Bigelow’s lithotrites, catheters, and evacuator.

This is suprapubic cystotomy or epicystostomy, according to the purpose for which it is intended. It serves not only for removal of calculi but for extirpation of tumors, or enlarged prostates, and perhaps for permanent drainage. By the silk loops at first introduced the bladder wall may be attached to the abdominal wound, while other stitches may be added to any desired extent. In most instances it is desirable to reduce the opening, for which purpose buried and superficial sutures may be used. As leakage, however, may produce infection it is customary either to provide for drainage by insertion of a catheter through the urethra, or by the implacement of a small tube, whose lower extremity shall reach the base of the bladder and serve for drainage, which latter may be made more effective by siphonage.

PERINEAL LITHOTOMY.

Perineal section for exploration, drainage, or stricture is practically accomplished as follows: The patient is first placed in the so-called lithotomy position, i. e., upon the back with the limbs flexed and knees parted, the feet or legs being held either by assistants or in suitable leg holders upon the operating table. This is the position in which nearly all perineal operations in both sexes are made.

A grooved staff, with large curve and long beak, is introduced into the bladder, and not only held in the vertical position by an assistant, but in such a manner as to make its curve bulge the perineum as much as possible toward the operator. The rectum, which should have been previously thoroughly cleaned, may be utilized for identification or for necessary assistance during the operation. The scrotum is held up out of the way by the assistant who holds the staff. The perineum being thus put upon the stretch may be most quickly opened by a straight, sharp-pointed bistoury, which is inserted a little posteriorly to the scrotal junction, its point driven through the tissues and made to engage in the groove of the staff, from which it should not escape until finally withdrawn. As the instrument is pushed backward the handle is depressed; a triangular-shaped opening is thereby effected, whose apex is in the membranous urethra and whose base occupies the raphé of the perineum, to the extent of perhaps one and a half inches. The entire incision may be made with one effort. Its effect is to open the membranous urethra. Into the groove of the staff, the knife being withdrawn, may be introduced either a species of grooved director or the finger-nail of the index finger, which may be passed backward and made to enter the prostatic urethra, while at the same time the staff is withdrawn. If the prostatic urethra be constricted it will be difficult to enter the bladder with the finger, otherwise it will readily yield to pressure, and it is thus possible to enter the bladder within a few seconds after the first incision is begun ([Fig. 655]).

It is preferable in all these cases to have first washed out the bladder, and then to have filled it with a mild antiseptic solution. This will escape instantly an outlet is made from below. If there is a small calculus within the bladder the effect of the stream will be to carry it toward this outlet, where it is identified by the finger.

The prostatic urethra will bear a considerable amount of gradual dilatation, which will make it more than easily accommodate an ordinary finger. In this way a sufficient channel is made, through which forceps may be introduced and calculi of small or medium size withdrawn. They should be seized as carefully as possible within the proper grasp of these instruments, so that a minimum of laceration may be effected as they are extracted. A small calculus will be easily removed; a large and soft one may crumble in consequence of the pressure made upon it during its extraction. In this event the fragments should be separately removed, the bladder then repeatedly washed out, and the finger finally used to make sure that no particles remain.

Whether one stone or several be present the opportunities for the purpose of their extraction afforded by this median operation are the same. The bladder having been emptied and washed out a self-retaining drainage tube, or a hard rubber or metal perineal tube should be inserted, with such gauze packing around it as may be necessary for its retention and for the checking of hemorrhage. The intent of the tube is a double one, it being intended to serve for easy drainage and for gentle pressure. Sometimes the prostate is more or less torn in the process of dilatation, and in this case will bleed more freely than is comfortable. Such oozing may be checked by plugging gauze around the drainage tube.

Lateral lithotomy may be combined with median section, by deliberately passing a blunt bistoury into the prostatic urethra, and making with it an incision in the prostatic substance, the cut being directed toward a point midway between the anus and the ischiatic tuberosity, and carried to a depth of one-half or three-quarters of an inch. This affords a much larger opening through which to remove larger calculi. Obviously it will bleed more freely and will usually require packing. The old lateral method was to begin the external incision at a point, in the middle line, a little behind the scrotum, and direct it for one and a half or two inches backward and outward to a point between the tuberosity and the anus. The incision was then deepened through the perineal fascia until the index finger-nail of the left hand could identify the staff within the urethra, after which the urethra was opened at this point (i. e., just behind the bulb), when the knife was again introduced and made to divide the prostate obliquely as above. In this way the membranous urethra and lateral aspect of the prostate were divided to the requisite depth. If such incision be extended too far backward and outward the internal pudic artery might be divided, which would at least be awkward and necessitate ligature, and this would be somewhat difficult because it would require further division of tissues.

Fig. 655