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The management of the bladder following abdominoperineal proctosigmoidectomy and other extensive abdominal surgical procedures
The Management of the Bladder Following Abdominoperineal Proctosigmoidectomy and Other Extensive Abdominal Surgical Procedures A FIFTEEN-YEAR SURVEY LOWRA1N E. b,IcCREA, M.D. AND HARRY E. BACON, M.D.,
Philadelphia, l~ennsyh'ania
ESlCAL atonia occurs quite frequently folprimary innervation, as is (lone in abdominoowing abdominopcrineal proctosigmoldccperineal proctosigmoidectomy, Miles' excision and other types of surgery on the bowel and tomy and other surgical procedurcs on the pelvis, tile accessory innerwltion takes over bowel. Tl.le presence of this complication need and normal urination is re-established. That the not be considered serious or permanent. Normal vesicaI fimction may be completely reaccessory innervation is capable, competent and able to sustain normal urination, is proved stored provided the coridition is recognized early and proper treatment is instituted and by the fact that following "proctosigmoklccmaintained. These statements are established tomy" and Miles' excision patients urinate and substantiated by a survey conducted from normally without residual urine. The accessory innervation was demonstrated to exist by serial x94o to x955, inclusive. A diagnosis of carcinoma of the bowel was made in 1,564 pasection of human' embryos and by actual dissection of tile adult. The nerve fibers of the tients. Of these, 1,294 underwent resection of the bowel. Preoperative urologic examinations accessory innervation were shown to rise from the sacral nerve roots (as does the primary were performed on 933 patients who were observed and/or received therapy when necesinnervation), traverse the endopelvic fascia sary postoperatively. Ninety-three patients and enter the bladder at the insertion of the with temporary vesical atonia were.observed ureter. The distribution from that point is and treated during the time of this survey. similar to that of primary innervation. Due Normal urinary function was obtained in all to the normal behavior of the bladder following but two patients: one committcd suicide and surgery it was concluded that both sympathetic the other had urinary incontinence for six and parasympathetic nerves are present, as in years following an extended Miles abdominothe primary innervation. However, it is inlperineal excision. possible to demonstrate microscopically the The cause of temporary vesical atonia is still different types of nerve fibers. Temporary considered to be surgical interference with the vesical atonia is considered to be the result of innervation of the bladder. The ideas and trauma to the nerve, fibers of the accessory thcories of the cause of veslcal atonia were innervation following excision of the primary advanced in I946. However, it was not until innervation. If permitted a period of grace, x952 that original anatomic research in cooperanormal fimctional ability is returned, as tile tion with Dr. Donald Kimmel was presented. ninety-one cases in the survey have shown. At that time it was shown that an accessory Veslcal atonia has been shown to have occurred innervation to the bladder exists. It was further ninety-one times (fifty-four males, thirtydemonstrated that after the removal of the seven females). (Table I.) Vesical atonia was American Journal of Surger}', Volume 92, Norember, lOS6 752
V
M a n a g e m e n t of the Bladder noted as a complication following proctosigmoidectomy slxty-two times (thirty-nine males and twenty-thrcc females) and following Miles' excision twenty-six times (fourteen males, twelve females). Atonia was exhibited by two women following sigmoidectomy and
drainage until the atonia is corrected. Panendoscopy in the presence of prostatic hyperplasia will always reveal an intrusion of a lobe or Iobes of the prostate on tile posterior urethra. Baslea[[y, prostatic disease may exist when the patient is first seen. It is believed that a patient
TABLE 1 VESICAL ATONIA A b d o m i n o p e r l n e a l p r o c t o s i g m o i d c c t o m y (562 tients) .................................... Males ................................... Females ................................. M i l e s ' e x c i s i o n (193 p a t i e n t s ) . . . . . . . . . . . . . . . . . . . . Males .................................. Females ................................. S i g m o i d c c t o m y (89 p a t i e n t s ) . . . . . . . . . . . . . . . . . . . . Males ................................... Females ................................. Anterior resection .............................. Male .................................... Females .................................
TABLE II PROSTATIC OPERATIONS PERFOILMED TO RELIEVE URINARY OBSTRUCTION Abdominoperincal proetosigmoldectomy .......... 14 Transurcthra[ prostatic resection ............ xl Suprapubic prostateetomy ................. 3 Miles' excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Transurethra[ resection .................... 8 Prostatcctomy (open surgery) .............. o Sigmoldectomy ................................ I Transurcthral rcscctlon .................... I Prostatectomy (open surgery) .............. o
pa6z 39 23 a6 14 12 z o 2 ! i o
by one man following anterior resection. Therefore, vesical dysfunction following abdominal surgery cannot be considercd the result of obstructive uropathy or prostatic hyperplasia in every instance. Urinary retention following surgery, due to existing and demonstrable prostatic hyperplasia, cannot be and is not considered vesical atonia. Prostatic hyperplasia was observed twenty-six times in this series. Twenty-three prostatic operations were performed, consisting of twenty transurethral and three suprapubic procedures. (Table H.) During this survey eleven transurethral resections and three suprapubic procedures were performed following abdonfinoperineal proctosigmoidectomy, eight transurethral procedures following Miles' excision and one transurethral resection following sigmoideetomy. Three patients have known prostatic enlargement with proved widespread metastasis. They are maintained by indwelling catheters. One patient has been advised to have prostatic surgery, but still has die suggestion under consideration. The differential diagnosis between vesical atonia and prostatic hyperplasla is done by cystometry and panendoscopy. Cystometry in obstructive uropathy due to prostatic hyperplasia will usually reveal a normal reading in contrast to tile hypotonle curve exhibited in vesieal atonia. It is possible that both conditions may exist simultaneously." In such instances it is suggested that prostatic surgery be performed, maintaining catheter 753
with proved, demonstrable malignant disease should benefit from surgery if the primary condition is treated before attention is surgically directed to the prostate. Infection should always be looked for or guarded against in either vesiea[ atonia or prostatic hyperplasia when catheter drainage is used. Surveillance should be constant and rigid. It has been a surprising revelation to observe the number of patients with demonstrable bowel lesions who exhibit evidence of infection when first examined. In a previous survey it was found that 68.9 per cent of persons with malignant disease of the bowel had a positive urine culture at the time of the original examination. In the present series, 933 patients were seen and examined (Table m) and 815 urine cultures were taken. A personal review of the hospital records revealed that in 313 patients (38.3 per cent) an infection of tile urinary tract was present before surgery or developed during hospitalization. Of 565 instances in which proctosigmoidectomy was done (3o3 males, 262 females) there were s66 individuals who exhibited positive urine cultures (ninetytwo inales, seventy-four females). Of these, seventy-four patients exhibited infection (fortyone males, thirty-three females). Sigmoidectomy was performed eighty-nine times (fortysix males, forty-three females). Infection was observed in twenty-five instances (fifteen males, ten females). The bacterial flora revealed by these cultures were not remarkable or unusual. In the majority of instances tile bacteria were confined to tile gram-negative group. However, there were instances when
M c C r e a and Bacon to ascertain the presence or absence of infection. Cystometrie studies will determine the muscle tone of the bladder. The value of preoperative eystoseopy and panendoscopy cannot be underestimated. In this series, primary transitional carcinoma of the bladder has been observed six times. These tumors were small, were proved by biopsy and were destroyed by transurethral resection or electrocoagulation. AII have been repeatedly rechecked eystoseopieaIly without evidence of recurrence. Invasion of tile bladder by an extrinsic malignant process has been observed nine times. Of these, two patients had partial resection (one male, one female), and seven had pelvic exenteration (four males, three females). Panendoscopy in the male will reveal the extent of the prostatie intrusion on the posterior urethra. All of this information is of inestimable value to the surgeon. Postoperatire. The bladder should be maintalned at complete rest either by catheter or by eystotomy. Catheter drainage is preferred. The bladder may be maintained by continuous catheter drainage or by tidal drainage. A cystometric reading is done on the fifth postoperative day. If normal, the patient is permitted to void and the residual urine, if any, is measured. If the residual urine is 6o ec or less, the patient is permitted to continue to void normally. If the cystometrie reading is not within the normal range, catheter drainage is continued. If the amount of residual urine is more than 60 cc., the catheter is reinsertcd and maintained until the tenth postoperative day when cystom.etry is repeated and the residual urine is measured. In males, it may then be determined whether the residual urine has a neurogenic basis or results from enlargement of the prostate. If atonia exists at the time of the patient's discharge from the hospital, the catheter is permitted to remain in situ and the patient is checked at weekly intervals, at which time the catheter is changed. Catheter drainage is maintaincd in patients who do not have obstructive uropathy, until the patient, is able to void with a residual of z ounces or less. It is imperative during this phase that infection be controlled and eradicated if possible. Of ninety-one patients with vcsical atonia, all have returned to the normal function of urination with the exception of the two previously mentioned cases.
gram-positive cocci were found in pure culture. The most commonly observed organisms were Bacillus pyocyaneus, B. coli, pseudomonas, Aerobacter aerogenes and B. proteus, in that order. Normal urinary elimination and antibiotic therapy are important factors in the TABLE
ill
URINARY TRACT INFECTIONS FOLLOWING SURGEI~.Y*
Abdominoperineal p r o c t o s i g m o l d c c t o m y . . . . . . . . . 166 Males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Miles' operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4s Females . . . . . . . . . . . . . . . . . . . . . . . . . '........ 33 Sigmoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lO I n f e c t l o n - - o t h e r surgical procedures . . . . . . . . . . . . . 48 * O f 815 urine cultures taken, 315 gave positive results. T h e following bacterial flora were reported: P s e u d o m o n a s p y o c y a n e a , coliform, B. coil, A. aerogenes, P r o t e u s vulgaris, paraeolon, Staphylococcus albus a n d Streptococcus hemolytieus.
control of infection of the urinary tract and must be individually considered in every instance. It was frequently demonstrated that these organisms were very resistant to therapy. In many instances it was necessary to perform sensitivity tests before eradication of the infection was complete. Once an infection is apparent, the medication to which the organism is sensitive is continuously administered until repeated cultures show the infection is eradicated. It is believed that in treating urinary tractinfections there is a tendency to stop medication too quickly and in many instances to administer minimal dosage rather than maximum dosage of the selected drug. MANAGEMENT OF VESICAL ATONIA
Rest is considered the best method of preserving the musculature of the bladder and of preventing permanent vesical atonia. Rest may be accomplished by insertingan indwelling catheter or by instituting cystotomy drainage. However, it is believed that catheter drainage is preferred as it does not subject the patient to further surgery. VeslcaI atonia should be anticipated in every patient undergoing surgery. Steps should be taken to control the dysfimction before it occurs. A definite and specific routine, such as the following, should be maintained. Preoperative. Urine cultures should be taken 754
M a n a g e m e n t of the Bladder treated twenty-five times (fifteen males, ten females), or 28.4 per cent. Transurethral prostatic resection was performed once. Primary transitional carcinoma of the bIadder occurred six times. All patients were treated by transurethral procedures. Invasion of the bladder from extensive malignancy was observed nine times. Partial or segmental resection of the bladder was performed twice (one male, one female). Total cystectomy and pelvic exentcration was performed seven times (four males, three females).
SUMMARY
A survey covering a fifteen-year period (194o to I955, inclusive) has been made. A total of 933 patients were seen and exattained preoperatively. Urine cultures were taken 8I 5 times. Abdominoperineal proctosigmoideetomy was performed 565 times (303 males, 262 females) with the occurrence of vesical atonia in sixty-two patients (thirty-nine males, twenty-three females), or Io.9 per cent. Urinary tract infection was observed in i66 instances (2o.I9 per cent). Prostatic surgery was performed on fourteen patients (transurethral resection, eleven, suprapubic prostatectomy, three). The Miles type of excision was performed 193 times 0 o I males, ninety-two females). Vesical atonia occurred in twenty-slx patients (fourteen inales, twelve females), or I3.4 per cent. Urinary infection was observed and treated seventy-four times (forty-one males, thirty-three females), or 39.9 per cent. Prostatic surgery was performed eight times; all were transurethral resections. Sigmoidectomy was performed on eightynine occasions (forty-six males, forty-three females). Vesical atonia occurred in two patients, both females. Infection was seen and
CONCLUSIONS
The value of routine preoperative and postoperative urologic examination of' patients undergoing major surgery on the bowel is clearly demonstrated. Vesical atonia occurs in botil males and females. Vesical atonia and urinary retention associated with prostatic enlargement differs widely in concept and management. Maintaining the bladder at complete rest without infection is considered the best management of temporary vesical atonia. Time and proper management will permit and promote a return to a normally functioning bladder.
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755
Philadelphia, l~ennsyh'ania
ESlCAL atonia occurs quite frequently folprimary innervation, as is (lone in abdominoowing abdominopcrineal proctosigmoldccperineal proctosigmoidectomy, Miles' excision and other types of surgery on the bowel and tomy and other surgical procedurcs on the pelvis, tile accessory innerwltion takes over bowel. Tl.le presence of this complication need and normal urination is re-established. That the not be considered serious or permanent. Normal vesicaI fimction may be completely reaccessory innervation is capable, competent and able to sustain normal urination, is proved stored provided the coridition is recognized early and proper treatment is instituted and by the fact that following "proctosigmoklccmaintained. These statements are established tomy" and Miles' excision patients urinate and substantiated by a survey conducted from normally without residual urine. The accessory innervation was demonstrated to exist by serial x94o to x955, inclusive. A diagnosis of carcinoma of the bowel was made in 1,564 pasection of human' embryos and by actual dissection of tile adult. The nerve fibers of the tients. Of these, 1,294 underwent resection of the bowel. Preoperative urologic examinations accessory innervation were shown to rise from the sacral nerve roots (as does the primary were performed on 933 patients who were observed and/or received therapy when necesinnervation), traverse the endopelvic fascia sary postoperatively. Ninety-three patients and enter the bladder at the insertion of the with temporary vesical atonia were.observed ureter. The distribution from that point is and treated during the time of this survey. similar to that of primary innervation. Due Normal urinary function was obtained in all to the normal behavior of the bladder following but two patients: one committcd suicide and surgery it was concluded that both sympathetic the other had urinary incontinence for six and parasympathetic nerves are present, as in years following an extended Miles abdominothe primary innervation. However, it is inlperineal excision. possible to demonstrate microscopically the The cause of temporary vesical atonia is still different types of nerve fibers. Temporary considered to be surgical interference with the vesical atonia is considered to be the result of innervation of the bladder. The ideas and trauma to the nerve, fibers of the accessory thcories of the cause of veslcal atonia were innervation following excision of the primary advanced in I946. However, it was not until innervation. If permitted a period of grace, x952 that original anatomic research in cooperanormal fimctional ability is returned, as tile tion with Dr. Donald Kimmel was presented. ninety-one cases in the survey have shown. At that time it was shown that an accessory Veslcal atonia has been shown to have occurred innervation to the bladder exists. It was further ninety-one times (fifty-four males, thirtydemonstrated that after the removal of the seven females). (Table I.) Vesical atonia was American Journal of Surger}', Volume 92, Norember, lOS6 752
V
M a n a g e m e n t of the Bladder noted as a complication following proctosigmoidectomy slxty-two times (thirty-nine males and twenty-thrcc females) and following Miles' excision twenty-six times (fourteen males, twelve females). Atonia was exhibited by two women following sigmoidectomy and
drainage until the atonia is corrected. Panendoscopy in the presence of prostatic hyperplasia will always reveal an intrusion of a lobe or Iobes of the prostate on tile posterior urethra. Baslea[[y, prostatic disease may exist when the patient is first seen. It is believed that a patient
TABLE 1 VESICAL ATONIA A b d o m i n o p e r l n e a l p r o c t o s i g m o i d c c t o m y (562 tients) .................................... Males ................................... Females ................................. M i l e s ' e x c i s i o n (193 p a t i e n t s ) . . . . . . . . . . . . . . . . . . . . Males .................................. Females ................................. S i g m o i d c c t o m y (89 p a t i e n t s ) . . . . . . . . . . . . . . . . . . . . Males ................................... Females ................................. Anterior resection .............................. Male .................................... Females .................................
TABLE II PROSTATIC OPERATIONS PERFOILMED TO RELIEVE URINARY OBSTRUCTION Abdominoperincal proetosigmoldectomy .......... 14 Transurcthra[ prostatic resection ............ xl Suprapubic prostateetomy ................. 3 Miles' excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Transurethra[ resection .................... 8 Prostatcctomy (open surgery) .............. o Sigmoldectomy ................................ I Transurcthral rcscctlon .................... I Prostatectomy (open surgery) .............. o
pa6z 39 23 a6 14 12 z o 2 ! i o
by one man following anterior resection. Therefore, vesical dysfunction following abdominal surgery cannot be considercd the result of obstructive uropathy or prostatic hyperplasia in every instance. Urinary retention following surgery, due to existing and demonstrable prostatic hyperplasia, cannot be and is not considered vesical atonia. Prostatic hyperplasia was observed twenty-six times in this series. Twenty-three prostatic operations were performed, consisting of twenty transurethral and three suprapubic procedures. (Table H.) During this survey eleven transurethral resections and three suprapubic procedures were performed following abdonfinoperineal proctosigmoidectomy, eight transurethral procedures following Miles' excision and one transurethral resection following sigmoideetomy. Three patients have known prostatic enlargement with proved widespread metastasis. They are maintained by indwelling catheters. One patient has been advised to have prostatic surgery, but still has die suggestion under consideration. The differential diagnosis between vesical atonia and prostatic hyperplasla is done by cystometry and panendoscopy. Cystometry in obstructive uropathy due to prostatic hyperplasia will usually reveal a normal reading in contrast to tile hypotonle curve exhibited in vesieal atonia. It is possible that both conditions may exist simultaneously." In such instances it is suggested that prostatic surgery be performed, maintaining catheter 753
with proved, demonstrable malignant disease should benefit from surgery if the primary condition is treated before attention is surgically directed to the prostate. Infection should always be looked for or guarded against in either vesiea[ atonia or prostatic hyperplasia when catheter drainage is used. Surveillance should be constant and rigid. It has been a surprising revelation to observe the number of patients with demonstrable bowel lesions who exhibit evidence of infection when first examined. In a previous survey it was found that 68.9 per cent of persons with malignant disease of the bowel had a positive urine culture at the time of the original examination. In the present series, 933 patients were seen and examined (Table m) and 815 urine cultures were taken. A personal review of the hospital records revealed that in 313 patients (38.3 per cent) an infection of tile urinary tract was present before surgery or developed during hospitalization. Of 565 instances in which proctosigmoidectomy was done (3o3 males, 262 females) there were s66 individuals who exhibited positive urine cultures (ninetytwo inales, seventy-four females). Of these, seventy-four patients exhibited infection (fortyone males, thirty-three females). Sigmoidectomy was performed eighty-nine times (fortysix males, forty-three females). Infection was observed in twenty-five instances (fifteen males, ten females). The bacterial flora revealed by these cultures were not remarkable or unusual. In the majority of instances tile bacteria were confined to tile gram-negative group. However, there were instances when
M c C r e a and Bacon to ascertain the presence or absence of infection. Cystometrie studies will determine the muscle tone of the bladder. The value of preoperative eystoseopy and panendoscopy cannot be underestimated. In this series, primary transitional carcinoma of the bladder has been observed six times. These tumors were small, were proved by biopsy and were destroyed by transurethral resection or electrocoagulation. AII have been repeatedly rechecked eystoseopieaIly without evidence of recurrence. Invasion of tile bladder by an extrinsic malignant process has been observed nine times. Of these, two patients had partial resection (one male, one female), and seven had pelvic exenteration (four males, three females). Panendoscopy in the male will reveal the extent of the prostatie intrusion on the posterior urethra. All of this information is of inestimable value to the surgeon. Postoperatire. The bladder should be maintalned at complete rest either by catheter or by eystotomy. Catheter drainage is preferred. The bladder may be maintained by continuous catheter drainage or by tidal drainage. A cystometric reading is done on the fifth postoperative day. If normal, the patient is permitted to void and the residual urine, if any, is measured. If the residual urine is 6o ec or less, the patient is permitted to continue to void normally. If the cystometrie reading is not within the normal range, catheter drainage is continued. If the amount of residual urine is more than 60 cc., the catheter is reinsertcd and maintained until the tenth postoperative day when cystom.etry is repeated and the residual urine is measured. In males, it may then be determined whether the residual urine has a neurogenic basis or results from enlargement of the prostate. If atonia exists at the time of the patient's discharge from the hospital, the catheter is permitted to remain in situ and the patient is checked at weekly intervals, at which time the catheter is changed. Catheter drainage is maintaincd in patients who do not have obstructive uropathy, until the patient, is able to void with a residual of z ounces or less. It is imperative during this phase that infection be controlled and eradicated if possible. Of ninety-one patients with vcsical atonia, all have returned to the normal function of urination with the exception of the two previously mentioned cases.
gram-positive cocci were found in pure culture. The most commonly observed organisms were Bacillus pyocyaneus, B. coli, pseudomonas, Aerobacter aerogenes and B. proteus, in that order. Normal urinary elimination and antibiotic therapy are important factors in the TABLE
ill
URINARY TRACT INFECTIONS FOLLOWING SURGEI~.Y*
Abdominoperineal p r o c t o s i g m o l d c c t o m y . . . . . . . . . 166 Males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Miles' operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4s Females . . . . . . . . . . . . . . . . . . . . . . . . . '........ 33 Sigmoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lO I n f e c t l o n - - o t h e r surgical procedures . . . . . . . . . . . . . 48 * O f 815 urine cultures taken, 315 gave positive results. T h e following bacterial flora were reported: P s e u d o m o n a s p y o c y a n e a , coliform, B. coil, A. aerogenes, P r o t e u s vulgaris, paraeolon, Staphylococcus albus a n d Streptococcus hemolytieus.
control of infection of the urinary tract and must be individually considered in every instance. It was frequently demonstrated that these organisms were very resistant to therapy. In many instances it was necessary to perform sensitivity tests before eradication of the infection was complete. Once an infection is apparent, the medication to which the organism is sensitive is continuously administered until repeated cultures show the infection is eradicated. It is believed that in treating urinary tractinfections there is a tendency to stop medication too quickly and in many instances to administer minimal dosage rather than maximum dosage of the selected drug. MANAGEMENT OF VESICAL ATONIA
Rest is considered the best method of preserving the musculature of the bladder and of preventing permanent vesical atonia. Rest may be accomplished by insertingan indwelling catheter or by instituting cystotomy drainage. However, it is believed that catheter drainage is preferred as it does not subject the patient to further surgery. VeslcaI atonia should be anticipated in every patient undergoing surgery. Steps should be taken to control the dysfimction before it occurs. A definite and specific routine, such as the following, should be maintained. Preoperative. Urine cultures should be taken 754
M a n a g e m e n t of the Bladder treated twenty-five times (fifteen males, ten females), or 28.4 per cent. Transurethral prostatic resection was performed once. Primary transitional carcinoma of the bIadder occurred six times. All patients were treated by transurethral procedures. Invasion of the bladder from extensive malignancy was observed nine times. Partial or segmental resection of the bladder was performed twice (one male, one female). Total cystectomy and pelvic exentcration was performed seven times (four males, three females).
SUMMARY
A survey covering a fifteen-year period (194o to I955, inclusive) has been made. A total of 933 patients were seen and exattained preoperatively. Urine cultures were taken 8I 5 times. Abdominoperineal proctosigmoideetomy was performed 565 times (303 males, 262 females) with the occurrence of vesical atonia in sixty-two patients (thirty-nine males, twenty-three females), or Io.9 per cent. Urinary tract infection was observed in i66 instances (2o.I9 per cent). Prostatic surgery was performed on fourteen patients (transurethral resection, eleven, suprapubic prostatectomy, three). The Miles type of excision was performed 193 times 0 o I males, ninety-two females). Vesical atonia occurred in twenty-slx patients (fourteen inales, twelve females), or I3.4 per cent. Urinary infection was observed and treated seventy-four times (forty-one males, thirty-three females), or 39.9 per cent. Prostatic surgery was performed eight times; all were transurethral resections. Sigmoidectomy was performed on eightynine occasions (forty-six males, forty-three females). Vesical atonia occurred in two patients, both females. Infection was seen and
CONCLUSIONS
The value of routine preoperative and postoperative urologic examination of' patients undergoing major surgery on the bowel is clearly demonstrated. Vesical atonia occurs in botil males and females. Vesical atonia and urinary retention associated with prostatic enlargement differs widely in concept and management. Maintaining the bladder at complete rest without infection is considered the best management of temporary vesical atonia. Time and proper management will permit and promote a return to a normally functioning bladder.
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