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Resection & anastomosis of the impervious urethra
RESECTION
V ANASTOMOSIS
IMPERVIOUS WILLIAM
OF THE
URETHRA*
NEILL,
JR.,
M.D.
BALTIMORE, MD.
I
and evacuated a moderate amount of bIood; N MY cIinic at the Cambridge-Marya finger in the rectum detected the catheter Iand HospitaI I am constantIy caIIed free in a cavity in front. upon to soIve the many and varied Diagnosis: compIete rupture of the urethra probIems in genera1 surgery. Prompted by with extravasation of blood. An x-ray examinaDr. H. H. Young’s articIe,l on the treattion of the peIvis discIosed a transverse fracment of compIete rupture of the posterior ture of the right descending pubic ramus arethra, I submit a compIete report of three in situ. patients with lesions in the bulbous urethra Operation: A longitudinal incision in the anterior to the trianguIar Iigament, two perineum opened into a large hematoma; of &ompIete rupture from a faI1 astride when this was evacuated an actively spurting artery was seen. This and a11 Iesser bIeeding some object, one recent, and the other points were controIIed by plain catgut Iigature. four and one-haIf months oId and after Investigation with a sound per urethrhm previous operation. The third, simiIarIy reveaIed the buIbous urethra compIeteIy Iocated and impermeabIe, was the seque1 severed just in front of the membranous ureto an oId gonorrhea1 infection and resistant thra and the trianguIar Iigament. The posterior to previous attempts at diIatation. end couId not be Iocated in the bruised and The Iesions found in rupture of the bIoody fieId and, as I did not fee1 a suprapubic urethra vary from slight Iacerations a11 retrograde catheterization advisable at the the way to a compIete division, compIitime, the skin was united IooseIy with catgut cated at times with an extensive fracture around a gauze drain. When the patient of the peIvis with urinary or feca1 extravarecovered from the anesthetic, voiding was normal through the perinea1 wound, no urine sation. Extreme cases are seen foIIowing crushing injuries rather than a faI1 as in passing from the meatus; this continued unti1 June 9, 1926, when heaIing was compIete two of my patients. In view of the imporexcept up to a smaI1 urinary sinus. On this tance of the departure from the routine date the second operation was done to anastomethods, I shaI1 report ,them separately mose the severed urethra. A rubber catheter and in detai1. CASE I.
was passed into the bIadder through the perinea1 sinus and the healed incision reopened and a meta sound passed through the meatus which reached to within 2% cm. from the posterior urethral opening. The compIeteIy cIosed anterior end was opened on the tip of a sound and freed with sufficient paraurethra1 tissue to assure circuIation and thoroughIy mobiIized. The posterior segment was Iikewise mobilized. A No. 24 F. soft rubber catheter was introduced anteriorIy to the perinea1 opening, when the origina catheter was removed, and passed on into the bladder. Around the catheter a transverse end-to-end anastomosis was done with interrupted No. o twenty-day catgut sutures. Additional sutures of pIain fme catgut were pIaced through the fibrinous and muscle tissue to reinforce the * From the Howard A. KeIIy Hospital. Submitted for publication December 3. 1929. 1072
White, aged thirty-eight, married; occupation, raihoad fireman, on May 4, 1926 sIipped into the water tank of his tender and feII severa feet on to a submerged pipe, sustaining a severe and painful perinea1 injury with immediate severe pain, inability to void and bIeeding from the urethra. Seen two hours Iater; exceIIent genera1 condition, hemogIobin was 80 per cent, abdomen negative, the ‘externa1 genitaIia not affected but a distinct buIging in the perineum. Per rectum a norma prostate was feIt and definite compression of the rectum by ,a soft mass extending up to the base of the bladder. A catheter passed into the urethra reached the region of the membranous urethra ‘Young, H. H. Trans. Am. Assoc. G.-U. Surg., 21: 1928.
h,-w
Sl;nrti.s
VOL.
VIII,
NO. j
Neill-Impervious
first line of cIosure. A small gauze drain was placed to the line of anastomosis, and the closure completed with pIain catgut. The convalescence was normal; the catheter, remaining in pIace without any Ieakage, was removed on the tenth day. Voiding was norma and in two weeks the incision was healed. The fracture gave no troubIe. Dilatations were carried out June 23, JuIy 2 and g, September 16, December I and January 24, 1927. JuIy, 1927, sounds reveaIed no stricture and erections were normaI. He has remained free from any sequelae. CASE II. White, aged sixty, married. Occupation: carpenter. While working September I, 1926 feI1 astride a saw horse and sustained a severe blow on the perineum. An operation done the same day for a ruptured urethra through a suprapubic and an inverted u incision in the perineum was unsuccessfu1, and the urine drained suprapubicaIIy and through two perinea1 fistuIae. PerineaI abscesses deveroped from time to time, either rupturing spontaneously, or calling for an incision. There was aIways a discharge of pus demanding a pad. For a short time a smaI1 amount of urine passed the meatus, but none for two months up to the time I first saw him on January ‘9, 1927, when he came through the advice of the first patient. Examination negative, outside the Iocal condition. The healed suprapubic scar drained a little urine through its lower angle. There were two smaI1 discharging sinuses in the perineum. He voided urine through both voIuntariIy, and the entire region was denseIy scarred. ExternaI genitalia were normal, prostate was diffuseIy hypertrophied, without symptoms. Rectal examination otherwise negative. Filiform bougies introduced into the perinea1 sinuses faiIed to enter the bIadder and a sound passed through the meatus only reached the membranous urethra, the tip just being paIpabIe per rectum through the dense scar tissue. Diagnosis: compIete traumatic rupture of the bulbous urethra with marked cicatrix and water-pot perineum. Operation on date of examination under ether anesthesia. The anterior urethra and both perinea1 sinuses were injected with methyIene bIue. A meta sound was passed through the anterior urethra to the point of obstruction and a second through the suprapubic fistuIa
Urethra
Amerkxn Journal of Sur~r~y
107 15
into the bIadder out through the prostatic urethra, the tip extending through the membranous urethra. A median incision was made in the perineum and both sinuses dissected out under the guidance of the methyIene blue, as they Ied by separate tracks to the tip of the sound in the membranous urethra just outside of the trianguIar ligament. A Iarge amount of scar tissue was dissected away, cIearIy exposing both sounds and completely destroying a gap of 3 cm. of the urethra. The severed ends were freely mobilized and all fibrous thickening removed out into the normal surroundings. A No. 24 F. soft rubber catheter was passed into the bladder through the posterior segment as the sound kvas removed and the dista1 end threaded on to the tip of the anterior sound and withdrawn out through the anterior urethra. An end-to-end transverse anastomosis was done around the catheter with interrupted No. I twenty-day catgut sutures, reinforced by additional sutures of plain catgut. The skin was loosely united with black silk and a pIain gauze drain left inserted at the posterior angIe. ConvaIescence normaI, heaIing without Ieakage or ertravasation. The suprapubic incision heaIed spontaneously. The catheter \vas removed on the twelfth day and sounds to No. 20 F. passed on the fourteenth day. When the patient was seen in two months voiding was normal and I was abIe to diIate to a No. 28 F. He was we11 in JuIy, 1927 when sounds were passed; a further recent report states that he is wel1.
CASE III. Differing from the preceding was the case of a patient with an impermeable stricture from an oId gonorrhea1 infection. As the operative procedure was somewhat similar, I incIude it here. The patient, white, aged fifty-one, married, was by occupation a water-man. As a youth he contracted gonorrhea, and for twenty years had attacks of dysuria lasting severa weeks; at no time was he able to void normally. This graduaIIy increased and no proIonged relief was experienced from diIatations. In March, 1929 an operation was done for hemorrhoids and the stricture UnsuccessfuIIy diIated and since then, particularly for the past three weeks, has been in constant pain, emptying the bladder most of the past week involuntarily by dribbling. Attempts to catheterize have failed. I first saw him September 12, rg2g, in great pain,
I074
American Journal of Surgery
NeiII-Impervious
with the bladder extending haIfway to the umbiIicus with an invoIuntary dribbIing of ammoniaca urine. A sound refused to go beyond the region of the trianguIar ligament; the obstruction was aIso impermeabIe to fiIiform bougies. The prostate was norma and above it lay the tense, distended bIadder. Rather than do a cystostomy I decided to resect the stricture from beIow. MethyIene blue was injected anteriorIy and miIked towards the bIadder. A median perinea1 incision was made and the tissues cut down to a sound passed to the obstruction. The urethra was dissected free over the sound and opened on its tip. It was markedIy thickened and the Iumen tortuous and threadlike, a fact cIearIy demonstrated by the methyIene bIue. The stained tract was foIIowed up to the norma urethra just in front of the trianguIar Iigament. The entire segment of the urethra (2.5 cm.) was excised with a11 enveIoping scar tissues. A No. 22 F. soft rubber catheter was then introduced into the bIadder, evacuating 1200 C.C. of fou1 urine. The dista1 end of the catheter was then threaded over the tip of the sound and drawn out through the meatus. With moderate tension the ends were joined transverseIy about the catheter with interrupted No. I twenty-day .catgut sutures, reinforced by pIain catgut sutures, and the skin cIosed with interrupted sutures, Ieaving a smaI1 cigarette drain up to the anastomosis. ConvaIescence normaI; no leakage or extravasation of urine unti1 the catheter was removed on the seventh day as the patient began voiding around it, with some Ieakage through the perineum. Voiding continued norma and the perinea1 Ieakage grew Iess and ceased at the end of the fourth week when the heaIing was compIet& At the end of the second week I passed a smaI1 sound into the bIadder. A No. 28 F. easiIy passed in the fifth week ‘and voiding was normaI. He was seen %33
Urethra
MAY, ,930
and dilated October 3oth;.Lsubsequent tions wiI1 be continued.
diIata-
CASE IV. A fourth patient was operated upon at the Church Home and Infirmary, BaItimore, in 1915. Since a portion of the history is Iost, a detaiIed report cannot be given. An empIoyee of a timber company in North CaroIina feI1 while at work, straddIing an object and sustained a severe blow on the perineum, foIlowed by bIeeding from the urethra. He remained in a IocaI hospita1 for three weeks with a retention catheter; foIIowing its remova he found voiding diffIcuIt at first, graduaIIy growing worse. Attempts to dilate gave no definite reIief. When I saw him approximateIy six months after the injury, I found the buIbous urethra markedIy indurated, and a sound stopped at this point. After consuItation with the Iate Dr. J. T. Geraghty, instead of an interna urethrotomy, an open operation was carried out as described in Case III; this was foIIowed by compIete reIief. Subsequent diIatations were carried out, the patient remaining perfectly we11unti1 I Iost track of him five years later. CONCLUSIONS I. Accurate knowIedge of the regional anatomy is a prime requisite. 2. PreIiminary injection of methyIene bIue is of great assistance, outhning the distorted urethra and any diverticuIa for
the subsequent operation. 3. Sharp dissection, dehcate instruments and fine sutures with carefu1 manipuIation insure the union of the approximated tissues. 4. Some foIIow-up diIatations urethra must be carried out obviate any stricture in the tract.
of the Iater to
V ANASTOMOSIS
IMPERVIOUS WILLIAM
OF THE
URETHRA*
NEILL,
JR.,
M.D.
BALTIMORE, MD.
I
and evacuated a moderate amount of bIood; N MY cIinic at the Cambridge-Marya finger in the rectum detected the catheter Iand HospitaI I am constantIy caIIed free in a cavity in front. upon to soIve the many and varied Diagnosis: compIete rupture of the urethra probIems in genera1 surgery. Prompted by with extravasation of blood. An x-ray examinaDr. H. H. Young’s articIe,l on the treattion of the peIvis discIosed a transverse fracment of compIete rupture of the posterior ture of the right descending pubic ramus arethra, I submit a compIete report of three in situ. patients with lesions in the bulbous urethra Operation: A longitudinal incision in the anterior to the trianguIar Iigament, two perineum opened into a large hematoma; of &ompIete rupture from a faI1 astride when this was evacuated an actively spurting artery was seen. This and a11 Iesser bIeeding some object, one recent, and the other points were controIIed by plain catgut Iigature. four and one-haIf months oId and after Investigation with a sound per urethrhm previous operation. The third, simiIarIy reveaIed the buIbous urethra compIeteIy Iocated and impermeabIe, was the seque1 severed just in front of the membranous ureto an oId gonorrhea1 infection and resistant thra and the trianguIar Iigament. The posterior to previous attempts at diIatation. end couId not be Iocated in the bruised and The Iesions found in rupture of the bIoody fieId and, as I did not fee1 a suprapubic urethra vary from slight Iacerations a11 retrograde catheterization advisable at the the way to a compIete division, compIitime, the skin was united IooseIy with catgut cated at times with an extensive fracture around a gauze drain. When the patient of the peIvis with urinary or feca1 extravarecovered from the anesthetic, voiding was normal through the perinea1 wound, no urine sation. Extreme cases are seen foIIowing crushing injuries rather than a faI1 as in passing from the meatus; this continued unti1 June 9, 1926, when heaIing was compIete two of my patients. In view of the imporexcept up to a smaI1 urinary sinus. On this tance of the departure from the routine date the second operation was done to anastomethods, I shaI1 report ,them separately mose the severed urethra. A rubber catheter and in detai1. CASE I.
was passed into the bIadder through the perinea1 sinus and the healed incision reopened and a meta sound passed through the meatus which reached to within 2% cm. from the posterior urethral opening. The compIeteIy cIosed anterior end was opened on the tip of a sound and freed with sufficient paraurethra1 tissue to assure circuIation and thoroughIy mobiIized. The posterior segment was Iikewise mobilized. A No. 24 F. soft rubber catheter was introduced anteriorIy to the perinea1 opening, when the origina catheter was removed, and passed on into the bladder. Around the catheter a transverse end-to-end anastomosis was done with interrupted No. o twenty-day catgut sutures. Additional sutures of pIain fme catgut were pIaced through the fibrinous and muscle tissue to reinforce the * From the Howard A. KeIIy Hospital. Submitted for publication December 3. 1929. 1072
White, aged thirty-eight, married; occupation, raihoad fireman, on May 4, 1926 sIipped into the water tank of his tender and feII severa feet on to a submerged pipe, sustaining a severe and painful perinea1 injury with immediate severe pain, inability to void and bIeeding from the urethra. Seen two hours Iater; exceIIent genera1 condition, hemogIobin was 80 per cent, abdomen negative, the ‘externa1 genitaIia not affected but a distinct buIging in the perineum. Per rectum a norma prostate was feIt and definite compression of the rectum by ,a soft mass extending up to the base of the bladder. A catheter passed into the urethra reached the region of the membranous urethra ‘Young, H. H. Trans. Am. Assoc. G.-U. Surg., 21: 1928.
h,-w
Sl;nrti.s
VOL.
VIII,
NO. j
Neill-Impervious
first line of cIosure. A small gauze drain was placed to the line of anastomosis, and the closure completed with pIain catgut. The convalescence was normal; the catheter, remaining in pIace without any Ieakage, was removed on the tenth day. Voiding was norma and in two weeks the incision was healed. The fracture gave no troubIe. Dilatations were carried out June 23, JuIy 2 and g, September 16, December I and January 24, 1927. JuIy, 1927, sounds reveaIed no stricture and erections were normaI. He has remained free from any sequelae. CASE II. White, aged sixty, married. Occupation: carpenter. While working September I, 1926 feI1 astride a saw horse and sustained a severe blow on the perineum. An operation done the same day for a ruptured urethra through a suprapubic and an inverted u incision in the perineum was unsuccessfu1, and the urine drained suprapubicaIIy and through two perinea1 fistuIae. PerineaI abscesses deveroped from time to time, either rupturing spontaneously, or calling for an incision. There was aIways a discharge of pus demanding a pad. For a short time a smaI1 amount of urine passed the meatus, but none for two months up to the time I first saw him on January ‘9, 1927, when he came through the advice of the first patient. Examination negative, outside the Iocal condition. The healed suprapubic scar drained a little urine through its lower angle. There were two smaI1 discharging sinuses in the perineum. He voided urine through both voIuntariIy, and the entire region was denseIy scarred. ExternaI genitalia were normal, prostate was diffuseIy hypertrophied, without symptoms. Rectal examination otherwise negative. Filiform bougies introduced into the perinea1 sinuses faiIed to enter the bIadder and a sound passed through the meatus only reached the membranous urethra, the tip just being paIpabIe per rectum through the dense scar tissue. Diagnosis: compIete traumatic rupture of the bulbous urethra with marked cicatrix and water-pot perineum. Operation on date of examination under ether anesthesia. The anterior urethra and both perinea1 sinuses were injected with methyIene bIue. A meta sound was passed through the anterior urethra to the point of obstruction and a second through the suprapubic fistuIa
Urethra
Amerkxn Journal of Sur~r~y
107 15
into the bIadder out through the prostatic urethra, the tip extending through the membranous urethra. A median incision was made in the perineum and both sinuses dissected out under the guidance of the methyIene blue, as they Ied by separate tracks to the tip of the sound in the membranous urethra just outside of the trianguIar ligament. A Iarge amount of scar tissue was dissected away, cIearIy exposing both sounds and completely destroying a gap of 3 cm. of the urethra. The severed ends were freely mobilized and all fibrous thickening removed out into the normal surroundings. A No. 24 F. soft rubber catheter was passed into the bladder through the posterior segment as the sound kvas removed and the dista1 end threaded on to the tip of the anterior sound and withdrawn out through the anterior urethra. An end-to-end transverse anastomosis was done around the catheter with interrupted No. I twenty-day catgut sutures, reinforced by additional sutures of plain catgut. The skin was loosely united with black silk and a pIain gauze drain left inserted at the posterior angIe. ConvaIescence normaI, heaIing without Ieakage or ertravasation. The suprapubic incision heaIed spontaneously. The catheter \vas removed on the twelfth day and sounds to No. 20 F. passed on the fourteenth day. When the patient was seen in two months voiding was normal and I was abIe to diIate to a No. 28 F. He was we11 in JuIy, 1927 when sounds were passed; a further recent report states that he is wel1.
CASE III. Differing from the preceding was the case of a patient with an impermeable stricture from an oId gonorrhea1 infection. As the operative procedure was somewhat similar, I incIude it here. The patient, white, aged fifty-one, married, was by occupation a water-man. As a youth he contracted gonorrhea, and for twenty years had attacks of dysuria lasting severa weeks; at no time was he able to void normally. This graduaIIy increased and no proIonged relief was experienced from diIatations. In March, 1929 an operation was done for hemorrhoids and the stricture UnsuccessfuIIy diIated and since then, particularly for the past three weeks, has been in constant pain, emptying the bladder most of the past week involuntarily by dribbling. Attempts to catheterize have failed. I first saw him September 12, rg2g, in great pain,
I074
American Journal of Surgery
NeiII-Impervious
with the bladder extending haIfway to the umbiIicus with an invoIuntary dribbIing of ammoniaca urine. A sound refused to go beyond the region of the trianguIar ligament; the obstruction was aIso impermeabIe to fiIiform bougies. The prostate was norma and above it lay the tense, distended bIadder. Rather than do a cystostomy I decided to resect the stricture from beIow. MethyIene blue was injected anteriorIy and miIked towards the bIadder. A median perinea1 incision was made and the tissues cut down to a sound passed to the obstruction. The urethra was dissected free over the sound and opened on its tip. It was markedIy thickened and the Iumen tortuous and threadlike, a fact cIearIy demonstrated by the methyIene bIue. The stained tract was foIIowed up to the norma urethra just in front of the trianguIar Iigament. The entire segment of the urethra (2.5 cm.) was excised with a11 enveIoping scar tissues. A No. 22 F. soft rubber catheter was then introduced into the bIadder, evacuating 1200 C.C. of fou1 urine. The dista1 end of the catheter was then threaded over the tip of the sound and drawn out through the meatus. With moderate tension the ends were joined transverseIy about the catheter with interrupted No. I twenty-day .catgut sutures, reinforced by pIain catgut sutures, and the skin cIosed with interrupted sutures, Ieaving a smaI1 cigarette drain up to the anastomosis. ConvaIescence normaI; no leakage or extravasation of urine unti1 the catheter was removed on the seventh day as the patient began voiding around it, with some Ieakage through the perineum. Voiding continued norma and the perinea1 Ieakage grew Iess and ceased at the end of the fourth week when the heaIing was compIet& At the end of the second week I passed a smaI1 sound into the bIadder. A No. 28 F. easiIy passed in the fifth week ‘and voiding was normaI. He was seen %33
Urethra
MAY, ,930
and dilated October 3oth;.Lsubsequent tions wiI1 be continued.
diIata-
CASE IV. A fourth patient was operated upon at the Church Home and Infirmary, BaItimore, in 1915. Since a portion of the history is Iost, a detaiIed report cannot be given. An empIoyee of a timber company in North CaroIina feI1 while at work, straddIing an object and sustained a severe blow on the perineum, foIlowed by bIeeding from the urethra. He remained in a IocaI hospita1 for three weeks with a retention catheter; foIIowing its remova he found voiding diffIcuIt at first, graduaIIy growing worse. Attempts to dilate gave no definite reIief. When I saw him approximateIy six months after the injury, I found the buIbous urethra markedIy indurated, and a sound stopped at this point. After consuItation with the Iate Dr. J. T. Geraghty, instead of an interna urethrotomy, an open operation was carried out as described in Case III; this was foIIowed by compIete reIief. Subsequent diIatations were carried out, the patient remaining perfectly we11unti1 I Iost track of him five years later. CONCLUSIONS I. Accurate knowIedge of the regional anatomy is a prime requisite. 2. PreIiminary injection of methyIene bIue is of great assistance, outhning the distorted urethra and any diverticuIa for
the subsequent operation. 3. Sharp dissection, dehcate instruments and fine sutures with carefu1 manipuIation insure the union of the approximated tissues. 4. Some foIIow-up diIatations urethra must be carried out obviate any stricture in the tract.
of the Iater to