Denervation Procedures

Because the etiologic mechanisms for the development of the OAB may lie in the neural control of the detrusor muscle, denervation procedures of the overactive bladder muscle has been tried with varying success using both central and peripheral approaches. Surgical or chemical denervation can be used at central or peripheral levels to interrupt motor and/or sensory reflex pathways.

In general,the central denervation procedures involve the levels of sacral roots S3 and S4,which are responsible for the parasympathetic and somatic innervations to the lower urinary tract and pelvic organs. Unfortunately, achieving stabilization of bladder filling and increases in reflex trigger volumes can be obtained with a posterior root rhizotomy, yet the attendant complications of induced sensory loss and sexual dysfunction at this sacral level restricts these procedures to only people with complete spinal cord injuries resulting in neurogenic detrusor dysfunction. Our experience with central deafferentation through posterior root rhizotomy procedures are currently reserved for those cases in which the implantation of the Brindley device for driving bladder voiding in spinal cord patients is accomplished through anterior sacral root stimulation.

Peripheral nerve transection, cystolysis, bladder tran-section, myomectomy, autoaugmentation, and chemical nerve ablation procedures with phenol or alcohol have all been performed over the last 50 years with controversial short-term reporting and no significant improvement in long-term outcomes that warrant the complications associated with these procedures. Although Ingelman-Sundberg described a transvaginal approach for partial bladder denervation in 1959 that was later modified by Cespedes and McGuire1 and reported in 1996, the consistent, reproducibility of this minimally invasive procedure remains to be tested against other evolving procedures providing similar 1-year outcomes in a refractory group of OAB conditions. What remains a challenge to the pelvic health specialist is the inability to reproducibly induce urinary retention and continence with peripheral and central denervation procedures when colleagues from neu-rosurgery, gynecology, and colorectal surgery invariably refer their patients to us with these "complications" after routine procedures on the spine or pelvic organs.

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