography.Results: Annual dynamic computerized tomography and/or biannual Doppler ultrasonography demonstrated vascularization and contractility of all transplanted muscle flaps. Mean follow-up is 44 months (range 18 to 74). Of the 20 patients, 14 were able to void spontaneously within 4 months postoperatively with post-void residual volumes of less than 100 cc, voluntary voiding was restored by bladder neck incision in 4, and 2 (10%) still require self-catheterization. Postoperative detrusor pressures ranged from 5 to 218 cm. H 2 O (mean 72, median 55). None of the patients had morphological and functional changes of the upper tract, or de novo incontinence postoperatively.