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Diverticulum of the Bladder
DIVERTICU LUM OF THE BLADDER JAMES A. GARDNER Buffalo, New York
Many cases of vesical diverticula have been reported within recent years and a large literature dealing with their etiology and treatment has developed. In former days the condition was frequently overlooked and an absolute diagnosis was possible only by exploratory operation. With the development of the cystoscope the diagnosis was made certain and much information regarding their size and shape learned by the employment of the X-ray. Concerning the etiology of the condition much has been written and most authorities agree upon the classification dividing them into congenital and acquired. English (1) inclines to the view that the elements composing the diverticulum determine the class to which it belongs: that the congenital variety has muscular coats while the acqu,ired form consists solely of mucosa. I am inclined to agree with Lower (2) that the division is an artificial one and that in reality all diverticula are acquired, being brought about by one factor, namely urinary obstruction. Thomas (3) has gone very carefully into a review of the literature concerning the embryology and etiology of diverticulum and those interested in the various views of the subject may refer to this paper. Diverticula vary greatly in size, ranging from very small outpouchings to sacs larger than the bladder itself. Since any condition resulting in urinary retention invites infection, it is not unusual to find marked grades of inflammation present. Calculus formation frequently complicates the condition and these are not infrequently present in the sac itself. The more conservative procedures such as catheterizatio n, bladder irrigations, etc., 439
440
JAMES A. GARDNE R
frequen tly fail in the preventi on of calculus -formati on and it is impossible to clear up the infectio n unless the divertic ulum anci its cause are radicall y removed . DIAGNOS IS
Divertic ula are usually discover ed during the routine cystoscopic examina tion. At times it is suspecte d and the suspicion is frequen tly confirme d following catheter ization, for a few minutes after the bladder is suppose d to have been emptied , a quantity of urine is found in the bladder. The cystosco pe usually makes possible only the diagnosis of the conditio n and gives little informa tion regardin g the size of the divertic ulum, for it is possible only in rare instance s to examine the interior of the divertic ulum itself. Regardi ng the size and the presence or absence of calculus, much can be learned by means of the X-ray. The methods which are usually employe d in this study are the curling up of a shadow-graph catheter in the sac, or the filling of the bladder with a solution imperm eable to the X-ray, as bismuth , thorium or one of the silver salts as argyrol, collargol or argentid e. After filling the bladder with one of these solutions it is examine d fluoroscopically and when its outlines are well defined, the plate is exposed with the patient in this position . Authori ties differ in opinion as to the advisab ility of cystosco ping patients before prostate ctomy, some claiming that it is unnecessar y and that sufficient informa tion can be gained without this frequen tly painful procedu re. In three cases of this series, two being in my own practice , prostate ctomy was advised and the divertic ulum overlooked. In one of these cases, the diverticulum was discover ed after the bladder had been opened and in the second, it was not until cystosco py was perform ed to explain the presence of 16 ounces of residual urine, that the diverticulum was discovered. The third case had had a suprapu bic prostate ctomy and eight months later a perinea! prostate ctomy by two differen t surgeon£. Both operatio ns were followed by no improve ment, there being 32 ounces of re:sidual urine. The finding of the large divertic ulum fully explaine d the presence of
DIVERTIC ULUM OF THE BLADDER
441
the large residual urine. Both conditions, namely, the enlarged prostate and the diverticu lum, should not be attacked at the same time, for in these feeble old men it is better to divide the shock and give them a rest between operation s. In case 7, five diverticu la were found, three of them quite large. The three larger ones were resected while the remaining two seemed so small that it was thought unnecess ary to do more than dilate the constricti on about the neck sufficiently to make them an integral part of the bladder. The patient made an uneventfu l recovery and at the time of his discharge from the hospital, he had no residual urine. Three months after operation, he returned with 5 ounces of residual urine. A urethral stricture was primarily the cause of the condition and upon investiga tion, it was discovered that this had contracte d causing an increase in size of the two small diverticul a. Dilatation of the stricture has caused a disappear ance of the residual urine and I hope by this means to render unnecess ary an operation for their removal. TECHNIQU E
As the majority of diverticu la are found on the floor of the bladder in the neighborh ood of the ureteral orifices, the technique of this removal is frequentl y difficult. The method of attack which I have usually followed is that suggested by Squier in his Transperitonea l Operation for Bladder Tumor. The sac is first stripped of its covering of peritoneu m, and the ureter is located, as transplan tation of it may be necessary later. The prelimina ry introduct ion of a catheter into the ureter as suggested by Beer, when possible, frequentl y simplifies the location of the ureter. Now and then the ureter is found emptying into the diverticu lum or is firmly attached to the wall of the sac making necessary ureteral transplan tation. In carrying out this part of the operation, care must be taken in selecting a point for transplan tation which will put the ureter under no tension. Young's idea of carrying the incision into the diverticu lum around the ureteral orifice, serves the excellent purpose of preservin g the ureteral sphincter , and renders unnecess ary the division and transplan tation of the ureter.
442
JAMES A. GARDNE R
After the divertic ulum has been freed of the peritone al covering, the bladder is opened above and the divertic ular sac packed with gauze, after the method of Cabot and Lower. This procedure greatly facilitat ed the handling of the divertic ulum, and renders less difficult the freeing of external attachm ents. After it has been complet ely freed, it is inverted into the bladder cavity, tied off, and divided with a cautery knife. The bladder wall is then reinforced, a stab wound made at the most superior point of the bladder, a Pezzer catheter inserted , and the original cystotomy wound closed. This idea of using a separate opening for the Pezzer catheter was suggeste d by Squier, and is far superior to its introduc tion through the upper end of the original opening . The presence of the catheter usually occasions more or less sloughing, frequen tly resultin g in the breaking down of the wound. The suprapu bic catheter is removed at the end of a week, and an in-dwelling catheter left in the ureter until the suprapu bic wound has healed. Case 1. D. D. G., age 68, married, admitted July 11, 1910, with
the history of frequent urination for three years. Examina tion re-vealed an enlarged prostate and on cystosco py a large vesical calculus was discovered. On July 20, 1910 a flat calculus which measured 2½ :inches in diameter was removed through a suprapub ic incision. On Novemb er 8, 1910 prostatec tomy with removal of large adenoma tous prostate. Followin g operation , the cystitis failed to clear up and on August 6, 1910 cystosco py revealed two calculi. A sup'r apubic cystostomy was performe d. One stone was readily removed but the other ,of dumb-be ll shape was found to be tightly fixed in the neck of a diverticulum, which lay to the left of the midline. Consider able difficulty was encounte red in dilating the neck of the diverticu lum sufficient to permit of the removal of the stone. This was accomplished, however, and the stone alone removed, as the patient's condition contraind icated further operative procedur e. On Decembe r 16, 1911, the patient return,e d to the hospital with profuse hemorrha ge per urethram and on the following day the suprapub ic wound opened. After continuo us irrigation the hemorrha ge was controlled. The patient was very weak, remainin g in the hospital for three months before the hemorrha ge ceased entirely. Surgical treatmen t was refused and he left the hospital with instructi on to irrigate the bladder twice daily. On October
DIVERTICULUM OF THE BLADDER
443
2, 1914, he reports that he was fairly comfortable on bladder irrigations. X-ray revealed diverticulum of left wall of bladder. Case 2. S., age 80, cotton planter, admitted June 23, 1913, complaining of hematuria with clots and detritus in the urine for three months. On cystoscopy, a diverticulum was found on the base of the bladder to the left of the midline, and blood was seen issuing from the diverticulum. On July 3, 1913, a suprapubic cystostomy was performed and the diverticulum which was small was found to contain a papilloma. The diverticulum was inverted into the bladder, the neck of the sac surrounded by a purse string suture and divided with the cau-
Fm. 1.
CYsTOGRAM OF CASE
3
tery knife. Recovery uneventful. The patient consulted Dr. Louis E. Schmidt in 1916 with the history of urinary difficulty and hematuria for several months. Examination showed a very extensive carcinoma almost completely filling the bladder and death followed an emergency cystostomy. Case 3. Age 60, married, admitted October 23, 1915 with a history of injury to the spine thirty years before, followed by paralysis of the lower extremities. Catheterization was necessary for five weeks, and while he continued to have more or less urinary difficulty, he did not resort to the catheter until ten years later when his physician advised catheterization and bladder irrigation before retiring. He was oper-
444
JAMES A. GARDNER
ated upon one year ago and a vesical calculus removed: Cystoscopy on admission revealed a stone in the bladder. On November 2, 1915, a litholapaxy was performed. Three days later a diverticulum was discovered cystoscopically and on the following day the bladder was filled with argentide and a cystogram taken. At operation on November 16, the bladder wall was found to be ¾ inch in thicknes&. It was impossible to pack the diverticulum and as this portion of the bladder was so densely adherent to the surrounding structures, the diverticulum together with a considerable portion of adjacent bladder wall, was resected. On November 21 paralytic ileus developed and the patient died on November 22.
FIG. 2.
CYSTOGRAM OF CASE
5
SHOWING DIVERTICU LUM ON L EFT LATERAL WALL OF BLADDER
Case 4. C. Z. K., age 49, widower, admitted December 22, 1913. This patient gave a history of gonorrheal urethritis at the age of twenty, and for the past twenty years has had more or less burning on urination. He passed blood in the urine for the first time six months ago, since which time he has had considerable urinary frequency, which has usually been most marked when walking. The urine was foul and there was a marked cystitis. Bladder capacity 7 ounces. A urethral stricture admitting a No. 20-F. sound was found and cystoscopy showed a diverticulum on the right wall of the bladder: Operation refused. Case 5. F. F. B., age 32, married. This patient was first seen on April 7, 1915. He gave no history of any previous illness and denied
DIVERTICULUM OF THE BLADDER
445
venereal disease. One year before after a strain while lifting he developed a left epididymitis and six months later the right epididymis became swollen. Since this,Jime he has had considerable burning on urination. On examination both epididymes were enlarged. Urine contained long shreds. Blood Wassermann negative. On cystoscopy on April 26, 1916, a diverticulum was found on the left side. Refused operation. Case 6. F. H. G., age 55, male. Admitted January 23, 1915, with the history of an attack of gonorrhea twenty-five years before. Ten years ago a urethral stricture was found and since this time sounds have been passed at intervals. Three weeks before admission, he began to pass pus and blood and was required to get up four or five times
Fm. 3.
CYsTOGRAM OF CASE
7
at night. Examination revealed a stricture in the deep urethra, admitting a No. 20-F. sound. This was readily dilated up to No. 28-F., and after silver nitrate irrigations, some improvement was noted. There were 3 ounces of residual urine. The instrumentation was followed by considerable local reaction and on July 23 it was not possible to pass an instrument larger than No. 18-F. This was followed by marked reaction and the patient was admitted to the hospital. On August 13 an internal urethrotomy was performed, following which the condition of the urine improved, although pus was still present. Instrumentation was always followed by chill and elevation of temperature. On November 15, 1915, catheterization :revealed 5 ounces of residual urine and urination was accompanied by burning. On December
446
,JAMES A. GARDNER
14 the residual urine had increased to 6 ounces and the patient was sent to the Homeopathie Hospital for operat ion. On January 3, 1915, a suprapubic cystostomy was performed and a large diverticulum resected. Death January 4. Case 7. C. G., age 42. First seen December 10, 1915, giving a history of four attacks of gonorrhea, the first attack twenty-five years before. Five years ago had urinary frequency and terminal hematuria. On examination the blood and urine were well mixed. A large calibre stricture was found in the posterior uret hra and cystoscopy revealed the opening of a diverticulum on the left side. At operation on January 7, 1916, the diverticulum after being packed with gauze wai,
FIG. 4.
CYSTO GRAM OF CASE
8
SHOWING DIVERTICU LUM OF LEFT BLADDER WALL
dissected loose from its attachments, inverted and tied off in bladder. Recovery uneventful. Case 8. Dr. J. E. This patient gave a history of scarlet fever seven years before, during which attack he had considerable urinary urgency. Eighteen months ago a small urethral discharge was noted. Shortly after an abscess of the prostate ruptured into t he urethra and since thib time slight hematuria has been noted at intervals. On October 20, 1916 cystoscopy revealed the orifice of a diverticulum in the region of the left ureter. He was operated upon November 2 and the diverticulum resected. Recovery uneventful. Case 9 . J. D., age 60. First seen on August 24, 1916, giving history of a gonorrheal infection complicated wit h epididymit is several years before. For twelve years he had noted more or less difficulty in
DIVERTICULUM OF THE BLADDER
Fro. 5.
447
AFTER THE REMOVAL OF THREE LARGE DIVERTICULA AND THE DIVISION OF THE NECKS OF Two SMALLER ONES
Fro. 6.
CYSTOGRAM OF CASE
21
SHOWING Two LARGE DIVERTICULA ON LEFT
LATERAL BLADDER WALL
... 448
JAMES A. GARDNER
voiding urine and during the five months prior to his admission, catheterization was necessary. Examinati on revealed a prostatic median bar, for which condition he was operated Septembe r 1, 1916. Follow• ing operation, 16 ounces of residual urine were still present and on cystoscopy, three large anp two small diverticula were found, this finding being confirmed by the X-ray. On November 13, 1916, the three larger diverticula were removed and the necks of the remaining ones, which were small and very shallow, were dilated until the condition seemed to be corrected. Following this operation, the patient made an excellent recovery. On February 23, 1917, examinati on revealed 5 ounces of residual urine and at cystoscopy on March 1, the two small diverticula which had been con.servatively treated at the former operation had enlarged considerably. Followi~ urethral dilatation t he patient was able to completely empty his bladder. Case 10. S. R. D., age 49. Admitted Jan,iiary 11, 1917, with the history of an attacj{ of gonorrhea at th~ age Qf 20,. In October, 1915, a suprapubic prostatect omy.had been perform~d, the .suprapubi c fistula remaining open for eight months. Following some perineal operation, t he· nature of which could ·not be learned, tbe suprapubi c wound healed, but the healing of the abdomina l wound was followed by the developme nt of a large ventral hernia. From this time on, the patient was unable to empty his bladder and on examinati on 32 ounces of residual urine were found, together with a stricture in the posterior urethra. The X-ray revealed a large diverticulu m at the apex of the bladder. The findings fully account for the large amount of residual urine and explain the inability of t he patient to empty his bladder. Case 11. C. E. B., age 53. First seen March 1, 1917, with the history of hematuria three years ago and more or less pain in voiding for nine or ten years. ·On examinati on a strict ure of 24-F. calibre was found in the posterior urethra. X-ray revealed two large ' diverticula on the right wall of the bladder. · On March 10 both diverticula were resected. Convalescence uneventful. REFEREN CES (1) (2) (3) (4)
ENGLISH: Isolier Entziin
Many cases of vesical diverticula have been reported within recent years and a large literature dealing with their etiology and treatment has developed. In former days the condition was frequently overlooked and an absolute diagnosis was possible only by exploratory operation. With the development of the cystoscope the diagnosis was made certain and much information regarding their size and shape learned by the employment of the X-ray. Concerning the etiology of the condition much has been written and most authorities agree upon the classification dividing them into congenital and acquired. English (1) inclines to the view that the elements composing the diverticulum determine the class to which it belongs: that the congenital variety has muscular coats while the acqu,ired form consists solely of mucosa. I am inclined to agree with Lower (2) that the division is an artificial one and that in reality all diverticula are acquired, being brought about by one factor, namely urinary obstruction. Thomas (3) has gone very carefully into a review of the literature concerning the embryology and etiology of diverticulum and those interested in the various views of the subject may refer to this paper. Diverticula vary greatly in size, ranging from very small outpouchings to sacs larger than the bladder itself. Since any condition resulting in urinary retention invites infection, it is not unusual to find marked grades of inflammation present. Calculus formation frequently complicates the condition and these are not infrequently present in the sac itself. The more conservative procedures such as catheterizatio n, bladder irrigations, etc., 439
440
JAMES A. GARDNE R
frequen tly fail in the preventi on of calculus -formati on and it is impossible to clear up the infectio n unless the divertic ulum anci its cause are radicall y removed . DIAGNOS IS
Divertic ula are usually discover ed during the routine cystoscopic examina tion. At times it is suspecte d and the suspicion is frequen tly confirme d following catheter ization, for a few minutes after the bladder is suppose d to have been emptied , a quantity of urine is found in the bladder. The cystosco pe usually makes possible only the diagnosis of the conditio n and gives little informa tion regardin g the size of the divertic ulum, for it is possible only in rare instance s to examine the interior of the divertic ulum itself. Regardi ng the size and the presence or absence of calculus, much can be learned by means of the X-ray. The methods which are usually employe d in this study are the curling up of a shadow-graph catheter in the sac, or the filling of the bladder with a solution imperm eable to the X-ray, as bismuth , thorium or one of the silver salts as argyrol, collargol or argentid e. After filling the bladder with one of these solutions it is examine d fluoroscopically and when its outlines are well defined, the plate is exposed with the patient in this position . Authori ties differ in opinion as to the advisab ility of cystosco ping patients before prostate ctomy, some claiming that it is unnecessar y and that sufficient informa tion can be gained without this frequen tly painful procedu re. In three cases of this series, two being in my own practice , prostate ctomy was advised and the divertic ulum overlooked. In one of these cases, the diverticulum was discover ed after the bladder had been opened and in the second, it was not until cystosco py was perform ed to explain the presence of 16 ounces of residual urine, that the diverticulum was discovered. The third case had had a suprapu bic prostate ctomy and eight months later a perinea! prostate ctomy by two differen t surgeon£. Both operatio ns were followed by no improve ment, there being 32 ounces of re:sidual urine. The finding of the large divertic ulum fully explaine d the presence of
DIVERTIC ULUM OF THE BLADDER
441
the large residual urine. Both conditions, namely, the enlarged prostate and the diverticu lum, should not be attacked at the same time, for in these feeble old men it is better to divide the shock and give them a rest between operation s. In case 7, five diverticu la were found, three of them quite large. The three larger ones were resected while the remaining two seemed so small that it was thought unnecess ary to do more than dilate the constricti on about the neck sufficiently to make them an integral part of the bladder. The patient made an uneventfu l recovery and at the time of his discharge from the hospital, he had no residual urine. Three months after operation, he returned with 5 ounces of residual urine. A urethral stricture was primarily the cause of the condition and upon investiga tion, it was discovered that this had contracte d causing an increase in size of the two small diverticul a. Dilatation of the stricture has caused a disappear ance of the residual urine and I hope by this means to render unnecess ary an operation for their removal. TECHNIQU E
As the majority of diverticu la are found on the floor of the bladder in the neighborh ood of the ureteral orifices, the technique of this removal is frequentl y difficult. The method of attack which I have usually followed is that suggested by Squier in his Transperitonea l Operation for Bladder Tumor. The sac is first stripped of its covering of peritoneu m, and the ureter is located, as transplan tation of it may be necessary later. The prelimina ry introduct ion of a catheter into the ureter as suggested by Beer, when possible, frequentl y simplifies the location of the ureter. Now and then the ureter is found emptying into the diverticu lum or is firmly attached to the wall of the sac making necessary ureteral transplan tation. In carrying out this part of the operation, care must be taken in selecting a point for transplan tation which will put the ureter under no tension. Young's idea of carrying the incision into the diverticu lum around the ureteral orifice, serves the excellent purpose of preservin g the ureteral sphincter , and renders unnecess ary the division and transplan tation of the ureter.
442
JAMES A. GARDNE R
After the divertic ulum has been freed of the peritone al covering, the bladder is opened above and the divertic ular sac packed with gauze, after the method of Cabot and Lower. This procedure greatly facilitat ed the handling of the divertic ulum, and renders less difficult the freeing of external attachm ents. After it has been complet ely freed, it is inverted into the bladder cavity, tied off, and divided with a cautery knife. The bladder wall is then reinforced, a stab wound made at the most superior point of the bladder, a Pezzer catheter inserted , and the original cystotomy wound closed. This idea of using a separate opening for the Pezzer catheter was suggeste d by Squier, and is far superior to its introduc tion through the upper end of the original opening . The presence of the catheter usually occasions more or less sloughing, frequen tly resultin g in the breaking down of the wound. The suprapu bic catheter is removed at the end of a week, and an in-dwelling catheter left in the ureter until the suprapu bic wound has healed. Case 1. D. D. G., age 68, married, admitted July 11, 1910, with
the history of frequent urination for three years. Examina tion re-vealed an enlarged prostate and on cystosco py a large vesical calculus was discovered. On July 20, 1910 a flat calculus which measured 2½ :inches in diameter was removed through a suprapub ic incision. On Novemb er 8, 1910 prostatec tomy with removal of large adenoma tous prostate. Followin g operation , the cystitis failed to clear up and on August 6, 1910 cystosco py revealed two calculi. A sup'r apubic cystostomy was performe d. One stone was readily removed but the other ,of dumb-be ll shape was found to be tightly fixed in the neck of a diverticulum, which lay to the left of the midline. Consider able difficulty was encounte red in dilating the neck of the diverticu lum sufficient to permit of the removal of the stone. This was accomplished, however, and the stone alone removed, as the patient's condition contraind icated further operative procedur e. On Decembe r 16, 1911, the patient return,e d to the hospital with profuse hemorrha ge per urethram and on the following day the suprapub ic wound opened. After continuo us irrigation the hemorrha ge was controlled. The patient was very weak, remainin g in the hospital for three months before the hemorrha ge ceased entirely. Surgical treatmen t was refused and he left the hospital with instructi on to irrigate the bladder twice daily. On October
DIVERTICULUM OF THE BLADDER
443
2, 1914, he reports that he was fairly comfortable on bladder irrigations. X-ray revealed diverticulum of left wall of bladder. Case 2. S., age 80, cotton planter, admitted June 23, 1913, complaining of hematuria with clots and detritus in the urine for three months. On cystoscopy, a diverticulum was found on the base of the bladder to the left of the midline, and blood was seen issuing from the diverticulum. On July 3, 1913, a suprapubic cystostomy was performed and the diverticulum which was small was found to contain a papilloma. The diverticulum was inverted into the bladder, the neck of the sac surrounded by a purse string suture and divided with the cau-
Fm. 1.
CYsTOGRAM OF CASE
3
tery knife. Recovery uneventful. The patient consulted Dr. Louis E. Schmidt in 1916 with the history of urinary difficulty and hematuria for several months. Examination showed a very extensive carcinoma almost completely filling the bladder and death followed an emergency cystostomy. Case 3. Age 60, married, admitted October 23, 1915 with a history of injury to the spine thirty years before, followed by paralysis of the lower extremities. Catheterization was necessary for five weeks, and while he continued to have more or less urinary difficulty, he did not resort to the catheter until ten years later when his physician advised catheterization and bladder irrigation before retiring. He was oper-
444
JAMES A. GARDNER
ated upon one year ago and a vesical calculus removed: Cystoscopy on admission revealed a stone in the bladder. On November 2, 1915, a litholapaxy was performed. Three days later a diverticulum was discovered cystoscopically and on the following day the bladder was filled with argentide and a cystogram taken. At operation on November 16, the bladder wall was found to be ¾ inch in thicknes&. It was impossible to pack the diverticulum and as this portion of the bladder was so densely adherent to the surrounding structures, the diverticulum together with a considerable portion of adjacent bladder wall, was resected. On November 21 paralytic ileus developed and the patient died on November 22.
FIG. 2.
CYSTOGRAM OF CASE
5
SHOWING DIVERTICU LUM ON L EFT LATERAL WALL OF BLADDER
Case 4. C. Z. K., age 49, widower, admitted December 22, 1913. This patient gave a history of gonorrheal urethritis at the age of twenty, and for the past twenty years has had more or less burning on urination. He passed blood in the urine for the first time six months ago, since which time he has had considerable urinary frequency, which has usually been most marked when walking. The urine was foul and there was a marked cystitis. Bladder capacity 7 ounces. A urethral stricture admitting a No. 20-F. sound was found and cystoscopy showed a diverticulum on the right wall of the bladder: Operation refused. Case 5. F. F. B., age 32, married. This patient was first seen on April 7, 1915. He gave no history of any previous illness and denied
DIVERTICULUM OF THE BLADDER
445
venereal disease. One year before after a strain while lifting he developed a left epididymitis and six months later the right epididymis became swollen. Since this,Jime he has had considerable burning on urination. On examination both epididymes were enlarged. Urine contained long shreds. Blood Wassermann negative. On cystoscopy on April 26, 1916, a diverticulum was found on the left side. Refused operation. Case 6. F. H. G., age 55, male. Admitted January 23, 1915, with the history of an attack of gonorrhea twenty-five years before. Ten years ago a urethral stricture was found and since this time sounds have been passed at intervals. Three weeks before admission, he began to pass pus and blood and was required to get up four or five times
Fm. 3.
CYsTOGRAM OF CASE
7
at night. Examination revealed a stricture in the deep urethra, admitting a No. 20-F. sound. This was readily dilated up to No. 28-F., and after silver nitrate irrigations, some improvement was noted. There were 3 ounces of residual urine. The instrumentation was followed by considerable local reaction and on July 23 it was not possible to pass an instrument larger than No. 18-F. This was followed by marked reaction and the patient was admitted to the hospital. On August 13 an internal urethrotomy was performed, following which the condition of the urine improved, although pus was still present. Instrumentation was always followed by chill and elevation of temperature. On November 15, 1915, catheterization :revealed 5 ounces of residual urine and urination was accompanied by burning. On December
446
,JAMES A. GARDNER
14 the residual urine had increased to 6 ounces and the patient was sent to the Homeopathie Hospital for operat ion. On January 3, 1915, a suprapubic cystostomy was performed and a large diverticulum resected. Death January 4. Case 7. C. G., age 42. First seen December 10, 1915, giving a history of four attacks of gonorrhea, the first attack twenty-five years before. Five years ago had urinary frequency and terminal hematuria. On examination the blood and urine were well mixed. A large calibre stricture was found in the posterior uret hra and cystoscopy revealed the opening of a diverticulum on the left side. At operation on January 7, 1916, the diverticulum after being packed with gauze wai,
FIG. 4.
CYSTO GRAM OF CASE
8
SHOWING DIVERTICU LUM OF LEFT BLADDER WALL
dissected loose from its attachments, inverted and tied off in bladder. Recovery uneventful. Case 8. Dr. J. E. This patient gave a history of scarlet fever seven years before, during which attack he had considerable urinary urgency. Eighteen months ago a small urethral discharge was noted. Shortly after an abscess of the prostate ruptured into t he urethra and since thib time slight hematuria has been noted at intervals. On October 20, 1916 cystoscopy revealed the orifice of a diverticulum in the region of the left ureter. He was operated upon November 2 and the diverticulum resected. Recovery uneventful. Case 9 . J. D., age 60. First seen on August 24, 1916, giving history of a gonorrheal infection complicated wit h epididymit is several years before. For twelve years he had noted more or less difficulty in
DIVERTICULUM OF THE BLADDER
Fro. 5.
447
AFTER THE REMOVAL OF THREE LARGE DIVERTICULA AND THE DIVISION OF THE NECKS OF Two SMALLER ONES
Fro. 6.
CYSTOGRAM OF CASE
21
SHOWING Two LARGE DIVERTICULA ON LEFT
LATERAL BLADDER WALL
... 448
JAMES A. GARDNER
voiding urine and during the five months prior to his admission, catheterization was necessary. Examinati on revealed a prostatic median bar, for which condition he was operated Septembe r 1, 1916. Follow• ing operation, 16 ounces of residual urine were still present and on cystoscopy, three large anp two small diverticula were found, this finding being confirmed by the X-ray. On November 13, 1916, the three larger diverticula were removed and the necks of the remaining ones, which were small and very shallow, were dilated until the condition seemed to be corrected. Following this operation, the patient made an excellent recovery. On February 23, 1917, examinati on revealed 5 ounces of residual urine and at cystoscopy on March 1, the two small diverticula which had been con.servatively treated at the former operation had enlarged considerably. Followi~ urethral dilatation t he patient was able to completely empty his bladder. Case 10. S. R. D., age 49. Admitted Jan,iiary 11, 1917, with the history of an attacj{ of gonorrhea at th~ age Qf 20,. In October, 1915, a suprapubic prostatect omy.had been perform~d, the .suprapubi c fistula remaining open for eight months. Following some perineal operation, t he· nature of which could ·not be learned, tbe suprapubi c wound healed, but the healing of the abdomina l wound was followed by the developme nt of a large ventral hernia. From this time on, the patient was unable to empty his bladder and on examinati on 32 ounces of residual urine were found, together with a stricture in the posterior urethra. The X-ray revealed a large diverticulu m at the apex of the bladder. The findings fully account for the large amount of residual urine and explain the inability of t he patient to empty his bladder. Case 11. C. E. B., age 53. First seen March 1, 1917, with the history of hematuria three years ago and more or less pain in voiding for nine or ten years. ·On examinati on a strict ure of 24-F. calibre was found in the posterior urethra. X-ray revealed two large ' diverticula on the right wall of the bladder. · On March 10 both diverticula were resected. Convalescence uneventful. REFEREN CES (1) (2) (3) (4)
ENGLISH: Isolier Entziin