Some Indications for ExternalUrethrotomy

BY

JOHN C. MUNRO, M. D„Surgeon to Out-Patients, Carnes Hospital; Assistant in

Anatomy, Harvard Medical School.

Reprinted from the Boston Medical and Surgical Jour7lal ofMarch 2, iBgj.

BOSTON;-

DAMRELL & UPHAM, PUBLISHERS,No. 283 Washington Street.

1893.

S. J. PARKHILL & CO., PRINTERSBOSTON

SOME INDICATIONS FOR EXTERNAL URE-THROTOMY. 1

JOHN C. MUNRO, M.D.

The following four cases of external perineal ure-throtomy are ordinary routine cases coming under mycare at the Carney Hospital, taken without selection;nevertheless, they seem to point some lessons that itmay not be amiss to emphasize, and with that in viewthey will be used simply as texts.

In reviewing the literature of this operation one isimpressed by the growing tendency to enter the blad-der over the pubes. That is as it should be, providedthe perineal route is not neglected. Although Harri-son has placed perineal operations on a definite, ra-tional basis— a basis established less than ten years,in fact there is still a tendency to disregard or to failto appreciate the simpler surgical indications in casesrequiring interference.

My first case might be prefaced by this quotationfrom Watson ;

“ Once a deep stricture is beyond con-trol of dilatation it seems to me best treated by exter-nal urethrotomy, not reserved until retention or ex-travasation are actual, present dangers, but while theurethra is still permeable to a guide.”

The patient, a sailor, thirty-nine years old, with agonorrhoeal history, had been dilated three times (atleast two of these being by rapid divulsion), and eachtime contraction rapidly followed. At entrance he hadthe swollen, indurated perineum of extravasation, withdifficult, painful micturition, high fever and the generalappearance of a very sick man. As he refused any

1 Read before the Boston Society for Medical Improvement, De-cember 12, 1392.

2

urethral treatment, I contented myself with thoroughlyopening and curetting the perineum and scrotum ; andin a short time he was discharged with the woundshealed. He returned soon after for further treatment,when examination showed anterior strictures of 22 and16 F. calibre and a filiform stricture at four and one-quarter inches. Under ether the posterior bulbousurethra was opened on a whalebone guide. From thispoint the dissection was carried backward for an inchwithout a guide through a mass of cicatricial tissueuntil the bladder was opened. The anterior strictureswere cut internally to 30 F., and the bladder drainedthrough the perineum. Convalescence was uneventful;and two months later the urethra took a 30 sound with-out trouble.

In this case, when it was found that recontractionrapidly followed dilatation, it was worse than uselessto employ rapid divulsion, because ragged tears of un-known depth and directionmust of necessity have beenmade into the peri-urethral tissues; and occurring inthe sagging part of the urethra, everything septic withinreach would certainly drain into the lacerations. Thehealing process would become one of inflammation anddisease. When extravasation had taken place, exter-nal, thorough division of the whole of the deep con-striction was the only thing to do. In this way a phy-siological rest would be assured “by enabling us,” asBangs says, “ to abrogate the functions of the diseasedurethra by draining away the urine drop by drop with-out any effort on the part of the urethra or perinealmuscles.” When one considers the part that the peri-neal muscles play in respiration, defecation, micturition,different positions of the body, etc,, it is easy to under-stand how important it is to obtain all the quiet possi-ble in this region when inflamed and to obtain it by asearly an operation as possible.

3

Moreover, where there is abundant perineal exuda-tion, nothing will do any good that does not have inview the absorption of as much of the exudation aspossible. The original irritant must be removed with-out leaving another in its place, which is bound to oc-cur with leakage into a ragged, peri-urethral tear. Byfree incision there can be no retention of blood, whichis almost invariably septic in such cases as the oneunder consideration; or of urine, which Harrison hasshown to be as potent as blood in spoiling tissue.

Of the advisability of combining an internal with theexternal urethrotomy 1 will speak later on.

The second case, a Portugese, fifty years old, hadhad chronic cystitis with occasional exacerbations forthree years. Internal treatment had failed to helphim ; and at entrance he was passing at frequent inter-vals a stinking, stringy urine. On sounding, no stonewas found, and the bladder was carefully irrigated fortwo weeks with only slight improvement. Under ethera stricture of 20 F. calibre was found in the deep bul-bous urethra, which was cut by external incision. Onexploring the bladder with the finger, nothing wasfound beyond a very slight sinking of the floor, whichwas filled with tenacious pus. After thorough wash-ing, the bladder was drained by a Watson tube. Nostricture was found anteriorly. In a week healthyurine was passed, the tube was removed, and with theexception of a temporary cloudiness that yielded toalkalies, convalescence was uneventful, the patient be-ing discharged about three weeks after operation, pass-ing healthy urine at normal intervals through a urethraof 30 calibre.

In this case there was a possibility of a stone unde-tected by the sound, a prostatic bar or an accompany-ing pyelitis. Digital examination eliminatedall doubts.The bladder, for the time being a pus cavity, could be

4

best drained at the same time that the stricture couldbe best removed. The latter would in all probabilityhave yielded readily to dilatation, but the slightestbreak in the wall of the urethra would have merelyserved as an entrance for septic germs. Had therebeen no stricture nor cystitis, except what might bedue to harboring the results of a pyelitis, it would nothave been amiss to drain externally. Had there beena prostatic bar, as seemed likely, a few days’ drainagewould have been a surgical preliminary to prostatec-tomy by either route.

The third case, a gaunt, spare man of seventy-two,with no genito-urinary trouble since an attack of gon-orrhoea when eighteen years old, began last year tohave frequent micturition followed a month ago by re-tention. Voluntary micturition followed the use of thecatheter after a week or so, until shortly before en-trance, when he suddenly and without known causepassed considerable blood. When I saw him he wasmildly delirious, passing almost pure blood, with ec-chymoses over the perineum, scrotum and inner sideof the left thigh. A large catheter passed easily intothe bladder, if it did not enter a false passage whichled into the left thigh. After stimulation the bladderwas opened on a staff and the lateral lobes were foundby the finger much enlarged, but of themselves offer-ing no permanent bar to a complete emptying of theviscus. Exploration of the latter’s walls showed noth-ing beyond moderate trabeculation. Haemorrhage,that had been constant up to operation, ceased as soonas an opening was made. No stricture was found.For two or three weeks the patient was hard to con-trol, frequently tearing off the dressings and gettingout of bed. The tube was kept in a week; but leak-age persisted about three weeks longer, that is, untilhis physical and mental condition had materially im-

5

proved. In about eight weeks he went home, passingnormally a good stream of healthy urine and takingwithout trouble a 30 sound.

This case emphasizes several points. He looked andacted like one suffering from toxaemia, and I expectedhim to die on the table because of his wretched condi-tion ; in spite of the extensive laceration there was nopus; the sudden bleeding suggested a secondary haem-orrhage following rough catheterization. Whateverelse existed, one would expect to find an oedematous,congested prostate that would best be relieved by drain-age. Although in somewhat less than one-third of thecases of enlarged prostates can the bladder be thor-oughly explored with the finger, there can be no ob-jection to surgical rest pending a future explorationover the pubes. Fortunately everything in this casecould be learned from below. Haemorrhages from thebladder, whether from growths or lacerations are oftenbest controlled by cystotomy. The endoscope can attimes be used through the perineum; it was tried inthis case, but the bleeding was too free to allow any-thing to be seen.

The fourth case opens up a wide field for argument.A carpenter, forty-nine years old, contracted gonor-rhoea during the war, but denied any subsequent attacks.Two years ago he noticed a narrowing stream; andfor the last six months he has dribbled constantly, dayand night. There was the characteristic shrivelledmeatus ; percussion showed the bladder only two inchesabove the pubes; and all attempts without ether topass a whalebone guide failed. The urine unfortu-nately was not collected, so that the renal conditionwas not known except in so far as his general goodhealth would indicate sound kidneys. Failing to gainanything by hot baths, opium, etc., he was etherized ;

and after patient trial with a bunch of filiform guides,

6

one was passed into the bladder, and the posterior bul-bous urethra was opened on a grooved sound, therebyfreeing the tightest stricture. Carrying the incisionbackwards a little, the bladder was explored, but noth-ing pathological found. Of course, upon opening away, the urine gushed forth before the wound could beplugged; but considering the small degree of disten-tion of the bladder, 1 did not feel apprehensive of anybad result. The series of anterior strictures of whichthe smallest measured No. 10 F., were cut to 32 withthe Otis urethrotome, and the bladder drained throughthe perineum after thorough irrigation. Recovery wasuneventful; and he returned home in two weeks witha healed perineum, and taking a 32 sound with ease.

One of the objections to treating a deep, permeablestricture by external incision is the enforced rest in beddue to the position of the wound, and the chance of afistula. But in a case like this, with a clear urine, thepatient is confined very little longer than in an inter-nal urethrotomy or a divulsion ; and where aseptictreatment is carried out, the risks of a fistula are verysmall. Had there been renal degeneration an externaloperation was indicated rather than the opposite, be-cause it is not uncommon for albumen and casts to dis-appear as soon as backward pressure is relieved ; andeven with considerable organic change in the kidney,the destructive process must be temporarily abated.

With regard to recurrence, authorities differ. Syme,Moullin. Bickersteth, Harrison and others report au-topsies from two to twenty-six years after externalurethrotomies, where not only recurrence had not takenplace, but the urethra at the point of incision was act-ually somewhat enlarged, possibly due to the givingaway of the cicatrix in the mucous membrane or to thetension of the cicatrix in the peri-urethral tissues.Chavasse says, When no precautions are taken, lam

7

satisfied that narrowing of the urethra takes placemuch more slowly after a free external division thanafter any other means of treatment.” Harrison recordsthe largest proportion of permanent cures from exter-nal operation in a large series of cases taken indiscrimi-nately, excepting those treated successfully by dilata-tion.

On the other hand, Keyes maintained in 1889 thatthe lumpy, irregular, tortuous stricture cannot be curedby perineal section, and recommended total excision ofall the morbid tissue, and suture of the healthy dividedends of the urethra, or by transplantation of healthymucous membrane if possible. But this has been prettythoroughly tried in France and elsewhere, with, so faras the reports show, no better immediate or remote re-sults than from the simpler operation.

As to the advisability of doing a combined internaland external operation, there can hardly be any ques-tion. Undoubtedly, the result of freeing a deep strict-ure externally is to materially do away with any con-tractions that lie anteriorly ; some observers even claima total disappearance of the latter when left untouched,if the wound is kept open long enough; but the addi-tional operation is of slight severity. It can be donethoroughly, and asepsis is far more easily carried outand maintained. Harrison goes so far as to advise ex-ternal urethrotomy for drainage when the stricturesare anterior alone. I can find no modern supportersof the method of combining an internal anterior ure-throtomy and a posterior divulsion ; it is condemned asunsurgical by every writer that refers to it.

In conclusion, the indications that I wish these fewcases to emphasize are as follows :

External perineal urethrotomy gives the best blad-der drainage; it allows old cicatricial deposits aboutthe urethra to soften down better and more quickly

8

than by any other method; it probably assures thebest permanent results in deep strictures; it allows aswollen, lacerated prostate to shrink and quiet downquickly; it pacifies an irritable bladder; it may stopvesical bleeding; it is rarely, if ever, amiss in casesuprapubic cystotomy is found necessary, and in manycases it is the best route to the bladder and prostate;it is not contraindicated with internal urethrotomy orwhere any operation is demanded, in renal disease, andordinarily with modern asepsis it does not confine apatient in bed over a week; it allows a definite, posi-tive or negative diagnosis in most instances, and inpathological cases it is rarely a difficult operation.

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