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SECTION I
GENERAL SURGERY
CHAPTER XVI
WOUNDS
OF
THE GENITOURINARY TRACT
Shortly after the establishment of the
American Expeditionary Forces a manual of
urology a was prepared and distributed to the Medical Department, A. E.
F., with the view of
standardizing, among other activities, the work of those medical
officers in whose hands would
fall cases requiring operative treatment for injury to the
genitourinary tract, incident to battle.1
Since
the text of this manual, in so far as the present subject is concerned,
was based
upon the existent literature, and since it proved of value in the work
of medical officers,
especially consulting urologists, it has been largely drawn upon in the
preparation of this
chapter.
It
is unfortunate that analytical studies of series of injuries to the
genito- urinary tract
could not have been made on cases while these were in hospital. Lacking
these, recourse has
been had to clinical records, which, being variously prepared,
frequently are silent as to features
that would have present value.
WOUNDS OF THE KIDNEY
Wounds
of the kidney in war are neither infrequent nor unimportant. It is true
they are
overshadowed in many instances by the more frequent and fatal lesions
of adjacent viscera and
so are frequently overlooked. But since they in themselves, though
often fatal, are singularly
amenable to intelligent treatment, the surgeon should not fail to focus
his attention upon them. In 2,385 gunshot wounds of the abdomen in the
American Expeditionary Forces, the kidney was
involved in 129 instances, a percentage of 5.44.2 To
determine the relationship of the kidney
injury with those of other organs, the clinical records of 66 members
of the American
Expeditionary Forces,3 showing injury to the kidney, were
analyzed. In 38 instances no other
viscus was involved. The association of lesions of other viscera was as
follows: Liver, 11;
spleen, 5; small intestine, 3; large intestine, 6. Thoracic viscera
were injured in 11 instances in
association, 2 of which are included above in connection with injuries
of abdominal viscera.
As
to the nature of the missile, in 61 of the cases this was given as
follows: Rifle and
machine gun, 41; shrapnel and high-explosive shell, 20.
PATHOLOGY
A
gunshot wound of the kidney itself may involve only the parenchyma, one
of the larger
renal vessels, or the pelvis. If the parenchyma alone is injured and
the pelvis scarcely opened, the
resulting microscopic hematuria may pass
a The
Manual of urology for the Medical Department, A. E. F., was prepared by
the author of this chapter in
collaboration with Maj. Edward L. Keyes, Capts. M. L. Boyd, Everard
L. Oliver, W. H. Mook, and D. M. Davis,
and Lieuts. J. E. Moore and William Jack, M. C.
471
unnoticed and the renal injury either escape
detection altogether or be disclosed by operation for
other injuries or by a lumbar hematoma. If an artery is divided or so
contused as to become
obstructed by clot, the renal parenchyma supplied by this vessel will
become gangrenous, for the
arteries of the kidney are terminal; they do not anastomose. Division
of one of the main branches of the renal artery, near the hilum,
usually results in hemorrhage so severe as to demand
operation, probably nephrectomy. Wounds of the renal pelvis of
themselves imply only
extravasation of urine, but, like those of the renal vessels, they are
almost always associated with
wounds of the renal artery and of the adjacent viscera as well.
The
wound in the parenchyma may be perforating, tangential, or explosive.
The edges of
the wound are usually contused; adjacent parenchyma may become necrotic
through arterial
injury, but the more remote portions of the parenchyma suffer no more
than temporary
congestion, expressed by a brief anuria.
The
later lesions are those of infection and extravasation, intraperitoneal
or
extraperitoneal. Destruction of fascial planes eliminates the usual
anotomical restriction to their
spread.
CLINICAL PICTURE
The
patient arrives at the evacuation hospital labeled as a wound of the
buttock, thigh,
abdomen, or chest. The surgeon's immediate concern is with the state of
shock, the amount of
hemorrhage, the length of time since the patient was wounded, the
general character of the
wound itself, and symptoms pointing to perforation of the
intraperitoneal viscera.
Unless
the situation of the wound itself, the presence of hematoma in the
loin, or of blood
in the urine call his attention to the probable existence of a kidney
injury, this does not usually
enter the surgeon's calculations, since injuries to the other abdominal
or the thoracic viscera are
of much more immediate importance and are far more common, the decision
to operate or not to operate is also reached with reference to the
patient's general condition and the presence of a
"penetrating" wound rather than with reference to a kidney injury.
SYMPTOMS
The
immediate symptoms of renal wounds are due to hemorrhage. Thus
hematuria is
absent only if the ureter is completely divided or obstructed by clot,
or if the wound does not
invade the renal pelvis. This hematuria is total, but usually not so
severe as to cause clotting in
the bladder. Retention of urine is common. Shock is not so severe as
that due to intraperitoneal injuries, unless the patient is
exsanguinated. It is noteworthy that the hemorrhage from renal
injuries, however severe, is rarely fatal. Hematoma in the loin
develops rapidly in wounds that
do not drain freely. It excites tenderness and rigidity of the
overlying muscles, and forms an ill-defined mass. Hemorrhage from the
wound is free. Intraperitoneal hemorrhage is obscured by
the symptoms due to lesions of other organs. Gas gangrene, sepsis,
extravasation, and secondary
hemorrhage are the causes of death at the base. Secondary
472
hemorrhage may occur as late as two months
after the wound. It is quite common in the second
and third week. It is more to be feared than the primary bleeding
because of its severity and its
marked tendency to recur, from each of which recurrences the patient
rallies less well than from
its predecessor. Renal infection and stone are late complications.
DIAGNOSIS
All
patients with abdominal injuries should he catheterized at the first
opportunity, unless
they can urinate freely. The urine obtained should be examined for
blood.
Large
wounds of the loin present no special diagnostic difficulties. The
diagnosis is
obscure under two conditions: (1) In the presence of hematuria. If the
wound gives no clue as to
the source of bleeding the diagnosis is made by cystoscopy, which
discloses blood from the
ureter, or by exploratory operation undertaken for the relief of other
visceral lesions. (2) In the
absence of hematuria. The renal injury is disclosed by cystoscopy and
ureteral catheterization;
operation for hematuria; retroperitoneal infection; lesions of other
viscera.
Ureteral
wounds seemingly do not occasion sufficient bleeding to permit an
immediate
diagnosis, except by surgical exploration.
TREATMENT
AT THE FRONT
When
there is doubt as to whether or not to open the belly or the loin
first, the loin should
be opened. The loin incision should be transverse and extend
approximately to the edge of the
rectus. It may be enlarged by a vertical transrectus incision or by a
vertical incision along the
outer border of the erector spinte muscle long enough to permit
division of all muscular and
ligamentous attachments to the last rib. The twelfth dorsal nerve and
artery may be avoided by
placing the transverse incision a finger's breadth below the rib. Thus
also one avoids the danger
of inadvertently entering the pleura, through mistaking the eleventh
for the twelfth rib.
If
there is a wound of the loin and hematuria, or if the wound plainly
leads to the kidneys,
enlarge it transversely, deliver the kidney and examine the hilum for
lesions of the renal vessels.
If the
main artery or vein, or the upper main branch of the artery, are
wounded, perform
nephrectomy. If smaller arteries or the lower branch of the renal
artery are wounded, or the renal
wound is a relatively slight one, there are three procedures: (a) For
wounds that are not very
extensive or ragged and do not involve any great destruction of the
arterial system of the kidney
it may be wise to do nothing more than to pack the loin wound down to
kidney.(b) But in case of
persistent hemorrhage, extensive contusion, presence of foreign bodies,
or division of arteries,
the kidney demands the surgeon's attention; the renal wound may be
packed or a portion of the
parenchyma excised and sutured. (c) At the evacuation hospital, where
such primary operations
are usually performed, conditions are often such as to prohibit
prolongation of the
473
operation for the purpose of resecting and
suturing the kidney or searching for shell fragments or
bullets. Resection is, however, the ideal operation for such cases--an
ideal which has been
realized in a few cases and one which the surgeon should always bear in
mind. When partial
nephrectony is performed the excised portion should include all that
part of the kidney
parenchyma which is deprived of circulation by division of its artery.
If
this has been opened, a small tube should be left in the pelvis of the
kidney two days,
in order to evacuate blood clots and to hasten the return of kidney
function by removing intra
pelvic pressure. Always open peritoneum in front of the colon in order
to examine the adjacent
viscera. Drain and suture the wound in the usual manner.
Complete
nephrectomy should be performed when more than one-third of the kidney
is
contused. On the other hand, when less than one-third is contused
resection may be considered.
If hematuria
suggests renal injury, but the wound is remote from the loin. the
decision in
favor of or against immediate operation should be based on the
following data: If the patient is
going to die of primary renal hemorrhage, he is likely to do so before
reaching the dressing
station. Though exploration of renal wounds usually starts a fresh
parenchymatous hemorrhage.
it discloses the fact that the primary bleeding has already stopped.
Therefore unless an external
wound leads directly to the kidney region the presence of hematuria or
of a retro peritoneal
hematoma is no indication for immediate operation. A retro peritoneal
hemorrhage discovered in
the course of a laparotomy may be disregarded (it often does not arise
from the renal vessels at
all) unless it is of enormous size, in which event it should be
evacuated extraperitoneally, before
the intestines are much handled, for it has been found that immediate
grave shock results from
turning the patient over and operating upon his loin after laparotomy.
Transperitoneal
nephrectomy is generally condemned.
AT THE BASE
All
secondary operations should be preceded by cystoscopy, to ascertain the
condition of
the opposite kidney, and fluoroscopy to locate fragments of bone or
missile. Large hematomata
should be evacuated to forestall infection. Secondary hemorrhage calls
for transfusion and,
usually, for prompt nephrectomy unless other complications prohibit
this, for the hemorrhage is
likely to recur and the effect of each return of bleeding is
cumulative. Sepsis is combated
according to general principles of drainage and antisepsis. Persistent
urinary fistulae in the loin
should be treated by the insertion of a ureteral catheter up to the
pelvis of the kidney. The
catheter may be left in place for an indefinite period if changed every
fourth or fifth day. If
healing is to occur this may be expected within 10 days.
If
the fistula fails to heal, the kidney may be explored for the purpose
of reestablishing
this urinary flow by plastic operation, or for nephrectomy, if the
opposite kidney is proved
sound.
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MORTALITY
The
mortality rate of injuries to the kidney, both complicated and
uncomplicated, proved
to be 55.81 among cases of the American Expeditionary Forces treated in
hospital. 2 The
clinical record of 66 cases showed a mortality of 50.3
To
shock and hemorrhage may be attributed a certain number of deaths in
kidney injury
at the front. However, with improvements in evacuation, so as to hasten
the arrival of the
wounded at hospital, and improvement in methods of treating shock,
obviously danger from the
above-mentioned causes of death was lessened. Thus, of 37 of the series
of 66 cases mentioned
above, 28 were operated upon on the day of injury; eight, on the second
day; one, on the third
day. In a series of 13 cases, in hospitals at the front, 3 died and 10
were evacuated to the base.4
When we
consider the frequency of involvement of other important organs, the
percentage of fatalities is not surprising. In the series of 66 cases,
the intestines were involved in
14 percent; liver, 16 percent; chest, 16 percent; peritoneal cavity,
39 percent.3
CASE REPORTS
Case
1 R. H., sergeant, Company F., 355th Infantry, A. E. F. Gunshot wound
of back, left kidney, received
in action October 21, 1918. Evacuation Hospital No. 10:
Through-and-through wound of back; wound of entrance,
left post axillary line; wound of exit, right post axillary line.
Urinary retention; catheter showed blood in urine. Base
Hospital No. 15: During night of October 27, severe hemorrhage into
bladder. Patient became pulseless. Salt
solution infusion. Cystoscopy showed bleeding from left kidney. Left
lumbar nephrectomy, suprapubic drainage of
bladder. Base Hospital No. 6: December 15, 1918. Gun-shot wound of
back, perforating left post axillary line to
right back, nephrectomy wound, left loin, suprapubic wound, bed sore,
paralysis below waist line, bladder
satisfactorily drained by putting large catheter in place of suprapubic
tube. Ultimate result, cure.
A. E. F. RECORDS
Case
2. J. E. H., 1204342, Company L, 105th Infantry. Wounded August 5,
1918. Gunshot wound of side,
penetrating abdomen, causing tear of ascending colon and damage to
lower pole of right kidney. Operation,
Canadian casualty clearing station, several hours after injury: Suture
of intra and extraperitoneal tear of ascending
colon. Liver and kidney sutured. Removal of foreign body from liver.
Drainage. Tedious convalescence. Ultimate
recovery. Demobilized January 8, 1919, 10 percent disability.
Case
3. J. G., Company D, 120th Machine Gun Company, 273042. Wounded October
8, 1918. Gunshot
wound entering right lumbar region, penetrating lower pole of kidney.
Wound of colon. Operation, same day:
Laparotomy, suture of colon and mesentery, drainage of right kidney,
debridement. Foreign body removed.
November 19, 1918, second operation for intestinal obstruction due to
adhesions. January 29, 1919, cystoscopy,
ureteral catheterization and functional tests negative. February 7,
1919, duty. February18, 1919, demobilized;
disability, 50 percent.
Case 4. H.
C., 101333, Company G, 168th
Infantry. Wounded September 12, 1918. Gunshot wound,
abdomen, rupture of left kidney. Operation, 10 hours later: Laparotomy,
nointestinal injury found; closure; dorsal
incision; kidney delivered; 3 clamps applied; kidney removed.
Recovery.
March 6, 1919, duty. March 13, 1919,
demobilization, 50 percent disability.
Case 5. E. M. P., 76925, shrapnel wound.
Gunshot wound, right lumbar region, hip, right kidney, and left
shoulder. Resection of colon. Operation, same day: Débridement, foreign
body removed, right kidney perforated,
drainage. February 5, 1919, nephrectomy,
475
right. Pyonephrosis. Fistula connecting
hepatic flexure of colon to pyonephritic sac. March 20, 1919, duty.
April 22,
1919, demobilized, 75 percent disability.
Case
6. C. A. B., 57153, Company D, 28th Infantry. Wounded July 21, 1918.
Gunshot wound,
penetrating upper right abdomen; fracture of eleventh and twelfth ribs;
injury to liver and kidney. Operation. Record
of first operation lost. August 8, 1918, abdomen drained. November 30,
1918, nephrectomy, right; complications:
Urinary fistula from right kidney, multiple abscesses, arthritis, sinus
tract of abdominal wall. July 23, 1919, demobilized, disability 75
percent.
Case
7. H. J. K., Machine Gun Company, 356th Infantry, 3173056. Wounded
September 12, 1918. Gunshot
wound, chest, penetrating right back at eleventh rib, perforating
kidney and liver. Operation, nephrectomy. January
30, 1919, demobilized, disability 40 percent.
Case
8. E. K., 2858609. Wounded September 12, 1918. Gunshot wound, right
side, passing through
diaphragm, liver, and kidney. Operation, laparotomy. Considerable blood
found in cavity; small injury to kidney,
inaccessible. Drainage of abdomen. Foreign body removed from back,
subcutaneously. Complication:
Bronchopneumonia. February 11, 1919, to duty, convalescent center.
January 15, 1920, demobilized, 30 percent
disability.
Case 9. M. F. B., Company E, Seventh
Engineers. Wounded September 17, 1918. Gunshot wound, left
lumbar region over left kidney, bullet lodging in kidney. Operation:
Foreign body removed from left kidney
through extraperitoneal incision. Recovery. December 25, 1918, duty.
Case
10. V. R., 1317456. Wounded September 29, 1918. Gunshot wound, back,
penetrating right kidney.
Operation: D ebridement, drainage. September 30, 1918, passing blood in
urine. October 13, 1918. Operation:
Eighth rib resected, liver drained; foreign body removed from right
back. January 25, 1919, nephrectomy, right. June
16, 1919, demobilized, disability, 25 percent.
Case 11. J. McK., 1207623. Gunshot wound,
left loin, penetrating kidney and diaphragm. Operation, same
day: Foreign body removed from upper surface of diaphragm, which was
sutured. Kidney drained. Recovery. March
6, 1919, demobilized, no disability.
Case 12. A. F., 3495499, Company
D, 165th Infantry. Wounded October 16,
1918. Gunshot wound, penetrating peritoneum and injuring kidney.
Operation: Débridement, drainage.
Recovery. November 14, 1918, operation: Resection of rib for empyema.
July 5, 1919, demobilized, disability, 30
percent, on account of old suppurative pleurisy and obliteration of
lung.
WOUNDS
OF THE URETER
The
brief mention of wounds of the ureter in medical periodicals throws
little light
upon the subject. There are records of four gunshot wounds of the
ureter in the American
Expeditionary Forces.2 Apparently the wound has always
been associated with visceral injury
requiring abdominal section. The ureteral lesion is disclosed by the
watery quality and urinous
odor of the intra or retro peritoneal drainage, or else by appearance
of urine in the dressings after operation.
The
treatment is expectant. Several such urinary fistulae have healed
spontaneously. In brief, the treatment of ureteral wounds is the
following:
Immediate repair by suture of the wound, if it is
reparable and if the patient's condition
permits.
If
these conditions can not be fulfilled, adequate drainage will be
provided for the
urine. The upper end of a completely severed ureter which can not be
repaired may be brought
up and sutured to the parietes. Primary nephrectomy is not to be
considered because of the added
danger to life.
476
If
the ureter is sutured the finest chromic gut should be employed, for
plain catgut will
not hold. But great care must be taken to catch the ureter at its very
cut edges so that as little as
possible of the suture remains within the lumen of the canal, for fear
of secondary stone
formation. A small drain should be led down to the ureteral wound.
If
the completely divided ureter is dislocated and sutured to the
parietes, no tension
whatsoever should be made upon it for fear of angulation. A few strands
of silkworm gut left in
the ureter will greatly facilitate the urinary drainage.
If
the ureter is known to be irreparably divided, nephrectomy is the
operation of choice,
after the patient has rallied from the immediate effects of his injury
and catheterization of the
ureter has proved the opposite kidney sound.
If
the opposite kidney is not sound, a cup should be fitted over the
ureteral fistula and
permanent drainage established.
If
the wound is not known to be irreparable, a precise diagnosis should be
established by
pyelography; if possible the kidney should be drained by the indwelling
ureter catheter. The
failure of ureter catheter drainage indicates the necessity for
operative treatment. While it may
be possible in certain instances to reestablish drainage by plastic
operation, such procedures are
notoriously inefficient in the treatment of infected kidneys, and the
masses of scar resulting from
the wound would doubtless still further diminish the probability of
success. Nephrectomy will
usually be required.
The
following case, reported by Stevens, concerns a ureteral injury:5
Case 13. Gunshot wound, penetrating, of back;
hematuria; bullet removed through perirectal incision.
Patient was admitted with hematuria. Gunshot wound of the back above
right costal margin; no wound of exit.
Cystoscopy showed blood coming from the right ureter, but urethral
catheter, which was passed up to the renal
pelvis, gave clear urine, miscroscopically free from blood.
Roentgen-ray examination showed machine-gun bullet
lodged in the bony pelvis back of bladder in region of lower pole,
right ureter. On rectal examination, missile could
be felt high up in this region. Fluoroscopic and X-ray examinations
with catheter in ureter showed that bullet had
probably injured the ureter. Through apteral perirectal incision bullet
was removed without difficulty.
WOUNDS OF THE BLADDER
In
the experience of the American Expeditionary Forces, battle injuries to
the bladder
bore about the same ratio to abdominal wounds as did injuries to the
kidney: that is to say, of
2,385 abdominal injuries, 127 involved the bladder, a percentage of
5.32.2
In
a series of 57 cases,3 rifle and machine-gun missiles injured the
bladder in 46
instances: shrapnel and high-explosive shell, in 11. There is no record
of piercing instruments
causing injury to the bladder in the American Expeditionary Forces.2 In the series referred to,
the abdomen was involved in 17 instances; the rectum, in 5; large
intestine, in 4; small intestine,
in 15.
CHARACTER OF INJURY
The
size and shape of the bladder perforation depend upon the type of
missile producing
the wound. The perforation varies from the small slitlike hole of the
rifle missile to the large
laceration of the shell fragment. Small
477
missiles may destroy very little of the
bladder substance, but larger ones may destroy a very
considerable portion of the bladder wall.
The
projectile may enter the bladder from any angle, and entrance wounds
high up in the
abdominal wall or back, and wounds of the buttocks, thighs, and hips,
or of the perineum, may
involve the bladder, and should always be viewed with suspicion, as it
is often impossible from
the position of the wound of entrance to tell whether or not the
bladder has been injured. It is
wise always to consider the possibility of vesical wounds in doubtful
cases.
Foreign
bodies, such as bits of clothing and spicules of bone have been carried
into the
bladder by the projectile, and the missile itself has sometimes lodged
there. If not removed, these
foreign bodies become nuclei on which stones may form.
Experience
of the World War has gone far to eliminate the classic distinction of
injuries
to the bladder whereby they are divided into two groups, the intra and
extraperitoneal. In the
description of symptoms and treatment, however, the distinction of
extra and intraperitoneal
injuries must be maintained for the sake of clarity. But in the field
the surgeon will find that
most of the intraperitoneal bladder wounds are associated with
extraperitoneal wounds and that the diagnosis of extraperitoneal
injuries founded upon the absence of abdominal tenderness
and rigidity may ultimately be belied by a fatal peritonitis. The
following classification
therefore simply represents the various combinations which may occur,
and artificially
dissociates the complex pathological conditions resulting from wounds
of the pelvis or abdomen
that involve the urinary bladder.
I. Intraperitoneal
injuries.
(A)
Wounds.
I. Uncomplicated.
II. Complicated by –
(a)
Perforations of other viscera.
1. The small
intestine.
2.. The colon.
(b)
Fractures or injuries of bones.
(c)
Injury to large blood vessels.
(B)
Ruptures by concussion.
I. Complicated.
II. Uncomplicated.
II. Extraperitoneal
injuries.
(A)
Wounds.
I. Uncomplicated.
II. Complicated by -
(a)
Injury to rectum.
(b)
Injury to deep urethra or prostate.
(c) Fractures of the bony pelvis
or femur.
(d)
Injury to important blood vessels.
478
INTRAPERITONEAL WOUNDS
Intraperitoneal
wounds of the bladder are almost invariably associated with other
intraperitoneal injuries, perforation of the small intestine being the
most common. Owing to this
frequent association no laparotony should be regarded as complete until
the bladder has been
inspected on the operating table.
SYMPTOMS
Symptoms
vary according to the position and size of the lesion and they depend
considerably on lesions to other organs, especially the small or large
intestine.
The
outstanding subjective symptom of a bladder injury is a desire to void
urine and an
inability to do so. Often the patient is able only to expel a small
amount of bloody urine.
Frequently, however, no urine can be passed, since a large part of it
is escaping into the
abdominal cavity. Hematuria is always present. The amount of blood in
the urine varies greatly.
Usually it is present in considerable amount, though sometimes it is
only visible as a smoky
cloud. In case bleeding is profuse large intravesical clots form.
Intestinal contents, especially in
cases associated with rectal wounds, have often been noted in the urine
drawn by catheter.
Symptoms referable to the abdomen are often very
indefinite. There are signs of slowly
developing peritonitis, namely, tenderness, rigidity, and dullness, at
first limited to the lower
abdomen. Later, this becomes general and the whole abdomen is tender
and rigid. At this state
there is usually nausea and vomiting. As the urinary collection in the
peritoneal cavity increases,
signs of intra-abdominal fluid appear; i. e., there is shifting
dullness in the flanks and marked
general abdominal distension.
DIAGNOSIS
Preoperative
diagnosis can not usually include a cystoscopy and therefore can be but
approximate. The hematuria indicates an injury to the urinary organs.
The wounds of entrance
and exit, the presence or absence of abdominal rigidity and tenderness,
and the signs of injury to
other viscera will suggest the location of this injury; that is,
whether of the bladder or kidney, or
whether intraperitoneal, extraperitoneal, or both. Under no
circumstances should fluid be forced
into a bladder through a catheter to determine whether or not it is
ruptured. The consensus of
surgical opinion is that such a procedure is both deceptive and
dangerous.
TREATMENT
The
peritoneal cavity is opened by a vertical incision through the rectus
muscle and
intestinal injuries are located and repaired. With the patient in the
Trendelenberg position a
finger is introduced through the perforation into the bladder to search
for blood clot and foreign
bodies, which if present are removed, and to locate the presence and
position of any
extraperitoneal tears. The hole in the bladder may be punctiform and
easily closed by a purse-string
479
suture. The tear may be of considerable size
and the method employed in repairing it will depend
upon its position in the bladder wall. Wounds of the summit or anterior
surface of the bladder are
usually readily accessible. The edges of the bladder wound should be
excised so that fresh
surfaces may be brought together by a continuous suture of catgut
approximating the muscular
walls. A retention catheter should then be introduced. If the wound is
situated at the base of the
bladder it may be quite impossible to suture it. In such instances the
best one can do is to convert
the intraperitoneal wound into an extraperitoneal one by closing the
peritoneum and carrying out
suprapubic cystotomy.
Suprapubic
cystotomy should not be done as a routine in these cases, as
practically all
authorities state that tight closure of the bladder and catheterization
is preferable. Catheterization
is usually necessary for only four or five days.
PROGNOSIS
The
mortality of intraperitoneal wounds of the bladder varies between 50
and 70 percent.
Peritonitis secondary to intestinal perforation is an important cause
of death. Perforations of the
posterior bladder wall have been overlooked and a urinary extravasation
into the peritoneum has
led to subsequent peritonitis and death. Unquestionably the immediate
mortality cases where
large blood vessels have been severed by the missile, has been very
high.
EXTRAPERITONEAL
WOUNDS
Wounds
of the buttocks, thighs, or hips, with little or no evidence of any
abdominal
disturbance or discomfort, frequently invade the bladder
extraperitoneally and should always be
carefully investigated. Sacral and perineal wounds involving the rectum
have often an associated
bladder injury of this type, while wounds of the lower abdominal wall
or flanks may obviously
cause an extraperitoneal bladder perforation. These wounds of the
bladder rarely exist
independently.
In
a series of 35 cases of extraperitoneal injury to the bladder,3 there was an associated
involvement, in 8, of either the bony pelvis or the femur. In three
instances, the rectum was
injured; in one, the prostate was injured.
Intraperitoneal
perforations are frequently produced by a missile entering the bladder
extraperitoneally. Thus, in a series of 44 such cases, 3 the small
intestine was injured in 8
instances, the large, in 1.
SYMPTOMS
An
uncomplicated extraperitoneal wound of the bladder produces hematuria
and difficult
urination; the signs of urinary extravasation are present. In these
cases the urinary extravasation
usually follows the path of least resistance, which is along the most
damaged fascial planes. The
wound of entrance may be of sufficient size adequately to drain the
bladder and in these
instances no extravasation into the tissues takes place. Severe
cellulitis and sepsis follow in the
wake of the urinary extravasation and often prove fatal.
480
DIAGNOSIS
The
diagnosis without cystoscopy can not be absolute. All patients with
wounds of the
buttocks or thighs should be catheterized. Hematuria will give a
valuable hint as to the presence
of bladder injury. Urine and blood maybe draining from the wound of
entrance. There may be
associated intraabdominal lesions and the signs and symptoms of
intestinal injury should always
be looked for. In cases where the rectum and bladder have both been
injured the urine will
usually contain feces as well as blood.
TREATMENT
Urinary
drainage must be provided for these cases, and the wound of the bladder
wall
repaired if accessible.
Urinary
drainage may be provided by (1) cystotomy, (2) interval
catheterization, (3)
retention catheter, or (4) enlargement of the wound of entrance and
drainage of the bladder
through it. Some surgeons believe that cystotomy should be done for all
bladder perforations.
Others, however, believe that in many extraperitoneal bladder wounds
satisfactory drainage can
be obtained through the wound of entrance. Whereas, in 45 cases in the
series of 57 bladder
wounds were drained, cystotomy was done on but 14.
In
general, it may be said that if the tract of the missile is short and
fairly large the
bladder can be properly drained through it and there is no need for
suprapubic cystotomy. In
cases where the missile has produced a long tract, satisfactory
drainage can not be obtained
through it. In wounds of the bladder complicated by compound fracture
of the pelvis or femur,
cystotomy should be employed as a routine. If urine is allowed to drain
over these open fractures
serious cellulitis results and sepsis develops, often leading to a
fatal outcome.
MORTALITY
There
were 68 deaths in the 127 cases of gunshot wounds of the bladder,
American
Expeditionary Forces. 2 The individual records 3 of but 57
cases have been discoverable. Among
these, 35 deaths are recorded; 25 give no cause; 2 were from
hemorrhage; 3 from shock; 3 from
septicemia; 2 from pneumonia.
CASE REPORTS
Case
14. A. S., :3489070, Company G, 47th Infantry. Wounded October 12,
1918. Gunshot wound,
penetrating right buttock, pelvis, and bladder. Shrapnel. Operation:
Sulpraplubic eystotony; foreign body not
removed. Debridemenit and drainage of buttock. Ligation of sciatic
artery. D bridement of wounds of arm.
Complications: Gas gangrene of arm, necessitating amputation below
shoulder. August 15, 1919, demobilized, 80
percent disability, because of amputated arm. Healed scars, suprapubic
and gluteal.
Case
15. M. C. G., 102628, Company M, 167th Infantry. Wounded July 28, 1918.
Gunshot wound of
abdomen between umbilicus and pubis, perforation of intestine and of
bladder. Operation, July 29. Wound,
debrided, two perforations in small intestine closed. Bladder wound
closed with drainage. Recovery. February 27,
1919, operation to cure postoperative hernia. May 15, 1919,
demobilized, 20 percent disability, because of weak- ness of abdominal
wall.
Case
16. E. D., 184581, Headquarters Company, 101st Engineers. Wounded
November 9, 1918. Gunshot
wound, penetrating abdomen in right lower quadrant, perforating
481
bladder and intestine. Operation, foreign
body removed; bladder drained; perforation of intestine and bladder
closed
by suture. Details of operation lost. May 7, 1919, cystoscopy, small
stone in bladder. July 14, 1919, demobilized, 30
percent disability, because of hernia in abdominal wound.
Case
17. McK. G., 1380683. Gunshot wound entering left buttock, passing
through intestine and bladder.
Operation same day. Resection and end-to-end anastomosis of injured
small intestine. Suture of wound in bladder.
Recovery. October 6, 1918, removal of foreign body. December 25, 1918,
returned to duty.
Case 18. J. H., 1415627, Company F, 165th
Infantry. Gunshot wound, through and through, of sacrum,
lower abdomen, bladder, right anterior abdominal wall, 7 cm. below
umbilicus. Operation, incision; insertion of
drainage tubes in front and behind. August 1, 1918, tube removed from
lower abdominal incision, urine escapes.
Able to void urine through urethra. October 5, 1918, wound healed,
scars firm. November 10, 1918, return to duty.
Case
19. L. V. G., 1417607, Company D, 102d Infantry. Gunshot wound
entrance, right buttock, passing
through ilium, perforating bladder and left groin. Pubic bones
fractured. Operation, November 18, 1918, median line
abdominal incision. Omentum in hernial canal ligated and excised. No
intestinal perforation found. Abdominal
wound closed without drainage. Hernial sac excised. Wound closed.
Drainage tube in bladder through tract of bullet.
Recovery. November 10, 1918, a suprapubic drain inserted. November 21,
1918, external urethrotomy. Suprapubic
fistula closed. December 20, 1918, No. 20 sound passes without
difficulty. Wounds healing. Complications:
Periurethral abscess, urinary fistula of lower abdomen. January 26,
1919, wounds healed. Demobilized, 50 percent
disability, because of wound of abdomen perforating bladder.
Case 20. W. J. D., 1456617, Company E, 139th
Infantry. Wounded September 27, 1918. Gunshot wound
penetrating the abdomen just above and to the right of the symphysis
pubis, perforating bladder and rectum, the exit
being through the center of the left buttock. Followed by a discharge
of urine through wound of entrance and feces
through wound of buttock. Operation, insertion of drainage tube into
the bladder through the wound of entrance.
November 7, 1918, urethral drainage provided. November 14, 1918, no
leakage from abdominal wound. Slight
discharge from sinus in buttock, but not of fecal character. January
20, 1919, culture from bladder urine showed no
growth. May 17, 1919, demobilized, 1.5 percent disability because of
cicatrices and weakened abdominal muscles.
No fistulae.
Case
21. R. K., 106426, Company D, 3d Machine-Gun Battalion. Wounded August
18, 1918. Gunshot
wound, right thigh, entering bladder. Operation, incision of wound of
thigh, evacuation of hematoma of right
buttock; suprapubic cystotomy, removal of foreign body in bladder;
drainage. Recovery. Complications: Indirect
inguinal hernia; operation therefor April 22, 1919. May 23, 1919,
returned to duty.
Case 22. D. N., 2239852. Gunshot wound,
through and through, of abdomen, perforating intestine and
bladder; exit, right buttock. Urine and feces escaped through the
wound. Operation. Wound of entrance debrided to
peritoneum; closed with external drain of rubber tissue. Wound of exit
d ebrided with cigarette drain inserted
through the sacrum. Dakin tubes inserted in buttock wound. Laparotomy,
median incision. Examination showed
bullet had not passed through adbomen. Wound closed in layers. October
6, 1918, urine escaped from drainage
incision in lower abdominal incision and fecal matter from right
buttock wound. December 19, 1918, examination
of fecal fistula showed opening into rectum 2 inches above internal
sphincter. December 31, 1918, pelvic abscess
pointed just to the inner side of the anterior superior spine, incised
and drained. November 19, 1919, abdominal
exploration, removal of Beek's paste from fistulous tract. Tube
drainage provided. No further record.
Case
23. F. H. C., 2715115, Company D, 315th Infantry. Gunshot wound,
penetrating, left thigh, pelvis,
and bladder. At operation, laparotomy, the foreign body was removed
from the pelvis, and perforation of bladder
closed. Suprapubic drainage afforded. Complications: Left foot drop
from injured sciatic nerve; urinary fistula,
which finally healed. February 16, 1920, demobilized, 40 percent
disability because of paralysis of extensor
muscles of left leg.
482
Case
24. R. B., 2846210, Company K, 355th Infantry. Gunshot wound, through
and
through, lower abdomen, perforating pubic hone and bladder; exit, right
buttock. Laparotomy
was performed the day of injury; examination showed perforation of
bladder; no other viscera
injured. Pubis was fractured; fragments removed. Bladder wound closed,
rubber drainage tube
inserted through wounds at entrance and exit. Subsequently vesicorectal
fistula was discovered
and on February 25, 1919, operation was done for this, successfully.
May 27, 1919,
demobilized, 15 percent disability because of scars; no fistulae
present.
WOUNDS
OF
THE POSTERIOR URETHRA AND PROSTATE
Wounds
of posterior urethra and prostate, like those of the bladder, are
usually one
element in an extensive wound of the pelvis or the thigh. The usual
injury is an extensive
laceration of the urethra by a bullet or shell fragment. The missile in
traversing the pelvis may
fracture this or the femur, and lacerations of the rectum and bladder
and pelvic vessels are
common complications.
The
usual symptoms of wound of the urethra is retention of urine, though if
the wound is
a large one, carrying away the neck of the bladder, there may be
incontinence of urine.
Urethrorrhagia
is an almost constant symptom. If the wound is transverse and does not
lacerate the superficial tissues of the perineum, the injury to the
urethra is disclosed by a perineal
hematoma and confirmed by the passage of a catheter. If the urethral
wound is neglected, the
retention is soon exchanged for incontinence by overflow of the
bladder, with resulting urinary
infiltration and infection of the perineum, the ischiorectal fossae,
and the whole pelvis. Only the
mildest injuries escape this fate.
The
associated shock, hemorrhage, fracture of the pelvis, and wounds of
rectum, bladder,
or other viscera should not distract the surgeon's mind from the
urethral condition. Whenever
there is a fracture of the pelvis, or a bullet wound of pelvis,
buttock, or thigh, a catheter should
be passed into the bladder. If the urethra is ruptured the catheter may
pass well up into the
pelvis, but it will not draw urine, and if there is any doubt as to
injuries about the perineum the
extravesical course of the catheter may be readily identified by
palpating it with the finger
introduced into the rectum.
A
slight injury to the prostatic urethra may produce only a hemorrhage
into the bladder,
which may be overlooked, may result in infiltration of urine, or may
leave a urinary fistula. Shock and the associated injuries to viscera,
vessels, and bone constitute the immediate dangers;
but if the passage of a catheter reveals rupture of the urethra,
provision must be made by perineal
or suprapubic section for drainage of the bladder, unless this is
assured by the character of the
wound. Lacking this, the patient will probably die of urinary
infiltration.
The
ultimate prognosis as to restoration of the urinary function and the
occurrence and
extent of traumatic stricture depends upon the nature of the injury and
the thoroughness of
treatment.
The
diagnosis is made by passage of a catheter. The shock and the wound are
treated in
the usual manner.
If
the catheter will not pass, the bladder is to be drained by
suprapubicor perineal section,
a tube being left in the wound for drainage.
483
No
immediate attempt at restoration of the urethra is warrantable, beyond
attaching the
two ends of the natural roof to each other and to the surrounding
fascia, if this is possible. The
perineal wound should always be left widely open, and if there is a
perineal hematoma this
should be opened by a median incision and the clots evacuated, even
though the bladder is
drained suprapubically.
Immediate
closure of a rectal tear may, however, be successful and this should
always be
attempted, using fine chromic catgut and protecting the suture line as
well as possible by
suturing the levator and across it. The propriety of immediate
colostomy may be considered.
After
infection has been controlled and the complete diagnosis made by
radiograph, and
if necessary, by cystography the urethral wound is attacked according
to the following
principles:
1.
An uncomplicated complete division of the posterior urethra may
sometimes be healed
by suprapubic cystotomy followed by suture of the urethra over a
catheter, any defects in the
urethral channel being pieced out by transplanted flaps of skin or
mucous membrane. If the loss
of tissue in the perineum is great this had better be filled in by a
skin flap swung over from an adjoining portion of the thigh. Otherwise
the dense perineal scar will obliterate the urethra.
2.
If there is considerable loss of tissue, after suprapubic drainage has
been established, a
graft of skin or mucous membrane is sutured in place between the
divided ends so as to form the
roof of the urethra. The wound is then packed and after a slow healing
and probably one or two
accessory plastic operations the urethra lumen may be reestablished.
3.
If complicated by a wound of the rectum a preliminary colostomy should
be done
rather early. This alone may be sufficient to cause healing of the
wound in the bowel, or it may
be necessary to freshen the cut edges and suture them or even bring the
bowel down to form a
new anus. Not until the rectal wound has been closed should any
attempts be made to close the
urethra. Thereafter the colostomy wound may be closed.
4.
Wounds of the prostatic urethra have usually been associated with so
great a loss of
tissue as to defy closure by operation.
WOUNDS OF THE BULBOUS URETHRA
Wounds
of the bulbous urethra like those of the posterior urethra, are usually
but a part of
grave injuries of the adjoining structures. The chief interest attached
to them relates to the
various plastic operations which may be performed for the restoration
of the urethra in the
perineum.
CASE RECORDS
In
detailing his experiences in France with wounds of the genitourinary
tract, as
consulting surgeon to a base center, Stevens5 cites the
following interesting case:
Case 25. Machine-gun bullet wound, the
entrance being in the left buttock and the exit in the right wall
of the scrotum. The patient had not tried to urinate. Nevertheless, it
seemed extraordinary that no swelling,
induration, or ecchymosis was present in the perineum.
484
The urethral lesion was
diagnosed by the patient's inability to urinate and the physician's
inability to pass a catheter. In its course the bullet had completely
divided the bulbous urethra,
and perforated an old right-sided hernia; this explained the presence
of a mass of omentum
protruding from the scrotal wall. The cord and testicle were uninjured.
Operation was performed
eight hours after the wound was received. The injured omentum was
excised and the hernia
repaired. Then, through a perineal incision, an end-to-end suture of
the urethra was done, and
perncial drainage established proximal to the suture line. The
subsequent course was entirely
satisfactory up to the fifth day, when the patient was evacuated to the
base.
Case
26. P. H. G., private, 23d Infantry. Wounded June 14, 1918, at 2 p. m.
Shell
fragment entered posterior aspect of right thigh, passed just posterior
to femur, exit wound being
on the inner aspect of the thigh close to the perineum. Projectile then
entered perineum, severed
the urethra close to the bulb, divided the left spermatic cord, and
tore its way out through the
abdominal wall in the left inguinal region without entering the
peritoneal cavity. Operation 10 p.
m., same date. De bridement of the thigh wound, left castration, and
suprapubic cystostomy.
Evacuated June 22, to Base Hospital No. 18, where, on June 23,
examination revealed a large
sloughing wound of hypergastric region involving the recti muscles;
suprapubic drainage wound;
wound of thigh; incisions in left groin, scrotum, and dorsal surface of
penis. Dakin's solution
applied continuously with frequent dressings. June 28, wounds were
cleaner and condition
better, but suddenly patient began to have clonic spasms, slight
strismus present, and his reflexes
were hyperactive. Diagnosis: Tetanus. Antitetanic serum, 20,000 units administered; general
condition, worse the next day. A lumbar puncture withdrew fluid under
tension. Patient received
antitetanic serum 10,000 units subcutaneously each day. On July 3 a
second lumbar puncture
was done and 20,000 units given intraspinally. Steady improvement now
began. July 6, external
urethrotomy, suprapubic tube removed. The good effect of dependent
drainage afforded by
external urethrotomy was soon demonstrated in the condition of all the
wounds. Several large
sloughings separated from the suprapubic wound and the thigh wound
filled in rapidly. Owing to
the fact that this hospital was functioning as an evacuation hospital
it was necessary to evacuate
on account of the exigencies of the service. Again seen June, 1919.
General condition excellent,
all wounds healed, perfect urinary control, urine passed entirely
through perineal fistula.
Case 27. W. B., sergeant, 30th
Infantry. Wounded by a rifle bullet, June 20, 1918.The missile entered
left
side of scrotum, severing urethra at penoscrotal junction, entering
inner aspect of left thigh and making its exit at
gluteal fold of left thigh. Patient reached Field Hospital No. 27,
where a paralysis of the left leg, retention of urine,
and inability to pass catheter were noted. Suprapubic cystotomy was
done and patient evacuated. At Evacuation
Hospital No. 7 it was impossible to introduce a catheter (either
anterior or retrograde). Admitted to Base Hospital
No. 18 June 23, where thigh wounds were opened and pus
evacuated-Dakin's solution. Found impossible to pass
catheter. July 8, external urethrotomy and operative attempt made to
approximate torn ends of the urethra. Tube was
placed in bladder through perineal wound and suprapubic tube removed.
July 13,catheter was passed through meatus
up into the perineal wound where it was introduced into the bladder;
perineal wound closed over it; small protective
drain to take care of any leakage. July 20, catheter withdrawn but
subsequently had to be reintroduced. August 10,
necessary to evacuate the patient; all wounds granulating well, patient
voiding, at normal intervals, clear uninfected
urine, No. 24 F sound could be introduced into the bladder
through
small perineal fistula present but rapidly closing.
Case
28. E. G., private, 39th Infantry. Wounded August 5, 1918, by
machine-gunmissile
which passed through left leg, upper inner portion of right thigh into
perineum, severing
membranous urethra and causing fracture of ischium and extravasation of
urine. Operation, Field
Hospital No. 19, wounds débrided, external urethrotomy with plastic
reconstruction of the
urethra, suprapubic cystotomy done. August 9, admitted to Base Hospital
No. 18; bladder was
draining well through suprapubic and perineal tubes; suture would of
perineum badly infected;
three stitches removed, pus evacuated. All wounds treated by continuous
Dakin's solution.
August 14, all wounds cleaner. Suprapubic tube
485
had been removed and all urine was
passed by perineal tube. It was planned to treat this case like
the preceding one, but in order to prepare for fresh convoys of
casualties it was necessary to
evacuate patient. This case illustrates the inadvisability of
attempting any plastic procedure for
the repair of the urethra at the first operation; resulting sear will
seriously hamper future
operative procedure for repair of urethra.
The
following case report has been taken from clinical records of members
of the
American Expeditionary Forces.3
Case
29. R. F. S., 105796, Company D, 2d Machine-Gun Battalion. Wounded
July18,
1918. Gunshot wound, entrance right buttock, exit left pubis,
perforation of urethra and fracture
of pubis. No record of operation, which was done in a French military
hospital. Complications:
Traumatic stricture of urethra and three urinary inguinal fistulae.
August 14, 1918, operation, A.
R. C., Military Hospital No. 1. Incision from wound in left groin to
perineum. Fracture of
superior ramus of pubis discovered. Evacuation of large abscess cavity
beneath pubis extending
to prostatic region of bladder. Urethra found completely severed in
front of prostate. Catheters
were inserted through penis into bladder and out suprapubic wound;
bladder irrigation; Carrel
tubes for other wounds. January 1,1919, impassable stricture. Perineal
urethrotomy; stricture
divided; suprapubic opening enlarged and opening into bladder through
sphincter determined;
rubber tube passed through perineal wound into bladder and suprapubic
wound closed. January
30, 1919, secondary hemorrhage, packing of perineal wound. September
27, 1919, demobilized,
30 percent disability, on account of traumatic stricture of urethra,
maximum improvement
attained.
FISTULA OF THE URETHRA
Urethroperineal
fistulae are usually irregular and embedded in dense scar. They may
heal
even after remaining open for months. If healing is despaired of, they
may be closed by a plastic
operation; but before this is attempted several specimens of tissue,
excised from the region of the
orifice of the fistula should be stained and examined for tuberculosis,
as a persistent perineal
fistula is often due to this disease. If acid-fast bacilli are found,
the treatment should be
conservative, consisting of a thorough curettage of the fistulous tract
with excision of all pockets
and followed by cauterization of the wound down to its urethra orifice.
This operation produces
surprisingly good results both in reducing the size and complications
of the stricture and in some
cases even closing it.
In
the absence of tuberculosis the following operation should be
performed: A sound
should be introduced into the urethra and the whole of the perineal
scar excised, the structured
urethra being dealt with according to the requirements of the case.
Drainage is procured by a
small tube introduced into the bladder through the suprapubic opening.
The perineal urethra is
then closed by fine chromic gut sutures, the perineal muscles carried
over this line of suture and
ample drainage left in the superficial tissues.
FISTULA OF THE PENILE URETHRA
A
fistula of the penile urethra, if small, may be encouraged to heal by
touching lightly
with the actual cautery.
If
the loss of tissue is considerable the urethra may best be closed by
the following
operation: 1. Drainage of the bladder by suprapubic tube. 2. The skin
or scar about the fistulous
orifice is divided at a point far enough away from this orifice to
permit a flap to be lifted and
turned in, so that the skin
486
surface will form the floor of the urethra.
This incision will usually have tobe made about 1 cm.
from the orifice. It is convenient to keep a sound in theurethra while
making it. The flaps may be
rectangular or the incision maybe an ovoidal one surrounding the
fistulous opening. In lifting up
the flap, great care should be taken not to puncture the underlying
urethral mucosa an to retain a
fair blood supply for the flap itself. The tissues will usually beso
thin about the edges of the
fistula that the flap can not be dissected upanrv nearer than about 0.5
cm. from its orifice. The
flap edges are then turnedin by one of two methods; viz, either the
edges themselves are sutured
togetherwith plain catgut or else the whole cuff or flap is caught up
in a purse-stringsuture, the
ends of which are drawn into the urethra through the fistula,
broughtout at the external meatus
and tied rather tightly over a small piece of gauzeacross the meatus.
If the latter procedure is
employed it is wise to insert a split tube of a few strands of silkworm
gut through the external
meatus intothe urethra to provide for the exit of the secretions which
accumulate in it.The
superficial skin and fascia are then dissected free in a lateral
direction halfway around the penis
on each side and brought together by mattress sutures of heavy catgut.
URETHRORECTAL FISTULA
This
condition results frequently from wounds by missiles, or from
abscessesinvolving
the prostate and posterior urethra.
The
escape of urine into the rectum and of gas and feces into the urethra
lead to great
discomfort. As a rule the condition is not associated with
in-continence of urine, but if the
internal sphincter has been injured urine mayflow constantly from the
bladder into the rectum,
and if the external sphincteris impaired incontinence of urine and
frequent escape of gas and
liquid fecesthrough the penile urethra may occur.
Not
infrequently a previous perineal operation upon the prostate, or the
incision of a
prostatic abscess through the rectum, may be responsible forthe
rectourethral fistula.
TREATMENT
When
it is discovered that the wound involves both the rectum and urethra,
its
spontaneous closure should be encouraged by providing suprapubic
drainageto divert the flow of
urine, and by dilating the sphincter ani widely to facilitate the
passage of feces.
No
attempt at primary closure of the rectal and urethral openings should
be
made unless,
in the removal of the missle, the rectal opening is small and the wound
conditions are such as to
justify attempt at primary closure.
During
the convalescence examination for urethral stricture should he made,
and if
present it should be dilated with filiforms, followers, and sounds,
controlled by finger in rectum.
In many cases, especially where
suprapubic drainage has been maintained,spontaneous closure
of the fistula occurs, but where this does not occur, after many weeks,
operation should usually be
undertaken.
487
OPERATION TO CLOSE FISTULA
The
many procedures which have been advocated attest to the great
difficulty which has
been encountered in curing urethrorectal fistulae. A method which has
shown almost invariable
success is as follows: 7
First,
suprapubic drainage of the bladder is established, with the patient in
dorsal posture.
The patient is then shifted to the exaggerated lithotomy position. A
racquet-shaped incision,
beginning in the midline of the perineum about 3 cm. anterior to the
anal margin, is carried
backward to this margin, and then encircles it at the mucocutaneous
junction. Through the circular part of this incision the mucosa of the
rectum is dissected free all round until a cylinder
of the membrane is stripped from its attachments well above the point
at which the rectal orifice
of the fistula opens, the fistulous tract being divided transversely in
this process. This dissection
of the bowel is carried upward until sufficient mucous membrane is
loosened to permit the pulling of the segment containing the fistulous
orifice well out of the anus. The orifice and a
small margin of normal mucosa above it, and all that below it, lying
outside of the skin level are
excised later. This procedure may be described as an exaggeration of
the Whitehead principle in
operating for hemorrhoids. The Young long urethral tractor is often
very useful in drawing down the prostate and in facilitating the
separation of rectum and prostate.
A
minor point of some practical importance consists in beginning the
dissection of the
mucosa at the posterior or dorsal part of the circle. By so doing, not
only is it easier to find
normal planes of cleavage here, where there is no scarring but also the
field is rendered less
obscure by hemorrhage than would be the case if the anterior side be
first attacked, as blood then
runs down over the posterior half of the anus.
The
structures of the perineal body are next divided through the straight
incision in the
midline (the handle of the racquet) so as to expose thoroughly the
urethral orifice of the fistula.
If the sphincter ani previously has been cut, the ends should be
dissected free from scar tissue. In
many cases the sphincter ani may be left intact, being pulled out of
the way with a retractor as
required. In some cases it may be advisable to divide it. The edges of
the urethral fistulous
opening then exposed are freshened and brought together with catgut
sutures over a sound which
has been previously passed through the urethra. These sutures do not
penetrate the surface of the
urethral mucous membrane. The levators, fascia, and smaller muscles are
then brought together by interrupted catgut sutures across the midline
of the perineum in several layers,
reconstructing the perineal body much as is done in gynecological
operations for relaxed vaginal
outlet. Finally, the sphincter ani, if it has been cut, is restored by
uniting its ends with a mattress
suture of catgut, and the midline incision is closed with interrupted
sutures. The last stage in the operation consists in the excision of
the protruding cuff of rectal mucosa in which the fistulous
opening lies, and the union of the lower end of the rectum to the anal
skin margin. This is done
by interrupted silk sutures after four submucous-subcutaneous sutures
of catgut have been placed
at quadrant points to help anchor the bowel in place.
488
It
will be seen that there are four essential principles in this
procedure. The first is the
protection of the repair from leakage and muscle spasm by diverting
urine from the urethra
through suprapubic drainage. The second principle is the complete
ablation of the damaged
portion of rectal wall and the reposition of perfectly sound mucosa
quite to the skin edge. The
third element in the operation is the closure of the urethral orifice;
and the final essential is the
interposition between rectum and urethra of a solidly built up perineal
body.
WOUNDS
OF THE EXTERNAL GENITALIA
Gunshot
wounds of the external genitalia occurred in the American Expeditionary
Forces
as follows: 2 Penis, 171; scrotum, 499; testicle, 237.
In
a series of 42 cases of injury to the penis, involving the penile
urethra or the penis
alone, rifle and machine-gun missiles were the cause of 27; shrapnel
and high-explosive shell,
14; indirect injury, 1. The entrance wound involved the penis in 29
instances; the thigh in 9;
buttock, 1; hip, 1; abdomen, 1. Secondary injuries numbered 20.
In
a series of 164 cases of injury to the scrotum and testicles,3 95 of
the wounds were due
to rifle or machine-gun missiles; 58 to shrapnel and high-explosive
shells; 5 to grenade
fragments; 2 to revolver missiles. In 83 cases of scrotal injury the
testicles were not involved, or
at least not sufficiently involved to require operative treatment.
There were 81 cases in which
injury to the testicles was recorded, necessitating a right
orchidectomy in 31 instances, a left
orchidectomy 23 times, and a bilateral orchidectomy twice. Among the 81
cases with testicular
injury, there were 10 deaths, but among the 83 cases in which the
scrotum was involved, 5
deaths occurred.
WOUNDS OF THE SCROTUM, TESTICLES, PENIS, AND
ANTERIOR URETHRA
Gunshot
wounds of the external genitals often involve both scrotum and penis,
producing
extensive laceration. The primary indications are the following: (1)
Control hemorrhage. (2)
Carefully excise all contused tissue so as to forestall infection. (3)
Do not remove a testicle
unless its blood supply is irreparably damaged. Even if the tunica
albuginea is split open the
wound edges in may be freshened and sutured with chromic catgut. (4) No
attempt should be
made at this time to replace the testicle in the scrotum. (5) A
catheter should be tied into the
urethra, both to prevent cicatrical contraction of its orifice and to
insure the patient against
retention of urine. If the urethra is completely divided this catheter
will issue from the wound
and a second section of catheter should be inserted into the anterior
portion of the urethra so as
to prevent cicatricial contraction of its cut end. (6) The penile wound
should be dressed wide
open. If the penis is partially divided, even though the slip of tissue
by which it adheres is
insignificant, every effort should he made to pre-serve the end of the
organ while dressing the
wound wide open and awaiting the opportunity for secondary plastic
operation.
489
RUPTURE AND TRAUMATIC STRICTURE OF THE URETHRA
Traumatic
stricture following wound or rupture of the urethra has the following
characteristics: (1) The gravest type of stricture may result from an
injury so slight as to cause
but little hematuria and no important disturbance of urination. (2)
Traumatic stricture usually
appears, and recurs after operation, with great rapidity. Stricture
resulting from even the slightest
injuries may contract so rapidly as to cause complete retention of
urine within a few weeks, and,
following simple external urethrotomy without resection of the urethra,
such a stricture may
recur and cause retention before the patient leaves the hospital.(3)
Traumatic stricture is usually
extremely resistant, rebellious to treatment by sounds and, as stated
above, to the simple forms
of operation.
PROPHYLACTIC TREATMENT
The
most important feature in the treatment of traumatic stricture is its
prophylaxis.
Wounds of the urethra that do not completely sever the canal are not
likely to result in severe
strictures, but all wounds severing the canal and all contusions or
ruptures of the urethra, be they
ever so slight, should be regarded with grave apprehension and serious
efforts made to prevent
the formation of residual traumatic strictures, as follows: The
indwelling catheter should not be
employed, since it only encourages infiltration and scar formation in
the wound. Stricture of the
prostatic urethra may be prevented by the bladder drainage which the
wound itself required.
Rupture of the membranous urethra (usually caused by the so-called
straddle injury) calls for
immediate perineal section and drainage with a large tube for three or
four days in order to estab-lish the lumen of the urethra and prevent
infiltration of urine and subsequent stricture. This rule
applies even to those cases whose only symptom is a slight urethral
hemorrhage. Perineal section
is likewise required to prevent stricture of the bulbous urethra. No
special measures need be
taken to prevent stricture following injuries to the pendulous urethra,
excepting the use of the
indwelling catheter in order to keep the cut ends from contracting
during the first week after
injury, and the frequent passage of sounds after reconstruction of the
canal. Stricture will surely
ensue, but it is readily controllable.
OPERATIVE TREATMENT
Stricture
of the prostatic urethra usually occurs at the bladder neck and may be
cured by
the use of Young's prostatic punch. If the stricture is so tight as not
to admit this instrument, it
may be attached by the suprapubic route, the pin-point urethral opening
being first divulsed and
then the whole floor of the urethra at the bladder neck being removed
by rongeur forceps,
scalpel, or scissors.
Traumatic
stricture of the bulbous or membranous urethra requires excision.
Through a
median or curved incision the perineal urethra is laid bare, and the
precise location of the
stricture identified by the passage of urethral instruments. The
stricture is then divided
longitudinally and one of three procedures follows:
490
(a)
If the scar is relatively narrow,
especially upon the roof of the canal, the urethra is resected
by Cator's method. The bulbous portion of the canal is freed for at
least 3 cm. from its
attachment to the corpora cavernosa. The scar tissue is split open on
the floor of the urethra in
the direction of the long axis of this canal and any dense masses of
scar tissue are excised. A
small sound is placed in the urethra as a guide and the gap in the
urethral wall is closed about
this by fine transverse chromic catgut sutures, beginning at the
lateral angles of the wound and
inserted alternately on each side, finishing at the median line. None
of these sutures is tied until
the last one has been inserted. Then a small puncture is made, upon a
staff, in the urethra behind
the suture line, and through this an 18 F soft rubber catheter is
introduced into the bladder for drainage. The sound is then
reintroduced and the sutures tied in the same order as they were
inserted. The mobilized urethra is thus drawn down into the perineum
and the urethral wound
tightly closed. The bulbo cavernosus muscle is now drawn across the
line of suture and the
dislocated bulbous urethra by a few catgut sutures, the anterior end of
the skin wound closed, but
a wide opening left in the superficial tissues about the catheter in
the perineum, so as to prevent
infiltration. The catheter is retained for 10 days. (b) If resection of
the roof of the urethra is
required, a transverse section of the urethra is excised, suprapubic
drainage established, the cut
edges of the urethra drawn together by a few fine chromic gut sutures,
and the urethral stumps
carefully supported by three or four heavier chromic sutures so as to
take the strain off the cut
edges. The deep tissues of the perineum are fully closed, but the
superficial tissues are drained. (c)
If the gap is so wide that no
reconstruction is possible, the scar is excised and the two cut
ends of the urethra brought out into the perineum for subsequent
reconstruction of the urethra. Traumatic strictures of the pendulous
urethra are controllable by internal urethrotomy. The
rapidity with which the stricture contracts makes the Maisoneuve
urethrotome the instrument of
choice.
REFERENCES
(1) Manual of Military Urology, including
Venereal Diseases, Skin Diseases and Wounds of the Genito-Urinary
Organs. Masson et Cie. Paris, 1919. (2d ed. Published for the American
Expeditionary Forces by the American Red
Cross.)
(2) Based on sick and wounded reports to the
Surgeon General.
(3) Clinical records, American Expeditionary
Forces. On file, A. G. O., World War Division, Medical Records
Section.
(4) Surgical reports made to the chief
consultant, surgical services, A. E. F. On file, Historical Division,
S. G. O.
(5)
Stevens, A. R.: Experiences in France with Surgery of the Genitourinary
Tract. Journal of the American Medical
Association, Chicago, 1919, lxxii, 1589.
(6) Colston, J. A. C.: Observations on
Gun-shot Wounds of the Urethra. Journal of Urology, Baltimore,
1920, iv,
185.
(7) Young, Hugh H., and Stone, Harvey B.: The
Operative Treatment of Urethro-Rectal Fistula (Presentation of a
Method of Radical Cure). Journal of Urology, Baltimore, 1917,
i, 289.
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