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Permanent Artificial (Silicone) Urethra
THE JOURNAL OF UROLOGY
Vol. 63, No. 1, January, 1950 Printed in U.S.A.
PERMANENT ARTIFICIAL (SILICONE) URETHRA R. ROBERT DE NICOLA From the Department of Surgery, Kadlec Hospital, Richland, Wash.
The case reported below is presented for two reasons: 1) for the unusual history of prolonged urethral mutilation resulting in a totally destroyed posterior urethra; and 2) this is the first report in the literature of apparently successful replacement of the human male urethra by artificial means. CASE REPORT
G. D., a 49 year old Negro, was admitted to the Kadlec Hospital April 14, 1948, for the relief of urinary retention. His good health was interrupted 30 years before admission by acute urethritis, presumably gonococcal in origin. There was no treatment, and symptoms subsided in 2 weeks. Approximately 3 years later difficulty in urination first occurred and for the next 10 years treatment consisted of urethral dilatation, "sometimes by doctors and sometimes by friends and others ,vho knew how to break the stricture." At the age of 28 urination consisted only of prolonged dribbling after great strain and an internal "boring out" was done by a colored "doctor" who often treated the Negroes in the patient's neighborhood, but was known not to be a licensed physician. The night of this "operation" the urine had all gone into the scrotal "sacs" (the patient describing the symptoms of extravasation of urine). Bed rest for 11 days brought little improvement and the patient entered an unremembered hospital where the first suprapubic cystotomy was done, supplemented by numerous scrotal incisions. Following discharge from the hospital, urination was little improved and urethral sounding was frequently done, sometimes by the patient himself using a blunted screw driver. For the next 12 years the history is even less specific as little can be remembered, except that continued urethral mutilation occurred. The patient states that during this period he "like as not was drunk most of the time." However, although the time and place are not recalled, a second suprapubic cystotomy was done during this period and the patient was advised not to remove the tube from his abdomen which he later did. During this period he also was treated for "spinal syphilis" for a "few \reeks." Approximately 1 year following the second suprapubic cystotomy, the operation was repeated for the third time and a short while following removal of the suprapubic catheter an opening occurred in the right scrotal sac from which urine continually dribbled. The patient states that by this time his penis and scrotal sacs were enlarged to four or five times the normal size and he was in almost constant pain. Complete retention occurred often, but he would "just wait it out" or "stick something in one of the holes" and relief would follow a gush or dribble of urine. During the 8 years preceding admission to the Kadlec hospital, two other urethral fistulas occurred, so that urine would dribble from either the glans penis, 168
R. ROBERT DE NICOLA
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a urethroscrotal fistula, or the right or left urethro-perineal fistulas. Often large abscesses occurred in these areas which would eventually discharge pus and urine. During the 2 weeks preceding admission, there had been slight urinary discharge from all fistulas. Urethral voiding had not occurred at all, huge painful swellings had developed in both groins and during the past 48 hours all fistulas had closed. The patient, therefore, presented himself in severe pain and extensive urinary retention. The temperature was 100.6 F, pulse 90, respiration 20, blood pressure 120/70. The significant findings were disclosed on examination of the abdomen and genital organs. There was moderate obesity of the upper and lateral regions of the abdomen, but from the umbilicus to the pubis, the abdomen was markedly indented and drawn together in a 10 cm. by 6 cm. area of thick board-like scar. Over the pubis and base of the penis a diffuse, soft, adipose-like swelling was felt which was in sharp contrast to markedly swollen, tender and indurated areas in both groins, each of which drained a small amount of thin yellow pus. There was moderate elephantiasis of the penis and left scrotum. The right scrotum was shrunken in which scar tissue and neither testicle was felt. Fistulas were found in the left scrotal area and in the right and left perineal regions. These were superficially probed, but no drainage occurred. The hemoglobin was 12.5; red blood count 4,320,000; white blood count, 9,800. The blood urea taken 2 and 8 days following operation was 19 mg. The blood Kahn was negative. Frei antigen test was negative at 24, 48 and 72 hours. Culture of the scrotal and groin pus revealed Escherichia coli. Attempts to sound and catheterize the patient under local anesthesia were unsuccessful, but were followed by a small amount of urinary flow from the urethra. Warm saline packs to the groin caused the rupture of the right groin abscess with some urinary drainage, but in 24 hours it was apparent that a fourth suprapubic cystostomy was indicated. Accordingly a routine suprapubic cystotomy was done under sodium pentothal anesthesia supplemented with curare. Difficulty was encounteed in finding and freeing the urinary bladder which was trapped in scar tissue. However, the peritoneum was not opened and when finally liberated the bladder was found to be normal except for distention with 1200 cc of murky brownish urine. A large mushroom catheter was placed in the bladder and the surrounding tissues extensively drained. The tumors in the groin consisted of indurated "sarcomatous-like" tissue. A biopsy was taken and multiple incisions were made in these areas for drainage. The wound was loosely closed with No. 0 chromic catgut and warm saline packs were applied to the lower abdomen. The postoperative course was singularly uneventful. The temperature remained low-grade. The patient appeared comfortable, ate a regular diet and intake and output were at all times adequate. Chemotherapy consisted of 75,000 units of penicillin and 300 mg. of streptomycin every 3 hours. Sulfanilamide in regular doses was added following receipt of the report on the biopsied tissue which read "sub-acute inflammation with abscess formation (? chancroid)."
170
PERMANENT ARTIFICIAL (SILICONE) URETHRA
Two weeks following the operation the suprapubic and groin wounds had healed. The suprapubic catheter was draining well, but all three urethral fistulas were intermittantly draining small amounts of urine. The patient was up and about and more definitive and permanent therapy in the form of urethral reconstruction was indicated. On May 5, 1948 a second operation was done under the same general anesthesia. The patient was placed and draped in the lithotomy position, the operator thereby having access to both the abdomen and perineal regions. AN o. 16 sound was placed in the pendulous urethra but was blocked within 4 inches of the glans penis. Accordingly a finger was placed in the suprapubic wound, the mushroom catheter was removed and suprapubic and bladder wounds were enlarged. With one finger in the internal opening of the urethra (through the bladder) the elephantitic penis and scrotum were held up and a transverse perinea! incision was
Fm. 1. Silicon tube used to replace destroyed urethra
made to the central tendinous point of the perineum in the region of the posterior and prostatic urethra. A small sound was externally placed in the penile urethra and by pushing and teasing the instrument was made to emerge through thick scar tissue into the perinea! opening. There was no evidence in this area of any structure resembling urethra. Another small sound was placed into the remnants of the posterior urethra from within the bladder and by similar pushing was also made to emerge through the perineal wound. A block dissect:on of scar tissue in this region was then performed. Care was taken to avoid the region of the external sphincter. A small catheter was placed over the tip of the sound traversing the bladder and remnant (not apparent) of the posterior urethra and this catheter was drawn into the bladder. The catheter was then threaded through a 3¾ inch silicon tube (General Electric Co.) (fig. 1). The objective was to use the silicon tube as a permanent complete posterior urethra and partial pendulous urethra. The distal end of the catheter was then brought out the remaining pendulous urethra over the sound which had been placed through it (fig. 2). The silicon tube was then lightly tied over the ridge on its middle to the surrounding scar tissue at the base of the penis with a medium silk suture ligature.
R. ROBERT DE NICOLA
171
The flexible silicon tube was then adjusted to the contour at the base of the penis and care was exercised not to encroach on the external sphincter to allow for voluntary urinary control. The perineal and suprapubic wounds were lightly closed with interrupted medium silk sutures. The suprapubic mushroom catheter was replaced in the bladder and both the abdominal and perinea! wounds were drained by Penrose tubes.
Fm. 2. A, artificial urethra shown with a small catheter threaded through it. B, silicon t.ube shown snug in its permanent position. Following this, perineal wound was closed. A caU,eLer draining bladder traverses tube, and is seen emerging from penile urethra.
Fm. 3. A, x-ray retouched for clarity. Contour of artificial posterior urethra. Penis and scrotum are seen in outline. B, antero-posterior view of artificial urethra, and its relation to pubis, penis and scrotum. Normal curve of posterior "urethra" is apparent.
The postoperative course ,vas again uneventful. The same chemotherapy was ordered for 5 days. All drains were removed by the fifth postoperative day. Clear urine drained from both the urethral and bladder catheters and the wounds healed cleanly. The urethral fistulas ceased to drain and closed permanently by the tenth postoperative day. The suprapubic catheter was removed after 2 weeks and the abdominal wound closed within 4 days. The patient was up and about
172
PERMANENT ARTIFICIAL (SILICONE) URETHRA
17 days after the operation and the urethral catheter was clamped off (following completed healing of the suprapubic wound) and opened every 3 hours at which time the patient was instructed to attempt to void through the catheter. A stream of urine under moderate pressure indicated some voluntary control. He was discharged 21 days following the second operation with the urethral catheter still threaded through the silicon tube and instructed to continue the three hour draining program. Five weeks following operation, the catheter was removed in the surgical clinic. Fortunately the silicon tube had formed no adherance to it and remained in position. Several minutes later the patient voided 258 cc of urine spontaneously. It was apparent that he had "stop and go" control and he remarked that he had not voided in such a manner in at least 15 years. The artificial urethra has now functioned almost normally for nearly 5 months. The perineal wound showed a pin point opening for a short time and leaked an occasional drop of urine. This opening closed after several applications of silver nitrate. The urethral fistulas have remained closed and all wounds are healed. X-rays of the pelvis show how the flexible tube has remained in position and follows the normal contour of the posterior urethra and penis (fig. 3). There has been no sexual impotency.
Addendum: At the end of 14 months the artificial urethra had been retained with normal genito-urinary function. Urinary symptoms of infection on two occasions quickly subsided under sulfathiazole treatment. COMMENT
It is impossible to use the ·word "permanent" in connection with this prosthesis. However there is no evidence at this time that the tube is acting as a foreign body irritant, nor is there evidence of stiffening or plugging. It is quite possible that the urethral mucosa has been replaced, the silicon tube acting as a splint. In view of the extensive destruction and the environment of scar tissue this does not seem probable and an attempt to remove the tube does not seem logical. The silicon tube used in this patient was originally constructed for use in connection with common bile duct reconstructions. Lahey has used it because of the advantage of flexibility as compared to vitallium tubes. It was mainly the characteristic of flexibility that prompted the use of this tube in this region, and the hope that organic material such as mucus or pus would not adhere to its surface and that liming would not occur. Ferris and Grindlay have shown the extensive amount of liming which occurs even after a few days when ordinary rubber tubes are used as urinary drainage tubes in connection with nephrostomy and ureterostomy procedures. It is possible that the polythene and polyvinyl tubing they have described could be used in the same manner as the silicon tube in urethral reconstructions. REFERENCES F. H.: In a discussion of results from using vitallium tubes in biliary surgery, Pearse, H. E., Ann. Surg., 124: 1020, 1946. FERRIS, D. 0. AND GRINDLAY, J. H.: Proc. of Staff Meet. Mayo Clinic, 23: 385-391, 1948.
LAHEY,
Vol. 63, No. 1, January, 1950 Printed in U.S.A.
PERMANENT ARTIFICIAL (SILICONE) URETHRA R. ROBERT DE NICOLA From the Department of Surgery, Kadlec Hospital, Richland, Wash.
The case reported below is presented for two reasons: 1) for the unusual history of prolonged urethral mutilation resulting in a totally destroyed posterior urethra; and 2) this is the first report in the literature of apparently successful replacement of the human male urethra by artificial means. CASE REPORT
G. D., a 49 year old Negro, was admitted to the Kadlec Hospital April 14, 1948, for the relief of urinary retention. His good health was interrupted 30 years before admission by acute urethritis, presumably gonococcal in origin. There was no treatment, and symptoms subsided in 2 weeks. Approximately 3 years later difficulty in urination first occurred and for the next 10 years treatment consisted of urethral dilatation, "sometimes by doctors and sometimes by friends and others ,vho knew how to break the stricture." At the age of 28 urination consisted only of prolonged dribbling after great strain and an internal "boring out" was done by a colored "doctor" who often treated the Negroes in the patient's neighborhood, but was known not to be a licensed physician. The night of this "operation" the urine had all gone into the scrotal "sacs" (the patient describing the symptoms of extravasation of urine). Bed rest for 11 days brought little improvement and the patient entered an unremembered hospital where the first suprapubic cystotomy was done, supplemented by numerous scrotal incisions. Following discharge from the hospital, urination was little improved and urethral sounding was frequently done, sometimes by the patient himself using a blunted screw driver. For the next 12 years the history is even less specific as little can be remembered, except that continued urethral mutilation occurred. The patient states that during this period he "like as not was drunk most of the time." However, although the time and place are not recalled, a second suprapubic cystotomy was done during this period and the patient was advised not to remove the tube from his abdomen which he later did. During this period he also was treated for "spinal syphilis" for a "few \reeks." Approximately 1 year following the second suprapubic cystotomy, the operation was repeated for the third time and a short while following removal of the suprapubic catheter an opening occurred in the right scrotal sac from which urine continually dribbled. The patient states that by this time his penis and scrotal sacs were enlarged to four or five times the normal size and he was in almost constant pain. Complete retention occurred often, but he would "just wait it out" or "stick something in one of the holes" and relief would follow a gush or dribble of urine. During the 8 years preceding admission to the Kadlec hospital, two other urethral fistulas occurred, so that urine would dribble from either the glans penis, 168
R. ROBERT DE NICOLA
169
a urethroscrotal fistula, or the right or left urethro-perineal fistulas. Often large abscesses occurred in these areas which would eventually discharge pus and urine. During the 2 weeks preceding admission, there had been slight urinary discharge from all fistulas. Urethral voiding had not occurred at all, huge painful swellings had developed in both groins and during the past 48 hours all fistulas had closed. The patient, therefore, presented himself in severe pain and extensive urinary retention. The temperature was 100.6 F, pulse 90, respiration 20, blood pressure 120/70. The significant findings were disclosed on examination of the abdomen and genital organs. There was moderate obesity of the upper and lateral regions of the abdomen, but from the umbilicus to the pubis, the abdomen was markedly indented and drawn together in a 10 cm. by 6 cm. area of thick board-like scar. Over the pubis and base of the penis a diffuse, soft, adipose-like swelling was felt which was in sharp contrast to markedly swollen, tender and indurated areas in both groins, each of which drained a small amount of thin yellow pus. There was moderate elephantiasis of the penis and left scrotum. The right scrotum was shrunken in which scar tissue and neither testicle was felt. Fistulas were found in the left scrotal area and in the right and left perineal regions. These were superficially probed, but no drainage occurred. The hemoglobin was 12.5; red blood count 4,320,000; white blood count, 9,800. The blood urea taken 2 and 8 days following operation was 19 mg. The blood Kahn was negative. Frei antigen test was negative at 24, 48 and 72 hours. Culture of the scrotal and groin pus revealed Escherichia coli. Attempts to sound and catheterize the patient under local anesthesia were unsuccessful, but were followed by a small amount of urinary flow from the urethra. Warm saline packs to the groin caused the rupture of the right groin abscess with some urinary drainage, but in 24 hours it was apparent that a fourth suprapubic cystostomy was indicated. Accordingly a routine suprapubic cystotomy was done under sodium pentothal anesthesia supplemented with curare. Difficulty was encounteed in finding and freeing the urinary bladder which was trapped in scar tissue. However, the peritoneum was not opened and when finally liberated the bladder was found to be normal except for distention with 1200 cc of murky brownish urine. A large mushroom catheter was placed in the bladder and the surrounding tissues extensively drained. The tumors in the groin consisted of indurated "sarcomatous-like" tissue. A biopsy was taken and multiple incisions were made in these areas for drainage. The wound was loosely closed with No. 0 chromic catgut and warm saline packs were applied to the lower abdomen. The postoperative course was singularly uneventful. The temperature remained low-grade. The patient appeared comfortable, ate a regular diet and intake and output were at all times adequate. Chemotherapy consisted of 75,000 units of penicillin and 300 mg. of streptomycin every 3 hours. Sulfanilamide in regular doses was added following receipt of the report on the biopsied tissue which read "sub-acute inflammation with abscess formation (? chancroid)."
170
PERMANENT ARTIFICIAL (SILICONE) URETHRA
Two weeks following the operation the suprapubic and groin wounds had healed. The suprapubic catheter was draining well, but all three urethral fistulas were intermittantly draining small amounts of urine. The patient was up and about and more definitive and permanent therapy in the form of urethral reconstruction was indicated. On May 5, 1948 a second operation was done under the same general anesthesia. The patient was placed and draped in the lithotomy position, the operator thereby having access to both the abdomen and perineal regions. AN o. 16 sound was placed in the pendulous urethra but was blocked within 4 inches of the glans penis. Accordingly a finger was placed in the suprapubic wound, the mushroom catheter was removed and suprapubic and bladder wounds were enlarged. With one finger in the internal opening of the urethra (through the bladder) the elephantitic penis and scrotum were held up and a transverse perinea! incision was
Fm. 1. Silicon tube used to replace destroyed urethra
made to the central tendinous point of the perineum in the region of the posterior and prostatic urethra. A small sound was externally placed in the penile urethra and by pushing and teasing the instrument was made to emerge through thick scar tissue into the perinea! opening. There was no evidence in this area of any structure resembling urethra. Another small sound was placed into the remnants of the posterior urethra from within the bladder and by similar pushing was also made to emerge through the perineal wound. A block dissect:on of scar tissue in this region was then performed. Care was taken to avoid the region of the external sphincter. A small catheter was placed over the tip of the sound traversing the bladder and remnant (not apparent) of the posterior urethra and this catheter was drawn into the bladder. The catheter was then threaded through a 3¾ inch silicon tube (General Electric Co.) (fig. 1). The objective was to use the silicon tube as a permanent complete posterior urethra and partial pendulous urethra. The distal end of the catheter was then brought out the remaining pendulous urethra over the sound which had been placed through it (fig. 2). The silicon tube was then lightly tied over the ridge on its middle to the surrounding scar tissue at the base of the penis with a medium silk suture ligature.
R. ROBERT DE NICOLA
171
The flexible silicon tube was then adjusted to the contour at the base of the penis and care was exercised not to encroach on the external sphincter to allow for voluntary urinary control. The perineal and suprapubic wounds were lightly closed with interrupted medium silk sutures. The suprapubic mushroom catheter was replaced in the bladder and both the abdominal and perinea! wounds were drained by Penrose tubes.
Fm. 2. A, artificial urethra shown with a small catheter threaded through it. B, silicon t.ube shown snug in its permanent position. Following this, perineal wound was closed. A caU,eLer draining bladder traverses tube, and is seen emerging from penile urethra.
Fm. 3. A, x-ray retouched for clarity. Contour of artificial posterior urethra. Penis and scrotum are seen in outline. B, antero-posterior view of artificial urethra, and its relation to pubis, penis and scrotum. Normal curve of posterior "urethra" is apparent.
The postoperative course ,vas again uneventful. The same chemotherapy was ordered for 5 days. All drains were removed by the fifth postoperative day. Clear urine drained from both the urethral and bladder catheters and the wounds healed cleanly. The urethral fistulas ceased to drain and closed permanently by the tenth postoperative day. The suprapubic catheter was removed after 2 weeks and the abdominal wound closed within 4 days. The patient was up and about
172
PERMANENT ARTIFICIAL (SILICONE) URETHRA
17 days after the operation and the urethral catheter was clamped off (following completed healing of the suprapubic wound) and opened every 3 hours at which time the patient was instructed to attempt to void through the catheter. A stream of urine under moderate pressure indicated some voluntary control. He was discharged 21 days following the second operation with the urethral catheter still threaded through the silicon tube and instructed to continue the three hour draining program. Five weeks following operation, the catheter was removed in the surgical clinic. Fortunately the silicon tube had formed no adherance to it and remained in position. Several minutes later the patient voided 258 cc of urine spontaneously. It was apparent that he had "stop and go" control and he remarked that he had not voided in such a manner in at least 15 years. The artificial urethra has now functioned almost normally for nearly 5 months. The perineal wound showed a pin point opening for a short time and leaked an occasional drop of urine. This opening closed after several applications of silver nitrate. The urethral fistulas have remained closed and all wounds are healed. X-rays of the pelvis show how the flexible tube has remained in position and follows the normal contour of the posterior urethra and penis (fig. 3). There has been no sexual impotency.
Addendum: At the end of 14 months the artificial urethra had been retained with normal genito-urinary function. Urinary symptoms of infection on two occasions quickly subsided under sulfathiazole treatment. COMMENT
It is impossible to use the ·word "permanent" in connection with this prosthesis. However there is no evidence at this time that the tube is acting as a foreign body irritant, nor is there evidence of stiffening or plugging. It is quite possible that the urethral mucosa has been replaced, the silicon tube acting as a splint. In view of the extensive destruction and the environment of scar tissue this does not seem probable and an attempt to remove the tube does not seem logical. The silicon tube used in this patient was originally constructed for use in connection with common bile duct reconstructions. Lahey has used it because of the advantage of flexibility as compared to vitallium tubes. It was mainly the characteristic of flexibility that prompted the use of this tube in this region, and the hope that organic material such as mucus or pus would not adhere to its surface and that liming would not occur. Ferris and Grindlay have shown the extensive amount of liming which occurs even after a few days when ordinary rubber tubes are used as urinary drainage tubes in connection with nephrostomy and ureterostomy procedures. It is possible that the polythene and polyvinyl tubing they have described could be used in the same manner as the silicon tube in urethral reconstructions. REFERENCES F. H.: In a discussion of results from using vitallium tubes in biliary surgery, Pearse, H. E., Ann. Surg., 124: 1020, 1946. FERRIS, D. 0. AND GRINDLAY, J. H.: Proc. of Staff Meet. Mayo Clinic, 23: 385-391, 1948.
LAHEY,