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A New Technique for Diverticulectomy of the Bladder: A Preliminary Report
A NEW TECHNIQUE FOR DIVERTICULECTOMY OF THE BLADDER: A PRELIMINARY REPORT WILFORD A. COUNCILL From the James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore
It is the purpose of this paper to describe a new operative technique for diverticula of the urinary bladder and to make a preliminary case report. The technique is executed intravesically with the aid of a rubber balloon which envelopes the end of a urethral catheter. The balloon may be made from finger cots, the fingers of a rubber glove, or from a special type balloon. They are tied over a No. 24 F. rubber catheter with thread, gut or a rubber band which is reinforced with rubber tape (fig. 1) . The balloon is inflated with an ordinary atomizer bulb (fig. 1) . Cystograms should always be made to predetermine the size and type of balloon to be used. The usual suprapubic approach is made to the bladder, the peritoneum reflected and the bladder opened and held with Young's self retaining retractor (fig. 2, 2) . One or both ureters are catheterized if necessary, and the diverticulum located. The balloon tipped end is introduced into the sac (fig. 2, 2) partly inflated and the catheter clamped. A purse-string suture of No. 1 plain catgut is taken around the orifice, tightly tied to the catheter and retied on the opposite side. A second purse-string suture running in the opposite direction is taken and tied as above (fig. 2, 3) . This holds the balloon firmly in the diverticulum, thus facilitating dissection. The balloon is further inflated to fit the diverticulum snugly, and the catheter clamped at the distal end. An incision is made through the mucous and submucous coats 0.5 cm. from the purse-string sutures and after encircling same, the resection is carried out distal to the inflated balloon using the catheter as a tractor (fig. 2, 4) . After excision of the sac (fig. 3, 1- 2) , a Penrose drain is carried down to the cavity extravesically and then brought out through a stab wound laterally. The opening in the bladder is closed with continous No . 1 plain gut (fig. 3, 3), and a Pezzer catheter left in place for suprapubic drainage. The bladder is closed with continuous No . 1 chromic catgut, and the muscles and fascia with interrupted No . 2 chromic catgut. A small drain is left in the space of Retzius and the skin closed with interrupted black silk. 382
DIVERTICULECTOMY OF BLADDER
383
The time of election for the correction of the obstruction depends on the type encountered. In the following case, it was elected to make the correction immediately following the diverticulectomy. B.U.I. 29375, R. N., aged 46, was first examined March 1, 1939. He complained of gastric pain and hematuria. For the past 5 years he had been troubled with frequency, burning and an inability to completely empty his bladder. On February 20, 1939, he passed blood for the first time. This
FIG. 1. Various types of balloons and atomizer bulb used for inflation
continued for 1 week after which acute retention developed, and he had to be catheterized for relief. The patient was a well developed white male and appeared to be in perfect health. His heart and lungs were negative. Abdomen and external genitalia were normal. Rectal: Sphincter relaxed, many hemorrhoids. The prostate was small and firm but freely movable, no nodules or adhesions. Seminal vesicles, were negative. Urine: cloudy, specific gravity 1.020, acid, negative for sugar, albumin 1 plus; Microscopic, epithelial cells, pus, blood and bacteria, no casts. Cultures: Staphylococcus albus and B. coli. On cystoscopic examination, the residual urine was 100 cc.; bladder capacity
384
WILFORD A. COUNCILL
300 cc. As a whole the bladder was markedly trabeculated and inflamed. The ureteral orifices were normal in site and function, the trigone depressed. The vesical neck was contracted. On the posterior wall, just to the outside
Rubber ba5 f a5lened lo cath.et er to be ir,serted into divertic uI urn and lh.en. dietended wiltc ai1~
1
Ba?, in diverticu\u
kino incisiorc
d.i~lended and -oli3ht traclion made on tu be
arouncl ont1ce of'
diverhculum external
lo pur0e-otrin.5
a'5 suture0
are plac<,,d
0utures and
l_/
on traction. (
FIG, 2, Diverticulectomy, 1, Bag to be introduced into diverticulum, distended with air, to be used as a tractor to facilitate dissection, 2, Bladder opened in midline, Young's self-retaining retractor in position giving excellent exposure, Bag is shown being inserted into orifice of diverticulum, 3, Bag has been distended with air, purse-string sutures are placed around orifice of diverticulum and then tied around catheter to hold bag in diverticulum, 4, Traction made on bag as wall of bladder around orifice of diverticulum is incised.
385
DIVERTICULECTOMY OF BLADDER
Pistended ba5 ·~ in. divBr-\:icu\urn.\ ?~rse-etrin~ <2>utureG ~-hed aroun.cf' cath.e.:ter J
of bladder
aner remo al of di verticulum
FIG. 3. Diverticulectomy. 1, Freeing diverticulum by blunt dissection. Traction maintained on catheter attached to bag. Distended bag outlines diverticulum and helps to maintain proper line of cleavage between wall of diverticulum and surrounding tissues. 2, Sectional view shows distended bag filling diverticulum and method of holding bag in· diverticulum by means of purse-string sutures at orifice. 3, Extravesical drain placed down to site of diverticulum. Suture of defect in bladder wall after removal of diverticulum.
386
WILFORD A. COUNCILL
and above the right ureteral orifice, was an opening 0.5 cm. in diameter. From this opening exuded bright red blood. The cavity was explored and there was found on the posterior wall a tumor approximately 0.5 by 1 cm. This was desiccated and in due course of time completely destroyed.
FIG. 4. X-ray of diverticulum on right posterior wall
Catheter a1tactcid to balloon. FIG. 5. Diverticulum removed with inflated balloon
He was examined from time to time and on April 8, 1940, entered the Brady Urological Institute for surgical relief. His urine was infected, the cultures showing Staphylococcus albus and B. coli. The phthalein was 50 per cent for the first hour; 30 per cent for the second. Non-protein nitrogen was 30 mg. per 100 cc. of blood, hemoglobin 90 per cent, sugar 100, red blood cells 5,500,000, white blood cells 11,000. Blood Wasserman negative.
DIVERTICULECTOMY OF BLADDER
387
A plain x-ray was negative, but a stereoscopic cystogram revealed a diverticulum 6 by 8 cm. on the posterior wall of bladder (fig. 4). The operative technique described above and a punch operation for the obstruction at the vesical neck were performed April 10. A Foley bag was used for urethral drainage and was left in place for 10 days. The extravesical drain was removed on the fifth day and the Pezzer catheter on the tenth. He voided on the twelfth day, and the suprapubic wound healed on the nineteenth. SUMMARY
A new operative technique has been presented for the cure of diverticulum of the bladder. The inflated balloon serves as a guide and buffer and the catheter as an excellent tractor. This method not only insures an excellent exposure but changes a difficult operation into a relatively simple one. I am of the opinion that any diverticulum of the bladder can be removed by this simple procedure, provided the balloon fits the diverticulum snugly.
9 E. Mt. Royal Ave., Baltimore, Md.
It is the purpose of this paper to describe a new operative technique for diverticula of the urinary bladder and to make a preliminary case report. The technique is executed intravesically with the aid of a rubber balloon which envelopes the end of a urethral catheter. The balloon may be made from finger cots, the fingers of a rubber glove, or from a special type balloon. They are tied over a No. 24 F. rubber catheter with thread, gut or a rubber band which is reinforced with rubber tape (fig. 1) . The balloon is inflated with an ordinary atomizer bulb (fig. 1) . Cystograms should always be made to predetermine the size and type of balloon to be used. The usual suprapubic approach is made to the bladder, the peritoneum reflected and the bladder opened and held with Young's self retaining retractor (fig. 2, 2) . One or both ureters are catheterized if necessary, and the diverticulum located. The balloon tipped end is introduced into the sac (fig. 2, 2) partly inflated and the catheter clamped. A purse-string suture of No. 1 plain catgut is taken around the orifice, tightly tied to the catheter and retied on the opposite side. A second purse-string suture running in the opposite direction is taken and tied as above (fig. 2, 3) . This holds the balloon firmly in the diverticulum, thus facilitating dissection. The balloon is further inflated to fit the diverticulum snugly, and the catheter clamped at the distal end. An incision is made through the mucous and submucous coats 0.5 cm. from the purse-string sutures and after encircling same, the resection is carried out distal to the inflated balloon using the catheter as a tractor (fig. 2, 4) . After excision of the sac (fig. 3, 1- 2) , a Penrose drain is carried down to the cavity extravesically and then brought out through a stab wound laterally. The opening in the bladder is closed with continous No . 1 plain gut (fig. 3, 3), and a Pezzer catheter left in place for suprapubic drainage. The bladder is closed with continuous No . 1 chromic catgut, and the muscles and fascia with interrupted No . 2 chromic catgut. A small drain is left in the space of Retzius and the skin closed with interrupted black silk. 382
DIVERTICULECTOMY OF BLADDER
383
The time of election for the correction of the obstruction depends on the type encountered. In the following case, it was elected to make the correction immediately following the diverticulectomy. B.U.I. 29375, R. N., aged 46, was first examined March 1, 1939. He complained of gastric pain and hematuria. For the past 5 years he had been troubled with frequency, burning and an inability to completely empty his bladder. On February 20, 1939, he passed blood for the first time. This
FIG. 1. Various types of balloons and atomizer bulb used for inflation
continued for 1 week after which acute retention developed, and he had to be catheterized for relief. The patient was a well developed white male and appeared to be in perfect health. His heart and lungs were negative. Abdomen and external genitalia were normal. Rectal: Sphincter relaxed, many hemorrhoids. The prostate was small and firm but freely movable, no nodules or adhesions. Seminal vesicles, were negative. Urine: cloudy, specific gravity 1.020, acid, negative for sugar, albumin 1 plus; Microscopic, epithelial cells, pus, blood and bacteria, no casts. Cultures: Staphylococcus albus and B. coli. On cystoscopic examination, the residual urine was 100 cc.; bladder capacity
384
WILFORD A. COUNCILL
300 cc. As a whole the bladder was markedly trabeculated and inflamed. The ureteral orifices were normal in site and function, the trigone depressed. The vesical neck was contracted. On the posterior wall, just to the outside
Rubber ba5 f a5lened lo cath.et er to be ir,serted into divertic uI urn and lh.en. dietended wiltc ai1~
1
Ba?, in diverticu\u
kino incisiorc
d.i~lended and -oli3ht traclion made on tu be
arouncl ont1ce of'
diverhculum external
lo pur0e-otrin.5
a'5 suture0
are plac<,,d
0utures and
l_/
on traction. (
FIG, 2, Diverticulectomy, 1, Bag to be introduced into diverticulum, distended with air, to be used as a tractor to facilitate dissection, 2, Bladder opened in midline, Young's self-retaining retractor in position giving excellent exposure, Bag is shown being inserted into orifice of diverticulum, 3, Bag has been distended with air, purse-string sutures are placed around orifice of diverticulum and then tied around catheter to hold bag in diverticulum, 4, Traction made on bag as wall of bladder around orifice of diverticulum is incised.
385
DIVERTICULECTOMY OF BLADDER
Pistended ba5 ·~ in. divBr-\:icu\urn.\ ?~rse-etrin~ <2>utureG ~-hed aroun.cf' cath.e.:ter J
of bladder
aner remo al of di verticulum
FIG. 3. Diverticulectomy. 1, Freeing diverticulum by blunt dissection. Traction maintained on catheter attached to bag. Distended bag outlines diverticulum and helps to maintain proper line of cleavage between wall of diverticulum and surrounding tissues. 2, Sectional view shows distended bag filling diverticulum and method of holding bag in· diverticulum by means of purse-string sutures at orifice. 3, Extravesical drain placed down to site of diverticulum. Suture of defect in bladder wall after removal of diverticulum.
386
WILFORD A. COUNCILL
and above the right ureteral orifice, was an opening 0.5 cm. in diameter. From this opening exuded bright red blood. The cavity was explored and there was found on the posterior wall a tumor approximately 0.5 by 1 cm. This was desiccated and in due course of time completely destroyed.
FIG. 4. X-ray of diverticulum on right posterior wall
Catheter a1tactcid to balloon. FIG. 5. Diverticulum removed with inflated balloon
He was examined from time to time and on April 8, 1940, entered the Brady Urological Institute for surgical relief. His urine was infected, the cultures showing Staphylococcus albus and B. coli. The phthalein was 50 per cent for the first hour; 30 per cent for the second. Non-protein nitrogen was 30 mg. per 100 cc. of blood, hemoglobin 90 per cent, sugar 100, red blood cells 5,500,000, white blood cells 11,000. Blood Wasserman negative.
DIVERTICULECTOMY OF BLADDER
387
A plain x-ray was negative, but a stereoscopic cystogram revealed a diverticulum 6 by 8 cm. on the posterior wall of bladder (fig. 4). The operative technique described above and a punch operation for the obstruction at the vesical neck were performed April 10. A Foley bag was used for urethral drainage and was left in place for 10 days. The extravesical drain was removed on the fifth day and the Pezzer catheter on the tenth. He voided on the twelfth day, and the suprapubic wound healed on the nineteenth. SUMMARY
A new operative technique has been presented for the cure of diverticulum of the bladder. The inflated balloon serves as a guide and buffer and the catheter as an excellent tractor. This method not only insures an excellent exposure but changes a difficult operation into a relatively simple one. I am of the opinion that any diverticulum of the bladder can be removed by this simple procedure, provided the balloon fits the diverticulum snugly.
9 E. Mt. Royal Ave., Baltimore, Md.