Urinary Retention

This complication is seen in about 16% of proctec-tomies[109,110] but fortunately when it happens it is usually transitory. Both sexes are at risk, although the highest incidence is in older men with benign prostatic enlargement [109,110]. Other contributing factors include history of bladder over-distension, poor bladder contractility and inhibition of the micturition reflex secondary to pain. It also may be more common in long-term anti-cholinergic users [110].

Bladder dysfunction often results from direct damage to the autonomic nerve plexus during pelvic dissection. Critical areas are represented by the pos-terolateral ligaments, where both sympathetic and parasympathetic branches constitute the inferior hypogastric plexus, the anterolateral ligaments and anteriorly the plane of Denonvilliers' fascia, which protects the vesical and prostatic plexus [111]. A complete section of nerve trunks is less common but results in permanent lesion. More often nerves are stretched or peripheral branches are sectioned, resulting in transitory problems [112]. The most frequent abnormality is temporary loss of bladder sensation [113]. Less frequently, damage can result as detrusor hypocontractility, bladder neck incompetence, loss of bladder compliance, bladder outlet obstruction[114,115].

A better knowledge of the pelvic anatomy and application of TME surgery and nerve sparing techniques, both for malignant and benign colorectal disease, have been essential in minimising this problem [111, 116-118]. In a Dutch series of 76 patients who received a proctocolectomy with TME followed by an ileal pouch-anal anastomosis, the incidence of severe bladder dysfunction was zero [119].

Usually retention can be prevented if the catheter is left in situ for at least 48-72 h postoperatively. Prophylactic administration of alpha adrenergic blockade has been effective in some series [120,121], while the use of parasympathicomimetic drugs did not show any benefit [122].

Urological consultation and urodynamic studies are suggested when retention persists beyond a week. However, most of these cases settle after 2-4 weeks of intermittent self-catheterisation. Sometimes resolution of symptoms requires a longer period. Del Rio et al. [123] followed-up of 14 patients in whom micturition disorders were still present 3 months after the operation and noticed that 6 of them were still symptomatic after 12 months and 3 after 3 years. Patients with permanent damage are doomed to intermittent self-catheterization.

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