Operations for this condition may be divided into palliative and radical—i. e., those which are intended to make it more tolerable and those which are really entitled to the latter term. Thus if only the exposed mucous surface can be covered with a skin covering, the condition may be mitigated since a urinal or some device may be worn by which its worst features may be controlled. Trendelenburg has recently called attention to the fact that a wide separation of the pubic arch not only weakens the pelvis, but constitutes a serious difficulty in closing the defect. He has, therefore, combined direct operation with separation of the pelvic bones at the sacro-iliac joints, afterward enclosing the pelvis in a comprehensive bandage, or suspending the patient in an apparatus in such fashion that the bony defect in front shall be narrowed, if indeed it be not completely obviated. This, of course, is a measure to be carried out in the early years of childhood; in connection with it the bones may even be wired at the symphysis. In fact immediately after the birth of such an infant the attempt should be made to narrow the pelvis, by surrounding that part of the body with a wide rubber band, which shall influence growth without too much interfering with nutrition. Later subcutaneous osteotomy may be done if necessary. At all events, the growing pelvis should be surrounded with an enclosure by which a constant influence may be maintained.
The various plastic operations for this defect have the common purpose of affording a covering, which must unfortunately be without a sphincter to guard the outlet of the cavity. The best that can be accomplished, then, by plastic methods is the formation of a more perfect cavity without affording sphincteric control. A theoretically ideal method would be one which should permit raising of skin flaps around the margin of the defect, and so turning them in that the skin should vicariate as mucous membrane. These flaps when united, and the anterior wall when thus formed, could be covered by other flaps or by skin grafts; but from these flaps hairs will grow into the bladder. These will become encrusted with urinary salts and an amount of irritation be produced which may become not only intolerable but locally destructive.
In the selection of any plastic method much will depend on the size of the defect and its completeness, the condition of the surrounding wall, and varying complications in the surrounding structures. The general method above suggested will answer especially for the smaller exstrophies. Beck has suggested an excellent device, namely, the dissection from the pubes of the recti muscles, their insertions being severed, and the partial division of the transversalis fascia until the muscles are so mobilized that they can be reflected and united, thus forming an anterior bladder covering. By a second operation these partially formed flaps may be again dissected off from the wall and a complete osteoplastic covering afforded. Practically no operation for extroversion can be completed in one sitting. Frequently repeated efforts have to be made, a little being accomplished at a time. One of the greatest difficulties met with is securing primary union along surfaces more or less bathed or in contact with escaping urine. These flaps, even if united, may separate in a few days as a result of this urinary maceration. Against this there is but little possible provision, save perhaps by catheterizing both ureters, and emptying them into a distinct receptacle.
Fig. 648
Roux’s autoplastic method of raising a perineoscrotal flap with which to cover the defect. Lines of incision. (Hartmann.)
Fig. 649
Roux’s autoplastic method of raising a perineoscrotal flap and its fixation. (Hartmann.)
More complicated methods of furnishing a complete cavity have been devised by Rutkowski and Mikulicz, both of whom have suggested to use a small loop of small intestine wherewith to complete the bladder cavity. In each of these methods the abdomen is opened, a loop of bowel brought down, a small portion completely separated by double division, end-to-end anastomosis of the main part being then made, while the separated part is in one method closed at one end, while the other end is fitted over the exposed bladder surfaces as a sort of cap. The method is exceedingly complicated and hazardous, and depends for local success upon a sufficient blood supply to the intestinal loop, which should be carefully ensured by caring for its vessels and mesentery. It has, nevertheless, been successful.