262 THE BRITISH JOURNAL OF SURGERY

RUPTURED URETHRA: A NEW METHOD OF TREATMENT. BY HARRY BANKS,

YURGEOh dND RADIOLOGIST, CELERAL HOSPITAL, AHEKIL4XN.

THE following method of treating rupture of the urethra is based on three cases which came under my care in 1924. So far as I am aware, thc method has not been described before.

Suprapubic cystotomy is donc and a fixlly curved metal prostatic catheter is passcd through the internal meatus along the urethra to the seat of rupturc. Another fully curved metal catheter is passed throiigli tlic external meatus along the urethra until i t conics in contact with the first. The two catheters are then taken one in cach hand and gcntly manipulated until their beaks lie in contact with one another, end to end. Ry gently withdrawing the first catheter and pushing the second one farther in, keeping tlic bcaks in contact, it is possible to guide thc second cathcter past the seat of the rupture and into the bladder. The second catheter is niadc to protrude through the suprapubic opening and a self- retaining rubber catheter is attached to i t by means of a silk thrcati. The metal catheter is then withdrawn from the external mcatus and in this way the sclf-retaining catheter is drawn into place past the rupturc. The opening in the bladder is closed and a small drain placed in the space of Retzius. Thc paticnt is given cystopurin and encouraged to drink plenty of water. Each day after the third day the bladder is gently irrigated with boracic lotion to diniinisli the formation of deposit on the beak of the cathcter. At thc end of ten days the sclf-retaining catheter is removed. This may require an an~sthct ic .

My three caws harc been of a similar nature, each being that of a rollier crushed underground, with multiple fractures of the pelvis and rupture of the membranous urethra. In no case had the patient passed urine between tlic time of the accidciit and the operation, nor had he attempted to do so, with the rcsult that tlierc was no extravasation of urine. Each was imme- diately warned not t o make the attempt.

With regard to diagnosis, this was made by trying to pass a catheter into the bladder. Failure to accomplish this is the indication for the opcra- tion dcsrribed. A soft rubber catheter should first be tried, and if unsuccessful i l medium-sized metal one. The metal catheter gives a better sense of touch tint1 position, and i t is sonictimcs possiblc to negotiate the rupture with it, particularly in cabes of iricomplcte tcar. Blecding from thc external nicatus and a swelling in the perincum were cwnstant signs.

In onc of my cases in which the violence causing thc accident was very severe, on passing a metal catheter for diagnostic purposes the instrument was felt to go in as far as the region of the triangular ligament, when i t became

No force is required.

RUPTURED URETHRA 263

quite free and appeared to be in a cavity, which indeed it was, in front of the bladder; with it could be felt loose bone, and at the subsequent operation it was found that the bladder and prostate had been literally dislocated from the urethra. In spite of loose bone no sepsis occurred and convalescence was uneventful.

Each case got on well and there has been no difficulty during the three years which have elapsed since the accidents, a mild orchitis in one case being the only complication. Operation was performed within three hours of accident.

Since performing this operation I have had made for me by Messrs. Weiss a special catheter. It is made of copper, size No. 8, and, being pliable, it can be bent to a suitable curve. As shown in the illustration (Pig. 192) one

FIG. 192. I

extremity is open and slightly bell-mouthed. This enables the point of the catheter introduced through the internal meatus to be more easily engaged. At the other extremity is a small hole to take thread for attaching the self- retaining catheter.

Although it is obvious that accurate conclusions cannot be drawn from so small a number of cases, it appears to me that this method offers the following advantages over opening the perineum : (1) The operation can be performed rapidly; this is of importance, as most of these cases have multiple injuries and suffer from severe shock. (2) There is less formation of scar tissue at the seat of rupture. (3) Drainage of the space of Retzius is provided for, and sepsis does not occur.