CHAPTER XIII

OPERATIONS UPON THE URETHRA AND BLADDER

EXTIRPATION OF A URETHRAL CARUNCLE

=Indications.= A urethral caruncle is a bright red, tender tumour, usually on the posterior portion of the urethral orifice.

The symptoms requiring interference are pain on micturition, dyspareunia, bleeding and discomfort on movement, and, occasionally, retention of urine which is probably due to apprehension of pain rather than to any mechanical obstruction.

=Operation.= To be effectual this must be thorough, and may take the form of deep cauterization with a Paquelin’s cautery, or excision. The latter operation consists in excising a wedge-shaped piece of the posterior wall of the urethra containing the caruncle. Free bleeding will usually take place, which must be controlled by means of hæmostatic forceps. The edges of the wound are brought together by fine silk or catgut sutures, which must be passed completely through the raw surfaces to prevent recurrent hæmorrhage.

The _after-treatment_ consists in keeping the wound as clean and dry as possible.

OPERATIONS FOR INCONTINENCE FOLLOWING LABOUR

This is probably due to injury to the pelvic floor and the anterior fibres of the levator ani, producing a backward displacement of the urethra.

=Operation.= The operation recommended by Dudley consists of first denuding the vaginal mucous membrane over a horseshoe-shaped space between the clitoris and the urethral orifice and then drawing the urethra forward with sutures passed through the anterior portion of the orifice and inserted near the clitoris. It will then be seen that the urethra is carried forward nearly an inch. The raw edges are brought together in the usual manner by catgut or silk sutures.

The author’s experience of this operation has been unsatisfactory on the whole, and he has obtained better results by the wearing of a ring pessary.

OPERATIONS FOR VESICO-VAGINAL FISTULA

=For simple vesico-vaginal fistula.= This condition is fortunately very rare at the present time. Many operations have been devised for this condition, but the original one recommended by Sims, with subsequent modifications, appears to the author to be most efficient and applicable to the large majority of varieties of this condition.

=Preparatory treatment.= The chief object is to obtain a healthy condition of the fistulous edges, which are nearly always inflamed, thickened, and covered by urinary deposits, usually of a phosphatic character. These are best removed by means of a soft sponge or cotton-wool, and the raw edges treated with a weak solution of nitrate of silver (gr. ij to the ounce). Hot vaginal douches of lysol solution (ʒj to a quart) should be given night and morning, and the parts freely smeared with vaseline to protect them from the action of the irritating urine. Any cicatricial tissue which may be present around the fistula should be treated by submucous division.

=Operation.= The instruments necessary are: a Sims’s or Auvard’s (Fig. 37) speculum; two flat spatulæ; three long-handled knives (Fig. 38), one with a long haft and a short straight narrow blade, and the others with angular blades (right and left); two long-handled, sharp-pointed, curved scissors (right and left); an Emmett’s hook for making counter-pressure (Fig. 40); toothed forceps (Fig. 39) and tenaculum; six Spencer Wells’s forceps; Schauta’s needle-holder (Fig. 73) with short curved needles.

The patient is placed in the lithotomy position. A strip of mucous membrane is then removed from the whole of the vaginal edge of the fistula by means of an angular knife. In the original operation Sims (Fig. 41) made the surface oblique, but Simon (Fig. 42) considered the raw surface should be at right angles to the mucous membrane. The blade of the knife should not wound the vesical mucous membrane.

After the bleeding has ceased, the sutures, which may be of silk or catgut, are passed by means of the needle through the pared edge of the fistula on one side, passing across the fistula, and piercing the raw surface on the opposite side. The entry of the needle should be made about 1/4-1/3 of an inch from the raw edge (Fig. 44). Emmett’s hook, shaped like a button-hook, is useful to produce counter-pressure against the needle point. The sutures are tied, and milk is injected into the bladder to test the accuracy of the union.

As a rule, fistulæ are bounded by rather scanty and inelastic walls, owing to the presence of cicatricial tissue; it is therefore more advantageous not to remove any tissue in order to produce a raw surface, or as little as possible. To fulfil this condition, the method of _dédoublement_ or flap-splitting, as practised by Walcher, may be carried out (Fig. 43, A, B, and C).

The patient is placed, as before, in the lithotomy position, and the cervix is pulled down, while the edges of the fistula are kept steady by a volsella on either side. The margin of the orifice is then split all round to a depth of from a quarter to half an inch. Vesical and vaginal mucous membrane flaps are thus produced, giving a large raw surface without any loss of substance. The sutures are passed as shown in Fig. 43, C.

=After-treatment.= This is very simple: if the patient is able, she should pass water, either in the dorsal or genu-pectoral position, otherwise a catheter should be passed every six hours.

_Modifications of this operation_ have been devised, more especially for the larger fistulæ: they will be briefly mentioned.

1. Repair by turning up vaginal flaps to form the base of the bladder is recommended by A. Martin of Berlin. He first frees the adherent edges of the fistula and then raises the flaps from the vaginal wall and brings them over the opening, suturing them carefully together. By this method the mucous membrane of the vagina forms the new lining to the bladder, and the exposed raw surface a new anterior vaginal wall. The edges of this latter denuded surface are united by sutures, as in the operation of colporrhaphy.

2. Closure of the fistula by detaching the bladder from the vagina and suturing it independently is described and practised by Mackenrodt.

The patient is placed in the lithotomy position, and the fistula is exposed: the cervix is drawn downwards and backwards by means of a wire loop or tenaculum, and the urethral prominence held with a pair of hooked forceps. An incision is then made in the median line extending across the fistula and through the vaginal walls down to the bladder, in this way exposing the entire base of the bladder. The edges of the fistula are then split so that the bladder and the vaginal walls are separated. The two vesical flaps are now carefully and separately sutured by catgut and the edges of the vaginal wound are brought together as much as possible: if necessary, the fundus of the uterus may be used to assist in closing the opening.

=For vesico-utero-vaginal or juxta-cervical fistula.= In this affection the cervix is involved, and it must therefore be carefully differentiated from the vesico-vaginal variety, in which the cervix is intact.

In operating upon such cases the chief difficulty will be found in denuding the surfaces necessary for the introduction of the sutures, owing to the density of the cicatricial tissues, which are always present. This is best overcome by drawing the cervix forcibly downwards and backwards and incising the anterior cul-de-sac; the bladder wall with its fistulous opening is then dissected off the anterior surface of the cervix and carefully sutured independently of the cervical laceration; the latter is treated by suture in the usual way (see p. 128). In the deeper forms of juxta-cervical fistula, the above technique is impossible, and suprapubic incision and suture of the bladder must be substituted.

RECTO-VAGINAL FISTULA

This condition may be defined as an opening between the rectum and vagina through which flatus, or fæces, or both, may pass from the former into the latter; it is chiefly the result of an imperfect union subsequent to an operation for complete perineum laceration. It may also be caused by the rupture of a pelvic abscess or by the spread of primary malignant disease of the rectal wall.

=Operation.= If the sphincter ani is incompletely united, it will be found much the most satisfactory proceeding to divide the healed portions of the perineum and make a complete perineal laceration; this may then be treated as described above (see p. 128).

If, however, the sphincter is intact and serviceable the fistula should be pared and the edges brought together by silk sutures. It is not infrequently necessary to perform a temporary colostomy (see Vol. II) in order to divert the fæcal contents of the bowel during the process of healing.

OPERATIONS FOR CYSTOCELE

In cystocele there is prolapse of the anterior vaginal wall and the corresponding area of the posterior bladder wall. Cystocele often complicates rectocele and prolapsus uteri, and operation upon it is often carried out in combination with colpo-perineorrhaphy.

=Operation.= The operation for the cure of this affection is very simple, and may be performed:--

(1) By denuding an oval space over the swelling and bringing the raw edges together.

(2) By Stoltz’s operation, which is really purse-string suture.

The instruments necessary are a bladder sound, two tenacula, sharp-pointed angular scissors, a needle-holder and fine silk.

(1) The parts are exposed with a Sims’s or Auvard’s speculum and a volsella, or silver wire is passed through the cervix, by means of which traction downwards and backwards may be exerted. The cystocele itself is fixed by tenacula, and, with the sound in the bladder, an oval incision is carried completely round the base of the cystocele. The whole area contained in this incision is denuded by knife or scissors, care being taken to avoid wounding the bladder mucous membrane.

Any bleeding having been controlled, a spiral buried suture, as in the operation for perineorrhaphy (see p. 128), is passed antero-posteriorly, thus reducing the size of the raw area and making a solid support in the median line. The raw edges are then brought together by sutures. The catheter should be passed every eight hours for three days, and then the patient should be allowed to micturate on her hands and knees.

(2) _Stoltz’s operation._ The instruments necessary are: a No. 8 male bladder sound; two tenacula; hooked forceps; sharp-pointed angular scissors, and a needle-holder (Schauta’s for preference).

The patient is placed in the lithotomy position and the parts are exposed by means of an Auvard’s speculum. A silver wire or tenaculum is passed through the posterior lip of the cervix, by means of which downward and backward traction may be exerted. Four points must be selected: two lateral (Fig. 45, 1, 1'), fixing the external boundaries of the surface to be denuded; one immediately behind the orifice of the urethra (2); and a fourth in front of the cervix (3). These four points should be capable of close approximation. They are carefully joined by curved incisions so that the area to be denuded is almost oval in shape. The bladder sound is now passed, and the mucous membrane of the vagina kept on the stretch by pressure on its point. The process of denudation should be carried out with a scalpel or pointed curved scissors. It will be found that bleeding rarely gives any trouble. The point of the needle threaded with silk is inserted on the operator’s right side of the urethral orifice and a little below it; it pierces the mucous membrane on the left side of the median line, and again appears upon the surface. By an in-and-out stitch all the way round the circle which has been pared, the point finally issues on the operator’s left side of the urethra and below it: by traction on these two ends the edges of the denuded surface are drawn together and the prolapsed bladder is sutured in its normal situation. A puckered cicatrix results. This method is valuable for prolapsus uteri when combined with the operation of posterior colporrhaphy.