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Suprapubic bladder drainage following radical hysterectomy
Volume Number
Communications
113 6
as in the case described by Philpott and Crichton.* Dr. M. Lancet” has had a case of postpartum shock, which at laparotomy revealed a transverse tear in the posterior wall of the uterus, involving the serosa and myometrium only, and with severe retroperitoneal hemorrhage. The usual classification of uterine rupture does not include this type. It is suggested that the name “incomplete external rupture of the uterus” should be used. The mechanism can be understood by considering the uterus as a hollow sphere with three layers : decidual, myometrial, and serosal, each with different degrees of elasticity. With pressure from within the less elastic layer will give way first, and in our opinion this is the serosal coat of the uterus and the outermost part of the myometrium. REFERENCES
1. Chassar Moir, J.: Munro Kerr’s Operative Obstetrics, ed. 7, London, 1964, Bailliere, Tindall & Cox, p. 879. 2. Pedowitz, P., and Perell, A.: AM. J. ORSTET. GYNECOL. 16: 161, 1958. E. B., and Bone, F. W.: AM. J. 3. Mendel, OBSTET. GYNECOL. 71: 1122. 1956. 4. Philpott, R. H., and Crichton, D.: Lancet 1: 883, 1964. 5. Lancet, M.: Personal communication.
rauprapubic bladder drainage following radical hysterectomy
J. R.
NAGELL, JR., M.D.* JR., B.A. J. W. RODDICK, JR., M.D. R.
VAN
M.
Department University
PENNY,
of Obstetrics of Kentucky,
and Gynecology, Lexington, Kentucky
S I N c E John Clark’s1 first description of radical hysterectomy in 1895, it has been the gynecologic operation most often associated with serious urologic complications. Various measures have been employed to reduce the incidence of such complications, but none has been more successful than the use of the indwelling Foley catheter to provide constant bladder drainage during the first 6 postoperative weeks. Green, Meigs, and Ulfelder,a in a study of over 600 patients, reported a reduction of over 50 per cent in major ureter-al complications when the duration of constant bladder drainage was increased “American
Cancer
Society
Advanced
Clinical
Fellow.
in brief
849
from 2 to 6 weeks following radical hysterectomy. Recent reports have shown that suprapubic bladder drainage is a very satisfactory method in patients undergoing gynecologic operation for benign disease. The major advantages of that method are improvement in patient comfort and reduced incidence of significant bacteriuria.” Therefore, it was reasoned that bladder drainage by means of suprapubic cystostomy might be superior to urethral catheter drainage in patients undergoing radical procedures. From January, 1964, to September, 1971, 104 radical hysterectomies were performed at the University of Kentucky Medical Center. Two of the patients died in the immediate postoperative period and were excluded from the study. Eightyfour patients had postoperative suprapubic bladder drainage. A small incision was made in the bladder at the time of operation and a No. 18 Foley or Malecott catheter was inserted. During the past 2 years, a Silastic Foley catheter has been used for this purpose. The catheter was brought out through a stab wound lateral to the midline abdominal incision and connected to straight drainage. The mean duration of suprapubic drainage was 50.5 days (range: 28 to 124 days). Each patient was instructed to irrigate the bladder three times daily with 0.25 per cent acetic acid solution and was seen every 2 weeks following discharge until catheter removal. The catheter was left in place at least 6 weeks and was removed only when the postvoiding bladder residual was under 50 C.C. The remaining 18 patients had urethral catheter drainage for an average of 37.3 days (range: 5 to 60 days). The same criteria for catheter removal were applied to both groups. Intraoperative urinary tract injuries are listed in Table I. There were 13 recognized intraoperative urinary tract injuries in the suprapubic catheter group and 2 of these patients subsequently developed urinary tract fistulas (one ureterovaginal and one vesicovaginal) . Four additional patients in the suprapubic catheter group who had no recognized uirnary tract injury at operation subsequently developed fistulas. These fistulas were all successfully repaired. However, one patient who had been irradiated prior to operation developed ureteral stenosis and consequent hydronephrosis requiring nephrectomy 8 months after repair of a ureterovaginal fistula. In 2 instances, there were complications related to the suprapubic catheter itself. One catheter did not function in the immediate postoperative period, and another pulled out of the blad-
850
Communications
July 15, 1972 Am. J. Obstet. Gynecol.
in brief
Table I. Types of bladder
drainage following
Previous irradiation
Mean
radical hysterectomy
duration (days)
Zntraoperative complications
tract
Patients
Urethral
18
1
37.3
1 Inadvertent cystotomy
2 Vesicovaginal
8 (44%)
Suprapubic
84
7
50.5
7 Inadvertent cystotomy 6 Ureteral laceration
4 Vesicovaginal
19 (23%)
Total
102
8
48.2
der after 30 days of normal function. In both cases, a urethral catheter was inserted without difficulty. Urine cultures were obtained in any patient in whom urinary tract symptoms developed and were checked at the time of catheter removal on all patients. The incidence of urinary tract infection (> 100,000 colonies per milliliter) in those patients with urethral catheter drainage was 44 per cent as compared to 23 per cent in the suprapubic drainage group. The infecting organisms were the same in both groups with E. coli and Klebsiella enterobacter being the most common organisms cultured. .4lthough the urethral catheter group was too
Fistula
Urinary infect+
Catheter
2 Ureterovaginal 8
14
27 (27%)
small for statistically meaningful comparison, it is apparent that suprapubic drainage following radical hysterectomy provides a safe and effective means of bladder decompression. The incidence of urinary tract complications and infection was not increased, and a major benefit of increased patient comfort was achieved. REFERENCES
1. Clark, J. G.: Johns Hopkins Bull. 53: 120, 1895. 2. Green, T. H., Meigs, J. V., Ulfelder, H., and Curtin, R. R.: Obstet Gynecol. 20: 293, 1962. 3. Hodgkinson, C. P., and Hodari, A. A.: AM. J. OBSTET. GYNECOL. 96: 773, 1966.
Communications
113 6
as in the case described by Philpott and Crichton.* Dr. M. Lancet” has had a case of postpartum shock, which at laparotomy revealed a transverse tear in the posterior wall of the uterus, involving the serosa and myometrium only, and with severe retroperitoneal hemorrhage. The usual classification of uterine rupture does not include this type. It is suggested that the name “incomplete external rupture of the uterus” should be used. The mechanism can be understood by considering the uterus as a hollow sphere with three layers : decidual, myometrial, and serosal, each with different degrees of elasticity. With pressure from within the less elastic layer will give way first, and in our opinion this is the serosal coat of the uterus and the outermost part of the myometrium. REFERENCES
1. Chassar Moir, J.: Munro Kerr’s Operative Obstetrics, ed. 7, London, 1964, Bailliere, Tindall & Cox, p. 879. 2. Pedowitz, P., and Perell, A.: AM. J. ORSTET. GYNECOL. 16: 161, 1958. E. B., and Bone, F. W.: AM. J. 3. Mendel, OBSTET. GYNECOL. 71: 1122. 1956. 4. Philpott, R. H., and Crichton, D.: Lancet 1: 883, 1964. 5. Lancet, M.: Personal communication.
rauprapubic bladder drainage following radical hysterectomy
J. R.
NAGELL, JR., M.D.* JR., B.A. J. W. RODDICK, JR., M.D. R.
VAN
M.
Department University
PENNY,
of Obstetrics of Kentucky,
and Gynecology, Lexington, Kentucky
S I N c E John Clark’s1 first description of radical hysterectomy in 1895, it has been the gynecologic operation most often associated with serious urologic complications. Various measures have been employed to reduce the incidence of such complications, but none has been more successful than the use of the indwelling Foley catheter to provide constant bladder drainage during the first 6 postoperative weeks. Green, Meigs, and Ulfelder,a in a study of over 600 patients, reported a reduction of over 50 per cent in major ureter-al complications when the duration of constant bladder drainage was increased “American
Cancer
Society
Advanced
Clinical
Fellow.
in brief
849
from 2 to 6 weeks following radical hysterectomy. Recent reports have shown that suprapubic bladder drainage is a very satisfactory method in patients undergoing gynecologic operation for benign disease. The major advantages of that method are improvement in patient comfort and reduced incidence of significant bacteriuria.” Therefore, it was reasoned that bladder drainage by means of suprapubic cystostomy might be superior to urethral catheter drainage in patients undergoing radical procedures. From January, 1964, to September, 1971, 104 radical hysterectomies were performed at the University of Kentucky Medical Center. Two of the patients died in the immediate postoperative period and were excluded from the study. Eightyfour patients had postoperative suprapubic bladder drainage. A small incision was made in the bladder at the time of operation and a No. 18 Foley or Malecott catheter was inserted. During the past 2 years, a Silastic Foley catheter has been used for this purpose. The catheter was brought out through a stab wound lateral to the midline abdominal incision and connected to straight drainage. The mean duration of suprapubic drainage was 50.5 days (range: 28 to 124 days). Each patient was instructed to irrigate the bladder three times daily with 0.25 per cent acetic acid solution and was seen every 2 weeks following discharge until catheter removal. The catheter was left in place at least 6 weeks and was removed only when the postvoiding bladder residual was under 50 C.C. The remaining 18 patients had urethral catheter drainage for an average of 37.3 days (range: 5 to 60 days). The same criteria for catheter removal were applied to both groups. Intraoperative urinary tract injuries are listed in Table I. There were 13 recognized intraoperative urinary tract injuries in the suprapubic catheter group and 2 of these patients subsequently developed urinary tract fistulas (one ureterovaginal and one vesicovaginal) . Four additional patients in the suprapubic catheter group who had no recognized uirnary tract injury at operation subsequently developed fistulas. These fistulas were all successfully repaired. However, one patient who had been irradiated prior to operation developed ureteral stenosis and consequent hydronephrosis requiring nephrectomy 8 months after repair of a ureterovaginal fistula. In 2 instances, there were complications related to the suprapubic catheter itself. One catheter did not function in the immediate postoperative period, and another pulled out of the blad-
850
Communications
July 15, 1972 Am. J. Obstet. Gynecol.
in brief
Table I. Types of bladder
drainage following
Previous irradiation
Mean
radical hysterectomy
duration (days)
Zntraoperative complications
tract
Patients
Urethral
18
1
37.3
1 Inadvertent cystotomy
2 Vesicovaginal
8 (44%)
Suprapubic
84
7
50.5
7 Inadvertent cystotomy 6 Ureteral laceration
4 Vesicovaginal
19 (23%)
Total
102
8
48.2
der after 30 days of normal function. In both cases, a urethral catheter was inserted without difficulty. Urine cultures were obtained in any patient in whom urinary tract symptoms developed and were checked at the time of catheter removal on all patients. The incidence of urinary tract infection (> 100,000 colonies per milliliter) in those patients with urethral catheter drainage was 44 per cent as compared to 23 per cent in the suprapubic drainage group. The infecting organisms were the same in both groups with E. coli and Klebsiella enterobacter being the most common organisms cultured. .4lthough the urethral catheter group was too
Fistula
Urinary infect+
Catheter
2 Ureterovaginal 8
14
27 (27%)
small for statistically meaningful comparison, it is apparent that suprapubic drainage following radical hysterectomy provides a safe and effective means of bladder decompression. The incidence of urinary tract complications and infection was not increased, and a major benefit of increased patient comfort was achieved. REFERENCES
1. Clark, J. G.: Johns Hopkins Bull. 53: 120, 1895. 2. Green, T. H., Meigs, J. V., Ulfelder, H., and Curtin, R. R.: Obstet Gynecol. 20: 293, 1962. 3. Hodgkinson, C. P., and Hodari, A. A.: AM. J. OBSTET. GYNECOL. 96: 773, 1966.