A far simpler method, perhaps the simplest of all, is that of Sonnenburg, which consists in extirpation of the bladder proper, with plastic closure of the opening, while the ureters are carefully separated and sutured into the upper portion of the urethral gutter. This removes all urinary cavity and provides only for continuous escape; but this latter is now provided in an accessible and convenient place, while the wearing of a urinal permits the achievement of the main purpose of the operation. Sterson operates upon young girls by suturing the loosened ureters to the labia minora, which are then sewed together in the median line, after which a urinal can be worn.[68]
[68] Cantwell has suggested the following method for bladder exstrophy, namely, to pass catheters through a perineal fistula up into the ureters, then to dissect off the bladder wall, bringing it over a small rubber balloon, pushing the whole into position, and uniting the abdominal wall in front.
It has occurred to many operators to more completely divert the urinary stream by displacing the ureters and turning them into the rectum or the sigmoid. Operations for this purpose have been described especially by Maydl ([Fig. 650]), and by Moynihan, while modifications have been suggested by many others. In practically all of these procedures catheters are first passed into the ureters for their identification and control. Some would dissect out the trigone with both ureters, and, making a sufficiently large opening in the rectum, would transplant it in its entirety within that cavity, closing the opening. Moynihan improved on this by making a vertical incision and entirely dissecting away the bladder, separating it also from the prostate, thus completely isolating it. Then the portion containing the ureters is held upward, while at the bottom of the wound the rectum can either be seen or made visible. The peritoneal reflection is then lifted upward from the front of the rectum, which is opened along its anterior surface by an incision perhaps three inches in length. Into this opening the bladder is placed, being so reflected that its former anterior surface now looks posteriorly. The ureters, instead of passing forward, now pass backward and the catheters contained within them are passed into the rectum and out of the anus. The edge of the bladder and the cut edges of the rectum are carefully sutured, after which the abdominal wound is closed. The sphincter is then stretched, while the catheters remain in the ureters for four or five days.
Fig. 650
Maydl’s operation; diversion of ureters into rectum. (Hartmann.)
A choice may be made, then, between some such method as that last described or that of Peters, who dissects out the ureters, retaining only a small circular patch of bladder wall, which is folded around the orifice of each, the rest of the bladder being extirpated. Each ureter, with its button of bladder wall, is then drawn through a small slip in the rectal wall, made large enough to admit it, and the end of the ureter is then left hanging for 1 or 2 Cm. into the rectum. It would probably be better to hold the ureters in place by a stitch rather than run the risk of their retraction; but care must be taken that these stitches make no unnecessary constriction. Others have substituted the sigmoid for the rectum, the procedure being otherwise the same, all of these rectal implantations having for their purpose the utilization of the rectum as a cavity, which may not only contain urine, but retain it reasonably under control. In many respects they would be ideal were it not for the attendant dangers. These are (1) those immediately connected with an operation which is serious, and (2) those connected with secondary infection of the kidneys, which seems to occur in almost all cases, no matter how apparently successful at first.
INJURIES TO THE BLADDER.
Injuries to the bladder proper may be accompanied by those of the parts without, or may be isolated. They divide themselves mainly into ruptures and lacerations, or penetrations directly connecting with the exterior. Among the causes which predispose to rupture and other injuries may be mentioned intoxication, partly because it is often accompanied by overdistention, and partly because of the partial or incomplete insensibility of the patient. Distention, no matter how permitted, is an important predisposing cause. The injuries usually include blows, falls, and crushes, and gunshot or other perforations.
The location of the rent is more commonly in the upper and posterior portion of the bladder—i. e., in its weakest part. Such tears may vary from one-half to four inches in length. When accompanying fracture of the pelvis the peritoneum is more likely to be injured.