|
| |
 |
|
| ORIGINAL ARTICLE |
|
| Year : 2018 | Volume
: 29
| Issue : 5 | Page : 237-242 |
|
Comparison of urodynamic bladder dysfunction in male patients with pelvic organ malignancies
Chian-Shiung Lin1, Mei-Jin Wu2, Cheng-Yao Lin3, Chih-Cheng Lu4
1 Division of Urology, Department of Surgery, Chi Mei Medical Center; Min-Hwei College of Health Care Management, Liouying, Tainan, Taiwan
2 Department of Nursing, National Cheng Kung University Hospital, Liouying, Tainan, Taiwan
3 Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University; Division of Hematology-Oncology, Department of Internal Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
4 Division of Urology, Department of Surgery, Chi Mei Medical Center, Liouying, Tainan; Department of Information Management System, National Chung Cheng University, Chiayi, Taiwan
| Date of Web Publication | 3-Sep-2018 |
Correspondence Address:
Chih-Cheng Lu
Department of Surgery, Division of Urology, Chi Mei Medical Center, No. 201, Taikang, Liouying, Tainan 736
Taiwan
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_30_18
Objective: Bladder dysfunction is a common complication after pelvic cancer treatments (radical pelvic surgery or chemoradiotherapy) that may affect patient satisfaction and quality of life. The aim of this study is to compare urodynamic bladder dysfunction among male patients with different pelvic organ malignancies (POMs). Materials and Methods: Data were collected from male patients with POM undergoing urodynamic studies (UDSs). Patients were stratified into three groups based on the origin of cancer (prostate, bladder, and colorectum). Selected data, including age, clinical tumor staging, lower urinary tract symptoms or acute urinary retention, and the parametric values of UDSs, were compared among the groups. SPSS 17.0.1 for Windows and Microsoft Office Excel 2007 were used for all statistical analysis. Results: A total of 640 patients with POM from the prostate (40.9%), bladder (33.5%), and colorectum (25.6%) were investigated. Patient age ranged from 39 to 89 years (mean 72.93 ± 9.08 years). In uroflowmetry (525 patients), the maximal urine flow rate was significantly lower in the prostate group (11.49 ± 5.53 ml/s). Cystometrograms (115 patients) showed that the first desire was more sensitive in the bladder group (85.52 ± 49.78 ml). Cystometric capacity was decreased in the prostate group (161.50 ± 94.29 ml); the maximum voiding pressure and compliance were significantly lower in the colorectum group (64.58 ± 50.09 cmH2O). Conclusion: Patients with POM may suffer from urination dysfunction. Impaired bladder function is more predominant in the colorectum oncology compared with urological pelvic organ (prostate or bladder) malignancies. Physicians are encouraged to be aware of these urinary complications after POM treatment.
Keywords: Bladder cancer, bladder function, colorectal cancer, prostate cancer, urodynamics
How to cite this article:
Lin CS, Wu MJ, Lin CY, Lu CC. Comparison of urodynamic bladder dysfunction in male patients with pelvic organ malignancies. Urol Sci 2018;29:237-42 |
| Introduction | |  |
Primary carcinomas of the pelvic organs are very common. In men, carcinoma of the prostate, colorectum, and urinary bladder accounts for approximately one-third of new cancer diagnoses.[1] In Taiwan, the incidence of male pelvic organ malignancies (POMs) (including carcinoma in situ) was in the top ten cancers in 2013; colorectal cancer was rankedfirst, prostate cancer fifth, and bladder cancer eighth. The mortality rates of colorectal, prostate, and bladder cancers were ranked third, seventh, and twelfth, respectively.[2] The principal curative treatments for cancer of the pelvic organs are radical surgery and radiotherapy. In addition to considering the cure rate, physicians design optional treatments that minimize posttherapy morbidity affecting the quality of life.[3]
Bladder dysfunction is a common complication after pelvic cancer treatment (radical pelvic surgery or chemoradiotherapy) that may affect patient satisfaction and quality of life. The causes of bladder dysfunction in males include aging, bladder outlet obstruction, denervation (pelvic neoplasms and trauma), and neurological disease.[4] The pelvic nerves consist of sympathetic nerves (the hypogastric plexus) emanating from the nerve roots T12, L1, and L2 and parasympathetic nerves (the pelvic plexus) arising from the sacral roots S2, S3, and S4. From the pelvic plexuses, numerous branches are distributed to the colorectum, bladder, and prostate.[5]
Injury to the pelvic autonomic nerves or pelvic plexuses can cause lower urinary tract dysfunction. Nerve involvement can result either from tumor invasion or surgical injury.[6]
Lower urinary tract function may be altered following the clinical/pathological staging or treatment of POM.[7] Urodynamic studies (UDSs) allow the direct assessment of bladder function by measuring objective pathophysiological parameters to identify the underlying causes for lower urinary tract symptoms (LUTSs).[8]
The aim of this study was to compare bladder dysfunction among male patients with different POMs through objective urodynamics.
| Materials And Methods | | |
Patient population
Between January 2010 and February 2015, the source of retrospective data included 10,778 patients presenting with LUTS or urinary retention underwent urodynamics at the urological outpatient department at a regional teaching hospital. Underscreening inclusion criteria (prostate, bladder, or colorectal cancers) and exclusion criteria (female gender, history of radical cystectomy, history of stroke, history of central nervous system surgery, and other neurological diseases), a total of 640 male patients with POMs were investigated in our studies. The study protocol was approved by the Institutional Board Review (IRB Serial No: 10407-L02). Collected data included gender, age, pelvic organ cancer origin (prostate, bladder, or colorectum), clinical tumor staging (American Joint Committee on Cancer[9]), treatments, and urinary symptoms (LUTS or acute urinary retention [AUR]).
Treatment options for the POMs investigated included operation, radiotherapy and/or chemotherapy, hormone therapy, or active surveillance. Surgical methods were divided into radical prostatectomy for prostate cancer; the organ conservation of transurethral resection of bladder tumor (TUR-BT) and/or partial cystectomy for bladder cancer; and lower abdominal resection (LAR) or abdominal perineal resection (APR) for colorectal cancer.
LUTSs were defined as one or more of the following symptoms: storage and voiding symptoms. Voiding symptoms included weak or intermittent urinary stream, straining, hesitancy, terminal dribbling, and incomplete emptying. Storage symptoms included urgency, frequency, incontinence, and nocturia.
Urodynamic evaluation
In this study, bladder function was assessed by UDS with a multichannel solar urodynamics system (Medical Measurement Systems BV Colosseum 25, 7521 PV Enschede, the Netherlands). Appropriate urodynamic tests were conducted according to the LUTS or urinary retention. In these patients, urinalysis was performed before the procedure to exclude urinary tract infection. Urodynamic procedures were supervised by an experienced urological physician. Urodynamic parameters included uroflowmetry by analyzing maximum urine flow rates, mean urine flow rates, voided volume, and postvoid residual urine and cystometrogram (CMG) at an infusion rate of 30 ml/min by analyzing volume atfirst sensation, maximum voiding pressure, maximum cystometric capacity, and compliance. Bladder detrusor contraction pressure was defined as intravesical pressure minus abdominal pressure. Bladder detrusor contraction was divided into four categories: normal (pressure: 20–40 cmH2O), neurogenic detrusor overactivity (NDO, pressure >40 cmH2O), neurogenic detrusor underactivity (NDU, pressure <20 cmH2O), and neurogenic detrusor areflexia (NDA, pressure: 0 cmH2O).[10],[11]
Compliance referred to the volume and pressure relationship of bladder filling (change in volume/change in pressure; ΔV/ΔP). A cutoff of bladder compliance was below 15 ml/cmH2O to define poor compliance.[8],[12],[13]
Statistical analysis
Mean and standard deviation (SD) were calculated for age, parameters of uroflowmetry (maximum urine flow rates, mean urine flow rates, voided volume, and postvoid residual urine), and parameters of CMG (volume atfirst sensation, maximum voiding pressure, and maximum cystometric capacity), and count and percentage were calculated for clinical cancer staging, treatment, urinary symptoms, bladder compliance, and four detrusor contraction categories. Baseline patient characteristics and differences in the urodynamic parameters in the sequential UDS were evaluated by one-way ANOVA, Chi-square test, and Fisher's exact test to investigate significance among groups, and P < 0.05 was considered statistically significant. SPSS 17.0.1 for Windows (SPSS Inc., Chicago, IL, USA) and Microsoft Office Excel 2007 (Microsoft, Redmond, WA, USA) were used for all statistical analyses.
| Results | | |
Baseline characteristics are shown in [Table 1]. Male patients with POMs were stratified into three groups: prostate (262/640, 40.9%), bladder (214/640, 33.5%), and colorectum (164/640, 25.6%). Age ranged from 39 to 89 years (mean: 72.93 ± 9.08 years). Age, clinical tumor staging, and treatments were significantly different among the three groups including older age in the prostate group (75.43 ± 6.49 years, P < 0.001), early clinical staging in the bladder group (148/214, 69.2%, P < 0.001), and a higher ratio of radical pelvic surgery in the colorectum group (155/164, 94.5%, P < 0.001). There was a significantly higher rate of AUR in the colorectum group (50/164, 30.5%, P < 0.001). Moreover, patients with AUR were younger in the colorectum group (71.36 ± 12.43, P = 0.016). | Table 1: Baseline characteristics of 640 patients with pelvic organ oncology
Click here to view |
Urodynamic parameters and abnormalities are shown in [Table 2], [Table 3], [Table 4] and [Figure 1]. | Table 2: Lower urinary tract symptoms or acute urinary retention in 640 patients with pelvic organ oncology
Click here to view |
 | Table 3: The parameters of uroflowmetry in 525 patients with lower urinary tract symptoms
Click here to view |
 | Table 4: The parameters of cystometrogram and sphincter electromyography in 115 patients with acute urinary retention
Click here to view |
 | Figure 1: Proportion of bladder dysfunction (neurogenic detrusor underactivity and areflexia) among three patient groups in 115 pelvic organ oncology patients with acute urinary retention. Bladder dysfunction was clearly poor in patients with colorectal cancer (P = 0.001, one-way ANOVA)
Click here to view |
Uroflowmetry
During the study period (from January 2010 to February 2015), there were 525 male patients with POMs exhibiting LUTSs on urodynamic testing. Age ranged from 44 to 89 years (mean: 72.59 ± 8.75 years). Among the three groups, the mean ± SD of maximum urine flow rates, mean urine flow rates, and voided volume were significantly lower in the prostate group (11.49 ± 5.53 ml/s, P < 0.001; 5.16 ± 2.95, P < 0.001; 176.76 ± 112.28, P = 0.002, respectively). Significantly higher postvoid residual urine was identified in the prostate group (77.47 ± 62.09, P = 0.031).
Cystometrogram
There were 115 male patients with POMs presenting with AUR on urodynamic testing. Age ranged from 39 to 88 years (mean: 74.48 ± 10.34 years). Among the three groups, thefirst desire volume and maximum cystometric capacity were significantly decreased in the bladder group (85.52 ± 49.78 ml, range: 17–186 ml, P = 0.009 and 130.26 ± 96.41 ml, range: 17–325 ml, P = 0.013, respectively); the maximum voiding pressure was clearly increased in the bladder group (107.30 ± 69.60 cmH2O, range: 0–247 cmH2O, P = 0.005). In contrast, the maximum voiding pressure and compliance were significantly lower in the colorectum group (64.58 ± 50.09 cmH2O, P = 0.005 and 36.0%, P = 0.01, respectively).
| Discussion | | |
To the best of our knowledge, the present study is thefirst to compare bladder dysfunction by urodynamics among male patients after treatment for different POMs. There are several urodynamic reports describing single pelvic organ malignancy after treatment.[3],[4] POMs may deteriorate the normal bladder function through either neurogenic or myogenic pathways.[14] The neoplasms of the pelvic organs will result in bladder dysfunction if the pelvic nerves that supply the bladder are damaged.[7] Apart from survival outcomes, physicians and patients are focusing on functional and adverse complications after treatments.
The normal bladder has a dual function involving both urine storage and emptying. The innervations of bladder function include the autonomic (sympathetic and parasympathetic nerves) and somatic (somatic nerves) systems. The sympathetic system innervating the bladder arises from the sympathetic chain at the T11–L2 levels, entering the pelvis through the hypogastric nerve synapse in the pelvic plexus. These predominate in the storage phase. The parasympathetic system from S2 to S4 levels traverses the pelvis through the pelvic nerve and enters the pelvic plexus.[15] This system plays a major role in the emptying phase. From the pelvic plexuses, numerous branches are distributed to the colorectum, bladder, and prostate.[5]
In our study, older age, advanced tumor staging, and organ conservative treatments were obvious in the prostate cancer group. In our UDSs, maximum urine flow rates, mean urine flow rates, and voided volume were significantly lower in the prostate group. Incomplete urine emptying was also prevalent in this group. Voiding dysfunction may be explained by bladder outlet obstruction due to prostate cancer itself and organ preservative treatments (hormone therapy, active surveillance, and radiotherapy) conducted in Taiwan. Metastatic prostate cancer is significantly higher in Taiwan's Chinese population than in the general American population (32.7% vs. 5%).[16]
Nearly 90% of prostatic metastases are invasive to the spine, with the lumbar spine three times more likely to be damaged than the cervical spine. Spinal metastases may lead to spinal cord compression with the resulting symptoms of spinal cord compression, including progressive localized back pain, muscle weakness, and autonomic dysfunction causing LUTS or urinary retention.[17] Although up to 80% of patients will have objective or subjective symptoms improved after hormone therapy, the duration of benefit is usually temporary.[18]
In patients with locally advanced prostate cancer, bladder outlet obstructive symptoms can be relatively common. Palliative transurethral prostatectomy can be performed in patients with advanced prostate cancer with clear improvement in obstructive voiding symptoms.[19]
Treatment options for localized prostate cancer include radical prostatectomy or radical radiotherapy. The anatomy and function of the bladder are changed following radical surgery or radiotherapy.[17] The development of bladder dysfunction may be related to bladder denervation after radical surgery.[20] Leach et al. identified bladder dysfunction as a major factor of incontinence in approximately 60% of 215 patients after radical prostatectomy.[21] In another study, Chung et al. identified detrusor underactivity in 41% of all patients (108/264) undergoing UDSs.[22]
As for the bladder itself, radiotherapy can cause capillary destruction with ischemia and tissue fibrosis, relative tissue hypoxia, inflammation mediated by oxygen reactive species, and decreased supply of nutrients.[23] Irritative symptoms from the pelvic organs are common, including LUTSs in addition to erectile dysfunction and proctitis.[24]
In our study, bladder hypersensitivity, decreased maximum cystometric capacity, and increased maximum voiding pressure were apparent in the bladder cancer group. The possible reasons for this may be explained by bladder conservative treatment modality (TUR-BT, 87.7%) and/or adjuvant intravesical chemotherapy or immunotherapy. Due to 75%–85% of bladder cancers are superficial, TUR-BT tends to be the major choice of treatment.[25] Bladder preservation treatments may result in lower urinary tract dysfunctions due to bladder cancer itself and/or TUR-BT that may injure the bladder and intravesical autonomic nerves. In addition to surgery, the peripheral nerves innervating the bladder may be altered by chemotherapeutic drugs and/or irradiation.[24]
Bladder urothelial cells maintain tight barrier function for local factors such as bacterial infection, mechanical or chemical trauma, and ischemia. When the bladder urothelium is injured, water, urea, and toxic agents can pass into the underlying tissue including bladder, neural, and/or muscle layers, resulting in bladder storage dysfunction such as urgency or frequency.[26] Furthermore, the common side effects associated with intravesical chemotherapy are described as irritative LUTSs (dysuria, frequency, or urgency), hematuria, and other adverse complications, such as decreased bladder capacity and paralytic ileus.[27]
Radical cystectomy and radiotherapy are two major curative treatments for muscle-invasive bladder cancer. In addition to considering cure rate, physicians design a treatment plan that minimizes posttherapy morbidity affecting the quality of life.[3] Radiotherapy can preserve the bladder; however, pelvic organ function may be changed because of injury to the surrounding nerves, blood vessels, sphincter, bowel, and bladder functions following irradiation.[28]
In our studies, bladder voiding dysfunction (NDU and NDA) was significantly higher in the colorectal cancer group. Furthermore, there were two bladder storage dysfunctions exhibiting statistically significant differences in the colorectal cancer group: impaired bladder compliance and relative hyposensitive bladder. The most common reasons for this may be related to a high ratio of radical pelvic surgery (APR or LAR, 82%, P < 0.0001). After pelvic surgery, the incidence of bladder dysfunction was 40%–60%. Male gender, age, preexisting urinary tract diseases, the tumor itself, surgeon's experience, preoperative radiotherapy, and surgical methods (LAR, abdominoperineal resection, or total mesorectal excision) represent the principal factors underlying postoperative low urinary tract dysfunction.[5],[6]
In addition to LUTSs, some papers have reported that the incidence of AUR was 24% in men and 15% in women after pelvic surgery.[29] The pelvic autonomic nerves consist of the sympathetic (superior hypogastric plexus and hypogastric nerves) and parasympathetic (inferior hypogastric or pelvic plexus and branches of the pelvic plexus) systems. Surgical resection includes the tumor, part of the healthy colon or rectum, and surrounding lymph node tissue. Injury to the pelvic autonomic nerves can cause lower urinary tract dysfunction. Pelvic nerve injury can result either from tumor invasion or surgical error during the dissection technique. Appropriate identification and preservation of the pelvic autonomic nerves is associated with a decrease in the development of bladder dysfunction.[6]
This study has several limitations. First, the time of occurrence of urinary retention after treatments was variable in patients with different POMs and different managements, such as time of occurrence of urinary retention ranged from 0 to 6 months after surgery in our study. Second, there were different behaviors among POMs including histological characteristics, different clinical or pathological staging, and the guideline of therapy. There are different factors to cause bladder dysfunction, and the exact cause is not always easy to find. UDSs are the most important tools in delineating pathophysiology of urinary retention after cancer treatment but may have difficulty in interpretation of data obtained. Third, future prospective studies should aim to compare urinary function before and after treatment among patients with prostate cancer, bladder cancer, or colorectal cancer.
| Conclusion | | |
Male patients exhibiting POMs may suffer from urination dysfunction. This is thefirst article to compare bladder dysfunction by urodynamics among male patients after treatment for different POMs. Impaired bladder function is more predominant in the colorectum oncology compared with urological pelvic organ (prostate or/and bladder) malignancies. The reasons for this may be related to a high ratio of radical pelvic surgery in patients with colorectal cancer, and organ conservative treatment modality is common in patients with bladder and prostate cancer among the Taiwanese population. Physicians are, therefore, encouraged to be aware of these urinary complications in male patients with POMs after treatment.
Acknowledgments
This study was supported in part by grant CLFHR10425 from the Chi-Mei Medical Center, Liouying.
Financial support and sponsorship
This study was supported in part by grant CLFHR10425 from the Chi Mei Medical Center, Liouying.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Boring CC, Squires TS, Tong T. Cancer statistics, 1991. CA Cancer J Clin 1991;41:19-36.  |
| 2. | |
| 3. | Fokdal L, Høyer M, Meldgaard P, von der Maase H. Long-term bladder, colorectal, and sexual functions after radical radiotherapy for urinary bladder cancer. Radiother Oncol 2004;72:139-45. |
| 4. | Drake MJ, Williams J, Bijos DA. Voiding dysfunction due to detrusor underactivity: An overview. Nat Rev Urol 2014;11:454-64. |
| 5. | Junginger T, Kneist W, Heintz A. Influence of identification and preservation of pelvic autonomic nerves in rectal cancer surgery on bladder dysfunction after total mesorectal excision. Dis Colon Rectum 2003;46:621-8. |
| 6. | Eveno C, Lamblin A, Mariette C, Pocard M. Sexual and urinary dysfunction after proctectomy for rectal cancer. J Visc Surg 2010;147:e21-30. |
| 7. | Possover M, Chiantera V. Neuromodulation of the superior hypogastric plexus: A new option to treat bladder atonia secondary to radical pelvic surgery? Surg Neurol 2009;72:573-6. |
| 8. | Schäfer W, Abrams P, Liao L, Mattiasson A, Pesce F, Spangberg A, et al. Good urodynamic practices: Uroflowmetry, filling cystometry, and pressure-flow studies. Neurourol Urodyn 2002;21:261-74. |
| 9. | Edge SB, Byrd DR, Comptom CC, Fritz AG, Greene FL, Trotti A. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 7 th ed. New York: Springer; 2010. p. 143-506. |
| 10. | Tanagho EA, McAninch JW, editors. Smith's General Urology. 17 th ed. New York: San Francisco; 2007. p. 461. |
| 11. | Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology of lower urinary tract function: Report from the standardisation sub-committee of the international continence society. Neurourol Urodyn 2002;21:167-78. |
| 12. | Cho SY, Yi JS, Oh SJ. The clinical significance of poor bladder compliance. Neurourol Urodyn 2009;28:1010-4. |
| 13. | Amir B, Farrell SA; Sub-Committee on Urogynaecology. SOGC committee opinion on urodynamics testing. J Obstet Gynaecol Can 2008;30:717-21. |
| 14. | Osman NI, Chapple CR. Contemporary concepts in the aetiopathogenesis of detrusor underactivity. Nat Rev Urol 2014;11:639-48. |
| 15. | Plotti F, Angioli R, Zullo MA, Sansone M, Altavilla T, Antonelli E, et al. Update on urodynamic bladder dysfunctions after radical hysterectomy for cervical cancer. Crit Rev Oncol Hematol 2011;80:323-9. |
| 16. | Kuo SC, Hung SH, Wang HY, Chien CC, Lu CL, Lin HJ, et al. Chinese nomogram to predict probability of positive initial prostate biopsy: A study in Taiwan region. Asian J Androl 2013;15:780-4. |
| 17. | Benjamin R. Neurologic complications of prostate cancer. Am Fam Physician 2002;65:1834-40. |
| 18. | Smith JA Jr., Soloway MS, Young MJ. Complications of advanced prostate cancer. Urology 1999;54:8-14. |
| 19. | Crain DS, Amling CL, Kane CJ. Palliative transurethral prostate resection for bladder outlet obstruction in patients with locally advanced prostate cancer. J Urol 2004;171:668-71. |
| 20. | Irwin DE, Milsom I, Hunskaar S, Reilly K, Kopp Z, Herschorn S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: Results of the EPIC study. Eur Urol 2006;50:1306-14. |
| 21. | Leach GE, Trockman B, Wong A, Hamilton J, Haab F, Zimmern PE, et al. Post-prostatectomy incontinence: Urodynamic findings and treatment outcomes. J Urol 1996;155:1256-9. |
| 22. | Chung DE, Dillon B, Kurta J, Maschino A, Cronin A, Sandhu JS, et al. Detrusor underactivity is prevalent after radical prostatectomy: A urodynamic study including risk factors. Can Urol Assoc J 2013;7:E33-7. |
| 23. | Gabka CJ, Benhaim P, Mathes SJ, Scheuenstuhl H, Chan A, Fu KK, et al. An experimental model to determine the effect of irradiated tissue on neutrophil function. Plast Reconstr Surg 1995;96:1676-88. |
| 24. | Sekido N, Miyanaga N, Kikuchi K, Takeshima H, Akaza H. Lower urinary tract function after intra-arterial chemotherapy with concurrent pelvic radiotherapy for invasive bladder cancer. Jpn J Clin Oncol 1999;29:479-84. |
| 25. | Biagioli MC, Fernandez DC, Spiess PE, Wilder RB. Primary bladder preservation treatment for urothelial bladder cancer. Cancer Control 2013;20:188-99. |
| 26. | Birder L, de Groat W, Mills I, Morrison J, Thor K, Drake M, et al. Neural control of the lower urinary tract: Peripheral and spinal mechanisms. Neurourol Urodyn 2010;29:128-39. |
| 27. | Koya MP, Simon MA, Soloway MS. Complications of intravesical therapy for urothelial cancer of the bladder. J Urol 2006;175:2004-10. |
| 28. | Marks LB, Carroll PR, Dugan TC, Anscher MS. The response of the urinary bladder, urethra, and ureter to radiation and chemotherapy. Int J Radiat Oncol Biol Phys 1995;31:1257-80. |
| 29. | Mariette C, Alves A, Benoist S, Bretagnol F, Mabrut JY, Slim K, et al. Perioperative care in digestive surgery. Guidelines for the French society of digestive surgery (SFCD). Ann Chir 2005;130:108-24. |
[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4]
|
Search Pubmed for