RECONSTRUCTIVE UROLOGY

Free neurovascular transfer of latissimus dorsi muscle for the treatment of bladder acontractility: II. Clinical results
Ninkovic M, Stenzl A, Schwabegger A, Bartsch G, Prosser R
From the Departments of Plastic and Reconstructive Surgery, Urology, and Surgery, Unit of Physical Medicine & Rehabilitation, University of Innsbruck Medical Center, Innsbruck, Austria, and the Department of Urology, University of Tuebingen Medical Center, Tuebingen, Germany
J Urol. 2003; 169:1379-83

• 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. H2O (mean 72, median 55). None of the patients had morphological and functional changes of the upper tract, or de novo incontinence postoperatively.
• Conclusions: Functioning free muscle transplantation was able to restore voluntary voiding in patients who had previously been dependent on long-term catheterization. Voluntary voiding has been maintained several years postoperatively without deterioration of upper tract function.
  
• Editorial Comment
  Previous work had shown that functional muscle transplantation may also be useful for the treatment of patients with bladder acontractility. This paper now shows for the first time a larger series of patients treated with free neurovascular transfer of latissimus dorsi muscle with a mean follow-up of 44 months, with a minimum follow-up of 18 months. This technique was successful in 90% of the patients who all were catheterizing themselves prior to surgery for at least 2 years. However, not all of them succeeded with the muscle transfer procedure alone. 20% of the patients needed a uni- or bilateral bladder neck incision to be able to void spontaneously with a residual volume of less than 100 cc. Is of note that none of the patients developed urinary incontinence.
  The present study shows that restoration of intentionally voiding is possible in patients with bladder acontractility using careful selection criteria and with results which are persistent and do not lead to secondary complications in the long run.

Dr. Arnulf Stenzl
Professor and Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany