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Bladder Pouch for Prolonged Tubeless Cystostomy
THE JQURNAL OF UROLOGY
Vol. 78, No. 4, October 1957 Printed in U.S.A.
BLADDER POUCH FOR PROLONGED TUBELESS CYSTOSTOMY BERGET H. BLOCKSOM, JR.
This paper is based on the thought that there are indications for unimpeded drainage of the bladder, permanent or prolonged-a simple procedure that could be used in patients who are poor risks and in those in whom urinary diversion without cystectomy is contemplated. Recourse, heretofore, has involved use of catheters with all the inherent complications of infection, incrustation, bladder spasms, pain, etc. The procedure I am about to describe can almost be gleaned from the title and will hence require but little elucidation. A midline incision is made commencing about three finger-breadths above the symphysis pubis and extended upward for a distance of 6-7 cm. The rectus sheath is cut in a similar manner and the anterior surface of the bladder exposed. After reflecting the peritoneum cephalad the bladder is entered through a high stab incision, unless, as in our case, there was already a pre-existing cystostomy hole which had accommodated a dePezzer catheter. With the index finger inserted into the bladder, further mobilization and elevation of the bladder are accomplished until it can be drawn well up into the wound in an area of the abdominal wall that is smooth and would be devoid of folds if the patient were to assume the sitting position. The walls of the bladder are then sutured to the rectus sheath with absorbable sutures and the skin edges in the vicinity of the marsupialized bladder are drawn down to the bladder walls and rectus sheath with similar sutures to provide an abundance of redundant bladder protruding from the wound. Closure is completed with a few heavy dermal sutures embracing all layers of the remaining defect in the abdominal wound. The cystostomy thus prepared should admit the index finger very easily. Sump drainage may then be provided for the patient's comfort while the wound is healing but thi.s is not essential. CASE REPORT
The patient, a 75-year-old white man, had been treated many years for urethral stricture. He also had a rather large adenomatous prostate without severe symptoms of prostatism although a prostatectomy had been considered. The urine was essentially clear. In December 1954 the patient complained of pain in the perineum and hard, fibrotic tissue could be felt in the location of the perineal urethra. He was put on cortisone for a few days follmving which a 24F sound ,vas easily passed; however, the patient was unable to void afterwards and had to be admitted to the hospital and placed on urethral retention catheter drainage. The diagnosis of possible carcinoma of the urethra was entertained and on Decembe1 22, 1954, under spinal anesthesia, a 24F McCarthy resectoscope was introduced. Inspection of the bladder and prostatic urethra showed 3 plus trabeculation with cellule formation and a large trilobar hypertrophy of the bladder. About 3 cm. distal to the external sphincter there was an area of narRead at annual meeting of South Central Section of American Urological Association, Mexico City, October 28-N ovember 1, 1956.
398
BLADDER POT.;CH FOR PHOLO->TGED TUBELESS CYSTOSTOMY
;\~)\)
rowing with di8rupted urethral mucosa corresponding to the area of palpabln hardness in the perineum. A generous piece of hard, rubbery tissue ,,·a8 Hwn resected from this area. In spite of tlw belief that a representative biopsy had been obtainud, the pathological report was negative for carcinoma. Following this procedure the patient ,nts unable to void after removal of the urethral catheter. On January 4, 1955 a punch cystostomy was done and the patient sent home with a .,mprapubic catheter in plaee. During the next month the mass in the perineum failed to recede in spite of diversion of the urinary stream, so ho ,vatl readmitted to tho hospitaL On February 7, 1955 an open biopsy was taken; the pathological report was squarnou;.; cell carcinoma. On February 10, 1955 a total penisectomy, carried down to triangular liga1mmt, was performed, The ,vound 11·as dosed around an indwelling Foley catheter which had to be soon removed because of intolerable bladder spasms. 11Ve ,vern forced, thereafter, to rely on drainage by ,vay of the suprapubic punch cystostorny ,vhich also was to cause much trouble in terms of recune11t episodes of bladder spasms, calcification and finally bladder calculi, in spiLe of every preventive measure. vVe persisted in follm,·ing the patient and put up with numerous calls of com. plaints relative to the catheter for the next 17 month8 chiefly because we took a dim view of his prognosis and of accomplishing further operative procedures. In June 19.56 we decided that there ,ms no discernible recurrence of the rnrci11onrn and that he possibly had non-x-rny-opaque bladder calculi. He was readmitted to the hospital, the bladder ,vas explored and one large bladder calculm, was removed in addition to a collection of gravel in the prostatic urethra. The LladdEr 1vaR marsupialized as heretofore descriLed. COMMENT
I have been unable to find a report of this procedure in the literature, and thr present editor of the YEARBOOK OF UnoLOGY, Dr. 'William Wallace Scott) as ,mres me there has been none in the 6 years of his tenure of office. I am not unmindful of Peyton and Headstream's recent report of construe .. tion of a perinea! urethra with a skin graft technique. In our case, hmn;ver, the patient would have had to have a preliminary prostatectomy for which he ·was neither physically 11or psychically a candidate. The procedure we are describing seemed a nearly ideal way out of a dilemma. We had considered other ways of diverting the urine, all of which 11ould have required more extensive surgery. Any method which leaves an intact bladder in place without drainage is contraindicated. vV c ha Ye observed an example of thi;.; where a general surgeon from another city perfonned a Bricker pouch opera .. hon because of incontinence and nenrogenic bladder supposedly due to spina bifida. Vv e were consulted because the patient had been having recmTeu1. chills and fever over a period of 2 ye<1rs. Insertion of a catheter through the normal urethra into the intact bladder produced a gush of extremely foul pus; thereafter the patient 1Yas instructed in the care of herself to prevent further such epiRodes.
400
BERGET H. BLOCKSOM, JI{,
I am led to speculate on other indications for this procedure. Persistent encrusted cystitis, from whatever cause, might be an indication. It would seem to me to be highly suitable also for some cases of neurogenic bladder, especially if dilated ureters with reflux are present and constant unimpeded drainage would be better than reconstituted near-normal micturition which might be achieved by other means. VVe have observed a case recently in an infant where there was a very thick walled bladder apparently due to partial bladder neck obstruction. The bladder itself contained no residual urine but the ureters were enormous and the urine,
FIG. 1. Two weeks postoperatively and with temporary bag.
BLADDER POUCH FOR PROLONGED TUBLESS CYSTOSTOMY
401
taking the lines of least resistance, continued to stretch the ureters. This case requires continual uninterrupted drainage to cause shrinkage of the ureters before tackling the bladder neck obstruction. I don't believe intermittent micturition, if it could be obtained, prior to shrinkage of the ureters would suffice because the bladder at best would be an almost rigid, undistensible conduit, and the thin ureteral walls would have to act as the detrusor. In such a case a large suprapubic catheter might suffice, but considering the potentiality of catheters to cause foreign bodies, the bladder pouch on a prolonged, though temporary basis would, in my opinion, be better. Since the infant is still in the wetting stage no prosthetic appliance would be needed. The procedure used in such a case as this obviously must be one that can be reversed at any time much as a loop colostomy can be repaired and an intact colon reconstituted. Its limitations need exploring; obesity may be a contraindication and the operation might prove to be difficult on a severely contracted bladder. However, it should be emphasized that our patient with the urethral carcinoma had a considerable degree of contraction after I½ years of constant suprapubic drainage. Our patient has had no bladder spasms since operation, carries no residual urine and so far has formed no stones. His bladder and even his prostatic urethra can be explored digitally without anesthesia. The greatest difficulty has been teaching him and his family to cement the bag properly, but success seems assured in this regard as he has gone more than three days without the bag coming off and, in any event, this is an individual problem. In this connection there is need for a better prosthetic appliance-one that has a more flexible rim to be cemented to the skin so that it will not tend to pop off when the contour of the skin changes with the position of the body. Even as it is, we are happier to be spared constant telephone calls, office calls and multitude of complaints we endured the many months the patient wore the catheter. SUMMARY
A simple method of using the bladder as a pouch for tubeless diversion of the urine has been presented. An illustrative case has been presented.
517 Medical Arts Bldg., Tulsa 3, Okla. REFERENCES A. B. AND HEADSTREAM, J. W.: Construction of perineal urethra by split thickness skin graft. J. Ural., 76: 90-93, 1956.
PEYTON,
Vol. 78, No. 4, October 1957 Printed in U.S.A.
BLADDER POUCH FOR PROLONGED TUBELESS CYSTOSTOMY BERGET H. BLOCKSOM, JR.
This paper is based on the thought that there are indications for unimpeded drainage of the bladder, permanent or prolonged-a simple procedure that could be used in patients who are poor risks and in those in whom urinary diversion without cystectomy is contemplated. Recourse, heretofore, has involved use of catheters with all the inherent complications of infection, incrustation, bladder spasms, pain, etc. The procedure I am about to describe can almost be gleaned from the title and will hence require but little elucidation. A midline incision is made commencing about three finger-breadths above the symphysis pubis and extended upward for a distance of 6-7 cm. The rectus sheath is cut in a similar manner and the anterior surface of the bladder exposed. After reflecting the peritoneum cephalad the bladder is entered through a high stab incision, unless, as in our case, there was already a pre-existing cystostomy hole which had accommodated a dePezzer catheter. With the index finger inserted into the bladder, further mobilization and elevation of the bladder are accomplished until it can be drawn well up into the wound in an area of the abdominal wall that is smooth and would be devoid of folds if the patient were to assume the sitting position. The walls of the bladder are then sutured to the rectus sheath with absorbable sutures and the skin edges in the vicinity of the marsupialized bladder are drawn down to the bladder walls and rectus sheath with similar sutures to provide an abundance of redundant bladder protruding from the wound. Closure is completed with a few heavy dermal sutures embracing all layers of the remaining defect in the abdominal wound. The cystostomy thus prepared should admit the index finger very easily. Sump drainage may then be provided for the patient's comfort while the wound is healing but thi.s is not essential. CASE REPORT
The patient, a 75-year-old white man, had been treated many years for urethral stricture. He also had a rather large adenomatous prostate without severe symptoms of prostatism although a prostatectomy had been considered. The urine was essentially clear. In December 1954 the patient complained of pain in the perineum and hard, fibrotic tissue could be felt in the location of the perineal urethra. He was put on cortisone for a few days follmving which a 24F sound ,vas easily passed; however, the patient was unable to void afterwards and had to be admitted to the hospital and placed on urethral retention catheter drainage. The diagnosis of possible carcinoma of the urethra was entertained and on Decembe1 22, 1954, under spinal anesthesia, a 24F McCarthy resectoscope was introduced. Inspection of the bladder and prostatic urethra showed 3 plus trabeculation with cellule formation and a large trilobar hypertrophy of the bladder. About 3 cm. distal to the external sphincter there was an area of narRead at annual meeting of South Central Section of American Urological Association, Mexico City, October 28-N ovember 1, 1956.
398
BLADDER POT.;CH FOR PHOLO->TGED TUBELESS CYSTOSTOMY
;\~)\)
rowing with di8rupted urethral mucosa corresponding to the area of palpabln hardness in the perineum. A generous piece of hard, rubbery tissue ,,·a8 Hwn resected from this area. In spite of tlw belief that a representative biopsy had been obtainud, the pathological report was negative for carcinoma. Following this procedure the patient ,nts unable to void after removal of the urethral catheter. On January 4, 1955 a punch cystostomy was done and the patient sent home with a .,mprapubic catheter in plaee. During the next month the mass in the perineum failed to recede in spite of diversion of the urinary stream, so ho ,vatl readmitted to tho hospitaL On February 7, 1955 an open biopsy was taken; the pathological report was squarnou;.; cell carcinoma. On February 10, 1955 a total penisectomy, carried down to triangular liga1mmt, was performed, The ,vound 11·as dosed around an indwelling Foley catheter which had to be soon removed because of intolerable bladder spasms. 11Ve ,vern forced, thereafter, to rely on drainage by ,vay of the suprapubic punch cystostorny ,vhich also was to cause much trouble in terms of recune11t episodes of bladder spasms, calcification and finally bladder calculi, in spiLe of every preventive measure. vVe persisted in follm,·ing the patient and put up with numerous calls of com. plaints relative to the catheter for the next 17 month8 chiefly because we took a dim view of his prognosis and of accomplishing further operative procedures. In June 19.56 we decided that there ,ms no discernible recurrence of the rnrci11onrn and that he possibly had non-x-rny-opaque bladder calculi. He was readmitted to the hospital, the bladder ,vas explored and one large bladder calculm, was removed in addition to a collection of gravel in the prostatic urethra. The LladdEr 1vaR marsupialized as heretofore descriLed. COMMENT
I have been unable to find a report of this procedure in the literature, and thr present editor of the YEARBOOK OF UnoLOGY, Dr. 'William Wallace Scott) as ,mres me there has been none in the 6 years of his tenure of office. I am not unmindful of Peyton and Headstream's recent report of construe .. tion of a perinea! urethra with a skin graft technique. In our case, hmn;ver, the patient would have had to have a preliminary prostatectomy for which he ·was neither physically 11or psychically a candidate. The procedure we are describing seemed a nearly ideal way out of a dilemma. We had considered other ways of diverting the urine, all of which 11ould have required more extensive surgery. Any method which leaves an intact bladder in place without drainage is contraindicated. vV c ha Ye observed an example of thi;.; where a general surgeon from another city perfonned a Bricker pouch opera .. hon because of incontinence and nenrogenic bladder supposedly due to spina bifida. Vv e were consulted because the patient had been having recmTeu1. chills and fever over a period of 2 ye<1rs. Insertion of a catheter through the normal urethra into the intact bladder produced a gush of extremely foul pus; thereafter the patient 1Yas instructed in the care of herself to prevent further such epiRodes.
400
BERGET H. BLOCKSOM, JI{,
I am led to speculate on other indications for this procedure. Persistent encrusted cystitis, from whatever cause, might be an indication. It would seem to me to be highly suitable also for some cases of neurogenic bladder, especially if dilated ureters with reflux are present and constant unimpeded drainage would be better than reconstituted near-normal micturition which might be achieved by other means. VVe have observed a case recently in an infant where there was a very thick walled bladder apparently due to partial bladder neck obstruction. The bladder itself contained no residual urine but the ureters were enormous and the urine,
FIG. 1. Two weeks postoperatively and with temporary bag.
BLADDER POUCH FOR PROLONGED TUBLESS CYSTOSTOMY
401
taking the lines of least resistance, continued to stretch the ureters. This case requires continual uninterrupted drainage to cause shrinkage of the ureters before tackling the bladder neck obstruction. I don't believe intermittent micturition, if it could be obtained, prior to shrinkage of the ureters would suffice because the bladder at best would be an almost rigid, undistensible conduit, and the thin ureteral walls would have to act as the detrusor. In such a case a large suprapubic catheter might suffice, but considering the potentiality of catheters to cause foreign bodies, the bladder pouch on a prolonged, though temporary basis would, in my opinion, be better. Since the infant is still in the wetting stage no prosthetic appliance would be needed. The procedure used in such a case as this obviously must be one that can be reversed at any time much as a loop colostomy can be repaired and an intact colon reconstituted. Its limitations need exploring; obesity may be a contraindication and the operation might prove to be difficult on a severely contracted bladder. However, it should be emphasized that our patient with the urethral carcinoma had a considerable degree of contraction after I½ years of constant suprapubic drainage. Our patient has had no bladder spasms since operation, carries no residual urine and so far has formed no stones. His bladder and even his prostatic urethra can be explored digitally without anesthesia. The greatest difficulty has been teaching him and his family to cement the bag properly, but success seems assured in this regard as he has gone more than three days without the bag coming off and, in any event, this is an individual problem. In this connection there is need for a better prosthetic appliance-one that has a more flexible rim to be cemented to the skin so that it will not tend to pop off when the contour of the skin changes with the position of the body. Even as it is, we are happier to be spared constant telephone calls, office calls and multitude of complaints we endured the many months the patient wore the catheter. SUMMARY
A simple method of using the bladder as a pouch for tubeless diversion of the urine has been presented. An illustrative case has been presented.
517 Medical Arts Bldg., Tulsa 3, Okla. REFERENCES A. B. AND HEADSTREAM, J. W.: Construction of perineal urethra by split thickness skin graft. J. Ural., 76: 90-93, 1956.
PEYTON,