7I

DRAINAGE OF THE BLADDERWITH SPECIAL REFERENCE TO URETHROSTOMY

By JOHN SANDREY, CH.M., F.R.C.S.St. Peter's Hospital, London

The objects of this article are threefold;firstly, to discuss the methods of bladder drainagenow in common use, secondly, to give an accountof the writer's personal experience of drainage ofthe bladder by urethrostomy and thirdly, toevaluate the various procedures and to determine,in the light of present knowledge, under whatcircumstances they should be employed.The history of surgical drainage of the bladder

is a relatively short one and, although temporaryrelief of the acutely distended viscus by catheteriza-tion or by perineal puncture had been practisedsince the remotest times, it was only towards theend of the last century that planned drainage of thebladder in the more chronic forms of retentionbegan to be employed. In his' Clinical Lectures onDiseases of the Urinary Organs ' (1879), Sir HenryThompson described his new method of per-manent suprapubic drdinage in cases of chronicprostatic obstruction, a method which he had em-ployed in five of his patients during the previousten years. This is the earliest description theauthor can find of the planned use of a flexibletube to serve as a permanent outlet for the urinefrom the bladder although intermittent suprapubicdrainage by the trocar and cannula methodappears to have been employed for some time be-fore this by Thomas Paget and others. Thomp-son's method, which is noteworthy for its in-genuity in avoiding injury to the peritoneum andfor the ease and safety with which it could beperformed, consisted of the passage into thebladder of a large hollow metal sound with awell-marked curve, its obturated end being madeto project anteriorly just above the symphysispubis. A small incision was then made throughthe linea alba and the anterior wall of the bladderso as to expose the point of the sound, and theend of the instrument was made to protrude intothe wound. On removal of the stylet the flexiblesuprapubic tube was threaded into the lumen ofthe sound. Withdrawal of the latter along theurethra then guided the tube into the bladder andthus provided a watertight outlet. A suprapubicoperation such as this must have been a revolu-tionary change for one whose routine approach tothe bladder had always been through the perineum,

but as the operation was adopted only as a lastresource in patients whose fate was already moreor less sealed by the effects of prolongedcatheterization, it is not surprising to learn thatthe period of survival in these earlier cases ofsuprapubic cystostomy averaged only a few weeks.Soon it became recognized, however, that only bydrainage of the obstructed bladder at a muchearlier stage could a reasonable prolongation of lifebe expected and it was not long before suprapubiccystostomy came to be adopted as a standard pro-cedure whenever the urethra was no longer apracticable channel for the passage of urine.

Harrison's description of bladder drainage byurethrostomy in cases of stricture also appeared atthis time (1878) and will be referred to later.Shortly afterwards, Freyer and other earlyprostatectomists introduced the wide-bore tubefor post-operative drainage of the bladder. Thismay well have constituted a more important ad-vance than the actual removal of the prostate glandbecause it enabled suprapubic operations on thebladder to be undertaken safely for the first time.

Efficient drainage must still be regarded as thefirst line of defence against the three serious com-plications which may follow any operation on thebladder, namely haemorrhage, infection andurinary extravasation. Improved methods ofhaemostasis and the chemotherapeutic control ofurinary infections may allow risks to be taken withthe first two but failure on the part of the surgeonto give good drainage whilst the bladder healsremains fraught with the gravest consequences.Extravasation into the paravesical cellular tissueswill always delay healing; it may form a urinaryfistula and, if cellulitis develops, may seriouslythreaten the patient's life.One of the main problems facing the surgeon

who carries out immediate closure of the bladderafter prostatectomy is that of satisfactory bladderdrainage. Post-operative extravasation of urine isthe most important local cause of the mortalityand morbidity of 'closed' operations and unless

Paper read at a meeting of the Section of Urology,Royal Society of Medicine, May 27, 1948, and publishedby permission of the Hon. Editors, Proc. Roy. Soc. Med.

copyright. on M

ay 17, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.25.280.71 on 1 F

ebruary 1949. Dow

nloaded from

POST GRADUATE MEDICAL JOURNAL

it is eliminated there is a real danger that thismethod will, in the long run, prove to be a stepbackwards in prostatic surgery.The presence of a tube of some sort to drain the

bladder post-operatively then must be an acceptedprinciple of bladder surgery, but it should also be'recognized that this arrangement will facilitatethe entry of bacteria into the urinary tract. The'inevitability of post-operative tube infection hasbeen emphasized by Rathbun (I934), Deming(I947) and Galbraith (1948), although WilsonHay (I945)' claims' to have largely abolished it byhis retrograde method of catheterization and theavoidance of 'pre-Qperative instrumentation. Theterm ' aseptic 'prostatectomy, however, implies asterile urine dluring the post-operative period butuntil accurate details of bacteriological examina-tions of the urinr, of such patients are available thiscan only be regarded as the expression of an idealand not as an established scientific fact.The methods of bladder drainage may be con-

veniently grouped 'under three headings; firstlydrainage. of.. the obstructed bladder, secondlydrainage' of the paralysed bladder and thirdlypost-operative drainage. In the first and secondgroups temporary or permanent drainage may berequired.

Methods' of 'bladder drainage to be consideredare (i) Perineal, (ii) Suprapubic, (iii) Catheter and(iv) Urethrostomy.Whatever the method used the surgeon's task

is by no means finished when a tube has beeninserted into the bladder in the operating theatre.Close supervision of the actual collection of theurine is necessary in order to prevent contamina-tion of the end of the catheter or tube by the bed-clothes when the patient is returned to the ward.Dukes (I929), who studied urinary infections afterexcision of the rectum, states that it is usu4l tofind the bladder urine'teeming with bacteria on thesecond or third day after the institution of the'wooden peg ' method of intermittent catheterdrainage'.' 'To avoid this contamination heevolved the St. Mark's apparatus, a manually con-trolled systetn of free drainage and irrigation of thebladder,!which not only greatly reduced the in-cidence of these infections but, when they didoccur, minimized their severity. Closed methodsof bladder draifnage' on similar lines to the St.Mark's apparatus have been universally adoptedbecause they are simple, effective and almost fool-proof. The experience gained in the treatment ofparalysed bladders during the second World Warshowed that- the advantages claimed for tidaldrainage, especially as regards the maintenanceof positive intravesical pressure, are moretheoretical than real.; In a series of 6i cases' ofspinal cord injuries Prather (I947) found that pro-

longed free drainage by any of the closed methodsdid not appreciably delay the return of bladderfunction.

Measures to prevent the spread of infectionalong the outside of the catheter or tube (byantiseptic dressings around the glans penis, pre-vention of excessive movement of tube or catheter,etc.), are details of nursing which must be strictlyenforced.

It is now becoming increasingly apparent thathaematuria, renal failure and many of the otherserious consequences of emptying the chronicallydistended bladder are due, not to purelymec,hanical causes as was formerly thought, but toinfection introduced by tube or catheter. Hencethe present tendency is to abandon the variousmethods of slow decompression and to concentrateinstead on free drainage with chemotherapy andother measures to control infection.

(i) Perineal drainage of the bladder is a methodnow only used to any great extent by the perinealprostatectomist. The author's experience ofperineal prostatectomy is limited to a series of30 cases operated on during 1937-9. At the timehe was most impressed by the smoother con-valescence and by the lessened incidence of urinaryinfections and other complications as comparedwith suprapubic methods and it was felt that thisdifference could only be accounted for by de-pendent perineal drainage. Unfortunately thisadvantage was sometimes more than offset by theunavoidable damage to the perineal muscles atoperation; moreover it was found that latecicatrization along the track of the tube could giverise to most formidable post-prostatectomy ob-struction.The mortality rate of perineal prostatectomy

should always be lower than that of methods whichinvolve an abdominal incision, but the merepossibility of such serious sequelae as permanentincontinence and stricture formation imposes, inthe writer's opinion, so severe a handicap on thisoperation that it can only be justified in exceptionalcircumstances. The fact that the perineal route,despite its crudeness and its many obvious draw-backs, had been used for all operations on thebladder, such as lithotomy, bladder-puncture forretention, etc., long before the birth of Hippocratesand was still being advocated by Thompson in astandard British textbook as a routine procedureas recently as I878, could only be due to thebetter results achieved by that method. We knowthat the far simpler suprapubic removal of calculi(' high ' operation) was described by Pierre Francoin the i6th century, but it seems obvious that, inthe absence of any drainage tube, the dependentposition of a perineal wbund would have over-whelming advantages.

Februa-ry x1949.72copyright.

on May 17, 2020 by guest. P

rotected byhttp://pm

j.bmj.com

/P

ostgrad Med J: first published as 10.1136/pgm

j.25.280.71 on 1 February 1949. D

ownloaded from

SANDREY: Drainage of the Bladder

Perineal cystotomy was quickly discarded whenthe suprapubic tube was introduced at the end ofthe last century, but the incidence of prevesicalcellulitis appears to have been high at first, duechiefly to inadequate precautions against leak-age of urine from the low cystotomy wound.Freyer (I908) laid down that water-tight suturingof the bladder wound around a large suprapubictube was one of the essentials to success after hismethod of prostatectomy. Later, Lynn-Thomas(1914), impressed by the advantages of free bladderdrainage, added counter-drainage in the perineum.By his ' combined' method of prostatectomy aperineal drain was introduced from below bycutting down on the point of a forceps thrustdown through the prostatic cavity after performinga suprapubic enucleation of the gland. Fullerton(1913) also practised the combined method ofprostatectomy and stated that added safety wasconferred on the suprapubic operation by de-pendent perineal drainage. In one of his casesincontinence of urine developed ' as the result ofprolonged pressure by the perineal tube ' and itmust be presumed that this method was quicklyabandoned when the possibility of this complica-tio n was realized.

From the anatomical point of view then,perineal drainage of the bladder is the idealmethod. Unfortunately its practical value islimited by possible damage to the perineal musclesand nerves in the incision, by pressure of the tube,or by late scarring in and around the wound.

(ii) Suprapubic drainage has three advantagesover other methods. The absence of any foreignbody in the urethra eliminates genital infection;urine can be collected by means of various types ofapparatus while the patient is ambulant, andthirdly, such drainage can be maintained in-definitely.

Unfortunately the defects of suprapubic drain-age are only too apparent, the most obvious beingleakage of urine around the tube with its attendantdiscomforts both physical and mental. When thecystostomy opening is low enough to becomeadherent to the symphysis pubis, urinary leakagebecomes more or less continuous throughout the24 hours. Riches (I943) advises an opening placedmidway between the symphysis pubis and theumbilicus and his simple and ingenious method ofsuprapubic catheterization is most effective in pre-venting leakage. Blind suprapubic puncture,however, at this level may damage the peritoneumwhen the reflection of this membrane in front ofthe bladder is low and this is more likely to occurin fat patients when the fundus of the distendedviscus is not readily palpable. Accidents of thiskind are common enough to impose a severehandicap on these methods and .the only certain

means of avoiding them seems to be by deliberateexposure of the bladder wall through a small in-cision before the puncture' is made although, ofcourse, this will increase the tendency. to leakage.

Because of the limited relief afforded by supra-pubic cystostomy many surgeons regard this pro-cedure as a confession of failure in the treatmentof the enlarged 'prostate and avoid it at all costs.This attitude is shared by our patients who,however elderly and feeble and however remotethey know their chances of survival to be, willrarely refuse prostatectomy as a means of endingtheir sufferings one way or the other.A less obvious but far more serious defect of

suprapubic cystostomy is that of uphill drainage.Any feeble siphonage by the tube is subject tofrequent interruptions by kinks, air-locks andother forms of blockage. The bladder is nevercompletely emptied and, even under the mostfavourable circumstances, always contains anounce or more of residual urine. We are renmindedof this fact by the gush of urine that follows thewithdrawal of a suprapubic tube, also by theimmediate appearance of urine whenever aurethral catheter is passed. A further illustrationof the incompleteness of suprapubic drainage isthe possible formation of vesical calculi andalthough this is more prevalent in paralysedbladders the author has, on several occasions, re-moved large calculi after cystostomy in patientssuffering from prostatic obstruction.The mortality rate of suprapubic cystostomy in

cases where radical surgery is contraindicated hasbeen stated by various writers to vary from I0 to30 per cent. Rees (I947), for instance, reported30 deaths amongst io6 patients so treated atQueen Elizabeth Hospital, Birmingham (mor-tality rate, 28 per cent.). In this series of casespost mortem examinations revealed the cause ofdeath to be some form of urinary infection,chiefly pyelonephritis, in more than 50 per cent.While it must be conceded that a considerableproportion of cases of this type are suffering fromadvanced cardiovascular and other non-urinarydiseases and are beyond medical aid, it is equallyobvious that the high incidence of fatal urinaryinfections might well be due to the method used todrain the obstructed bladder. In other words,the mechanical defects of uphill drainage to-gether with contamination of residual urine in thebladder is likely to give rise to ascending infectionin an upper urinary tract already damaged by theeffects of prolonged obstruction.For purposes of comparison 58 ' poor risk ' cases

with chronic retention whose blood ureas onadmission to hospital ranged from 40 to 290 mgm.per cent., were drained by urethrostomy. Therewere five deaths in the series, four due to cardio-

February I949 73copyright.

on May 17, 2020 by guest. P

rotected byhttp://pm

j.bmj.com

/P

ostgrad Med J: first published as 10.1136/pgm

j.25.280.71 on 1 February 1949. D

ownloaded from

POST GRADUATE MEDICAL JOURNAL

vascular causes (two cardiac failure, one pulmonaryembolus, one coronary embolus) and one to renalfailure due to gross dilatation of both kidneys andureters following bladder-neck obstruction of longstanding. The complete elimination of fatalurinarv infections in this series of cases by thesubstitution of dependent for uphill drainagerequires no further comment.

(iii) Catheter drainage, though simple and con-venient has one important limiting factor to itsusefulness, namely, urethritis. The retainedcatheter will act as a foreign body in the urethra,first stimulating the activity of the mucus-secreting glands, which are most abundant in themid-portion of the anterior urethra, and, after twoto three days giving rise to an inflammatory re-action, the thin mucoid secretion becomingfrankly purulent. The infection is primarilycaused by the staph. albus and aureus with coli-form and other organisms (s. fecalis, b. proteus,b. pyocyaneus, etc.) appearing later as secondaryinvaders.

Various mechanical factors may aggravate theeffects of this local inflammation. Firstly, acatheter tightly fitting at the external- meatus willprevent drainage of urethral secretions beside itso that pus will tend to accumulate in the anteriorurethra under tension. This is often made stillworse by the presence of tapes, strapping or otherretentive apparatus. The size of the catheter inrelation to the external meatus is the most im-portant factor in determining the severity of thereaction in the urethra. When the urethra islarge there will be no interference with free drain-age and the reaction will be mild; when small,however, pus under tension may be forced back-wards to the bladder or along the ejaculatory andprostatic ducts. Blockage of the mouths ofLittr6's glands in the more severe degrees ofurethritis may lead to periurethral suppurationand when this involves the peno-scrotal region apermanent stricture or fistula may result. Atightly fitting catheter may sometimes give rise toactual pressure necrosis at the meatus and sub-sequent ulceration in the fossa navicularis willlead to a dense stricture at the urethral outlet. Asevere ' catheter' stricture of the meatus is aserious and permanent disability and the patientwho finds, on leaving hospital after prostatectomy,that he has merely exchanged one form of obstruc-tion for another may feel that he has made a badbargain.The external meatus, the narrowest and least

distensible part of the male urethra, is subject towide variations in size in different individuals. Inorder to gain some exact information as to the rangein calibre of this part of the normal urethra, noteswere made of ioo consecutive cases at operation

where there was no history of previous catheteriza-tion or of urethral disease. Using a 22 Charriererubber catheter as a ' standard ' it was found that47 urethrae were ' normal' (i.e. the instrumentpassed easily), 23 were classed as ' tight' (i.e.the instrument could be passed only after dilata-tion) and 22 were ' very tight' (calibration zo Ch.or lower). Only eight of the series were classifiedas ' large ' (i.e. 24 Ch. or over) and consideredsuitable for urethral catheter drainage for periodsof seven days or lorger.Oedema of the external meatus may be an im-

portant additional factor in preventing drainagearound a tied-in catheter and tends to vary in-versely with the size of the or ening. In some casesoedema may cause a loosely-fitting catheter to betightly gripped in 24 hours, thus rendering anornal-sized urethra quite unsuitable for furthercatheter drainage.

Other factors influencing urethritis, such as thetime factor, rigidity of the instrument, amount ofmovemient, prevention of contamination of theoutside of the catheter, etc., can be more readilycontrolled.

(iv) UrethrostoSy drainage of the bladder hasbeen carried out for many years at St. Peter'sHospital in the treatment of urethral stricture.Harrison (i878) recommended the introductionof a tube along the posterior urethra to drain thebladder after external urethrotomy or perinealsection as a means of preventing post-operativefebrile reactions. It was not until I885, however,that he described the operation of combined in-ternal and external urethrotomy with urethrostomydrainage with which his name is now associated.Originally recommended for 'impassable or veryextensive strictures which will not dilate,' theoperation was also used in ' cases of periurethralabscess, fistula or extravasation ' and eventuallycame to be employed exclusively in the lattergroup. The value of combined perineal drainageof both the bladder and the subcutaneous tissues incases of stricture complicated by gangrenouscellulitis (' perineal phlegmon '), was emphasizedby both Freyer and Thomson-Walker and is stillto be regarded as the method of choice in thesecases, for, in addition to providing a direct escapefor urine from the bladder by the most dependentroute it avoids opening up fresh planes of tissue.Most of us have looked on helplessly whilst aspreading gangrenous cellulitis of the abdominalwall or a gas infection has developed after supra-pubic cystostomy in cases of this kind, yet howeasily this could have been prevented by drainagefrom below. Fortunately the so-called perinealphlegmon is becoming less common nowadays butin the half dozen cases the author has treated by,combined perineal section and urethrostomy in

Frebruary I94974copyright.

on May 17, 2020 by guest. P

rotected byhttp://pm

j.bmj.com

/P

ostgrad Med J: first published as 10.1136/pgm

j.25.280.71 on 1 February 1949. D

ownloaded from

SANDREY': DrainagS'of the Bladder

the past few years it has been gratifying to watchthe rapid recovery of patients who exhibited allthe signs of the profound toxaemia so character-istic of this form of urinary suppuration when ad-mitted to hospital. Furthermore, the infectionboth in the urinary tract and the cellular tissues hascleared up rapidly and completely. Incidentallythe divided stricture has become more amenableto dilatation afterwards.

Apart from its occasional use in urethral stric-ture, urethrostomy drainage of the bladder hasnever been popular with urologists in this countryalthough it appears to have been extensively usedfor some time in the United States. Young andhis associates (I926) recommend this procedurefor diverting the urine when operating for hypo-spadias and other deformities of the penis, andthe majority of British plastic surgeons now follow,this example. Young (1934), discussing the treat-ment of the obstructed bladder, advised thesubstitution of the urethral catheter for suprapubicdrainage because of the high mortality of thelatter. Where the urethra did not tolerate acatheter well he advised urethrostomy drainage.Barney (1934) described the simple method of'performing urethrostomy with catheter and clampused by him for many years. Lewis (I943) advo-cated urethrostomy for drainage of the paralysedbladder and claimed that there was less leakage,less infection, better drainage and, in fact, manyadvantages over other methods.

Dissatisfaction with routine methods of bladderdrainage by cystostomy or urethral catheter ledthe author to explore th'e possibilities ofurethrostomy for this purpose early in I946 andduring the past two years it has been employedalmost exclusively in more than 300 cases.The following table shows the various con-

ditions treated by urethrostomy drainage

Temporary or pre-operative bladder drainagePost-operative drainage:

a. Prostatectomy, one stage (retropubic, Freyer,vesico-capsular) ..

b. Prostatectomy, after suprapubic drainagec. Prostatectomy, after urethrostomy drainaged. Perurethral resection .e. Diverticulectomy ..f. Operations for carcinoma of the bladder

(open diathermy, partial cystectomy) . .

g. Miscellaneous (excision of stricture, perinealphlegmon, calculuw, etc.) ..

Totil .. .

I2

* 379

full length and the distal end securely clampedwith a curved artery forceps (Moynihan or curvedSpencer Wells pattern).- The forceps is advanced-until its beak reaches the bulbous urethra and byrotating the handle through'i8o0 the point is madeto present in the perineum where it is cut downupon. The end of the catheter is disengaged fron'the forceps and is withdrawn through the in-cision to the correct length for bladder drainage.'This method is rapid, simple and requires nospecial equipment. In seriously ill patients it canreadily be performed in bed under lo'cal an-aesthesia. In that group of cases, comprisingabout 2o per cent., where the external meatus isstenosed or the urethra congenitally small, the'open' method has been employed. An incisionis made in the perineum on the curve of a smallmetal bougie dividing the skin, fascia, bulbo-cavernosus muscle, the spongy tissue and theurethral mucosa. The edges of the latter must becarefully identified and grasped with fine tissueforceps before attempting to pass the catheter,otherwise the urethra will tend to invaginate andprevent the passage of the instrument. The openmethod is much more difficult than the closedmethod of urethrostomy as it requires' widerdissection in an extremely vascular area. It shouldnot be attempted under local anaesthesia.The best position for the urethrostomy opening

has been found to be in the scrotal raphe aboutone inch in front of the .perineo-scrotal angle.The site of this opening is a matter of some im-portance. If placed too far back it is less accessiblefor nursing, contamination from the anus is morelikely, kinking of the tube by the weight of thescrotal contents is hard to avoid and spontaneousclosure of the fistula after removal of the catheteris slower. If too far forward the catheter tends tokink excessively at the subpubic angle and if itshould come out replacement may be difficult.

Transfixion of the catheter was found to be un-.satisfactory mainly because of leakage from thestitch hole in the rubber and the best method offixation so far devised has been by numeroushalf hitches around the catheter stitched to the'skin in front. Silk, nylon or other non-absorbablesutures serve equally well.

For post-operative drainage after prostatectomy,partial cystectomy, etc., a ',whistle tip ' resecto-scope catheter with at least three lateral eyes hasbeen found to be the most satisfactory. Theperineal urethra will readily accommodate 22 and24 Ch. sizes and when haemorrhage was not wellcontrolled size 26 Ch. has been used on severaloccasions. In three cases urethrostomy has beencombined with suprapubic drainage and drip-irrigation when severe haemorrhage had occurredafter Freyer prostatectomy; as an alternative to'

The method used in the majority of the caseswas that. described by Barney and will be sub-sequently- referred to as the ' closed' method. Arubber catheter is passed along the urethra to its

Pebruary I949' 75,copyright.

on May 17, 2020 by guest. P

rotected byhttp://pm

j.bmj.com

/P

ostgrad Med J: first published as 10.1136/pgm

j.25.280.71 on 1 February 1949. D

ownloaded from

POST GRADUATE MEDICAL JOURNAL

the latter method a Foley type of catheter wasintroduced by open urethrostomy on one occasionand control of bleeding was complete.The best position for nursing the patient seems

to be with the tube draining over the thigh and thescrotum supported by means of an elastoplastbridge.

Disadvantages of the method are as followsFirstly, a scrotal haematoma may form. This doesnot appear to be a matter for great concern asrapid absorption without infection has been therule in the cases observed. Secondly, replace-ment of the urethrostomy tube may be difficult,especially if the attempt is delayed for more thana few hours. An opening made too far forwardwill further increase the difficulties of replacement.Thirdly, slight incontinence of urine is not un-common, especially after prolonged drainage withthe larger sizes of catheters. This is not severeand full control normally returns within a fewweeks. No case of permanent incontinence hasbeen observed. Finally, leakage of urine from theresulting perineal fistula after removal of the tubewill occur with each act of micturition. This is,of course, normally under voluntary control. Itceases, in the average case, after f6ur or five days,but may persist longer if the opening has beenmade too far hack in the perineum or if circum-stances hare n'ac'e it impossible to get the patientout of bed immediately after removal of the tube.In one of the cases after prostatectomy severehaematemesis f om a duodenal ulcer necessitatedthree months' treatment in bed. On getting thepatient up at the end of this time the perinealfistula, which had leaked intermittently all thistime, closed spontaneously within a few days. Inthe erect posture the weight of the scrotal contentstends to drag the external opening away from theurethra and thus accelerates the obliteration of thetrack. In all these cases, healing was spontaneous.Leakage is undoubtedly the chief disadvantage ofurethrostomy drainage but it is, after all, a smallprice to pay for the added safety the methodconfers on ' closed' operations on the bladder.Unlike the leakage associated with suprapubiccystostomy it is, however, under voluntary con-trol. It is always necessary to warn patients ofleakage before removing a perineal tube and to re-assure them that this will only be a temporarystate of affairs, otherwise they are apt to assumethat some mishap has befallen them.Most of the advantages of urethrostomy, es-

pecially the simplicity of the procedure, havealready been emphasized. Compared with supra-pubic cystostomy the outstanding features are thedifference between dependent and uphill drainageand, in bladder obstructions, the striking contrastbetween the mortality rates of the two methods.

Other features favouring urethrostomy are; first,an intact abdominal wall after pre-operativedrainage instead of an infected abdominal tubetrack, so that a subsequent suprapubic operationis safer, easier and cleaner; secondly, post-operative drainage of the bladder is away from thesuturevline and allows complete closure in mostinstances. Compared with catheter drainage themain advantage is the avoidance of most of theill effects of urethritis by excluding nearly two-thirds of the entire urethra; furthermore, there isalways adequate provision for free drainage along-side the perineal catheter. In addition, thelarger sizes of catheters, better methods of fixation,elimination of the distal (pre-pubic) bend of theurethra, the abolition of any time limit, are allfactors which make urethrostomy preferable tocatheter drainage with the possible exception ofthat small group of cases where the externalmeatus is large and where drainage will probablynot be required for longer than seven to ten daysWhile it can be said that a stricture will almostinvariably follow incision of the penile urethra itcan be stated, equally dogmatically, that this com-plication is unlikely to occur in the perineal urethraunless the entire circumference has been dividedand the ends separated.

Sumn arv and Conclusionsi. Suprapukic cystostomy offers no real solu-

tion to the relief of bladder obstructions because,in the first place, it is mechanically unsound andwill always be associated with a high incidence ofurinary infection; secondly, permanent supra-pubic drainage is worse than a sentence of death tomost individuals and almost any operative risk isjustified in avoiding it. In the treatment of theparalysed bladder, however, suprapubic drainageappears to be still the safest and most satisfactorymethod for routine use.

2. Having regard to the severe effects of trau-matic urcthritis, both immediate and late, theindiscriminate use of the tied-in catheter to drainthe bladder for periods exceeding two or threedays is condemned. Less than io per cent. of theurethrae examined were found to tolerate acatheter of size 22 Ch. or larger, for longer thana week and only this small group can be con-sidered as suitable for this form of drainage.

3. Urethrostomy drainage, though not ideal byany means, goes a long way towards solving manyof the defects of the other methods. Whenbladder drainage is required pre-operatively,urethrostomy has the great advantages ofmechanical efficiency, simplicity and added safetyover other methods. As an alternative to im-mediate prostatectomy, particularly in the ' poorrisk' case with extra-urinary complications,

n-L-v curuary 1194976

copyright. on M

ay 17, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.25.280.71 on 1 F

ebruary 1949. Dow

nloaded from

February 1949 MARTIN: The Ischaemic Limb 77

urethrostomy will, it is held, be found to yield thebest results. Post-operatively it confers an in-creased margin of safety on complete closure afteroperations on the bladder or prostate. Further-more drainage can be maintained indefinitely inorder to ensure sound healing of the abdominalwound.

BIBLIOGRAPHY

BARNEY, J. D. (I934), Trans. Amer. Ass. Gen.-Urin. Surg., 27, 73.DEMING, C. L. (I947), _our. Urol., 57, 49.DUKES, C. E. (1929), Proc. R. Soc. Med., 22, I.FREYER, P. J. (I908), 'Clinical Lectures on Surgical Diseases of

the'Urinary Organs,' London.

FULLERTON, A. (1913), Brit. Med. _Jour., I, 332.GALBRAITH, W. (I948), Proc. R. Soc. Med., 41, 73.HARRISON, R. (1878), 'Clinical Lectures on Stricture of the

Urethra and other Disorders of the Urinary Organs,' London.HEY, W. H. (I94S), Brit. Med. Tour., 2, 91.LEWIS, L. G. (I943), BuU. U.S. Army Med. Dept., 69, 46.LYNN-THOMAS, J. (I914), Lancet, I, 1456.PRATHER, G. C. (I947), Jour. Urol., S7, I5.RATHBUN, N. P. (I934), Trans. Amer. Ass. Gen.-Urin. Surg.,

27, 47.

REES, SKYRME W. (I947), Brit. Jour. Urol., Ig, 83.RICHES, E. W. (1943), Brit. J7our. Surg., 31, 135.THOMPSON, H. (1879),' Clinical Lectures on Diseases of the

Urinary Organs,' London.YOUNG, H. H. (I926), 'Practice of Urol,' Philadelphia, Vol. 2,

6oo.YOUNG, H. H. (1934), Trans. Amer. Ass. Gen.-Urin. Surg., 27, 71.

THE ISCHAEMIC LIMBBy PETER MARTIN, M.CHIR.

From the Department of Vascular Surgery, Post Graduate Medical Schvol, London; Surgeon, Chelmsford andEssex Hospital

The proper nutrition of a limb depends on,amongst- other things, a sufficient blood supply.The main arteries to a limb may become obstructedto a reinarkable degree, in fact, they may be com-pletely obstructed without the patient's knowledge,and often without his medical attendant's know-ledge, because alternative pathways exist. Apartfrom sufficient patency of the vessels, an adequatecardiac output is necessary, which depends onsufficient cardiac return and consequently aproper blood volume. Thus in severe arterialtrauma causing an interruption of a main vessel,the life of the limb may become precarious, notonly as a result of damaged vessels but also of adiminished blood volume resulting from severehaemorrhage at the time of the incident, and atimely and possibly massive blood transfusionmay well tilt the scale towards recovery of thelimb. Thus the- factor of anaemia must be con-sidered as well as the patency of the vessels.

Ischaemia of a limb may occur in the followingconditions:

(i) Trauma, causing rupture, contusion andthrombosis, spasm or later aneurysm of an artery.

(2) Embolism, from a fibrillating auricle orvalvular vegetation, from atheromatous plaquesin the largest vessels, and in paradoxical embolism,where there is patency between the right and leftside of the heart, fror the venous system.

(3) Thrombosis, where the vessel wall is diseasedas in arterio-sclerosis, thromboangiitis obliterans

or syphilis, or when the vessel is compressed, asin cervical rib, or invaded or compressed bytumour, or in severe blood diseases and infectiveconditions such as typhoid or pneumonia, theseat of intraluminar clot.

(4) The so-called spontaneous monarteritis ofindeterminate origin (Learmonth), in which thereis no overt cause of thrombosis.

(5) Certain spasmodic conditions such ag occurin the Raynaud syndrome, traumatic arterialspasm and, it may be, as a reflex phenomenon incertain cases of venous thrombosis, though thismust be rare.

Apart from trauma and.spasm it will be seenthat arterial obstruction results from embolism orthrombosis, and even in these two conditionsthrombosis is generally the factor which finallyseals the fate of the limb.

Morbid AnatomyWhether the original obstruction be due to

thrombosis or embolism the important factor isthe rapid addition of clot with blockage of valuablecollateral vessels, further embarrassing the cir-culation. A clot may extend widely, even throughthe whole length of a limb, and from the distal endof this clot fragments may break off and blockmore distal vessels previously unaffected. Thisis not infrequentlv seen when a rib presses on thesubclavian artery (resulting in dilatation beyondthe point of pressure, together with the formation

copyright. on M

ay 17, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.25.280.71 on 1 F

ebruary 1949. Dow

nloaded from