(1) By denuding an oval space over the swelling and bringing the raw edges together.
(2) By Stoltz’s operation, which is really purse-string suture.
The instruments necessary are a bladder sound, two tenacula, sharp-pointed angular scissors, a needle-holder and fine silk.
(1) The parts are exposed with a Sims’s or Auvard’s speculum and a volsella, or silver wire is passed through the cervix, by means of which traction downwards and backwards may be exerted. The cystocele itself is fixed by tenacula, and, with the sound in the bladder, an oval incision is carried completely round the base of the cystocele. The whole area contained in this incision is denuded by knife or scissors, care being taken to avoid wounding the bladder mucous membrane.
Any bleeding having been controlled, a spiral buried suture, as in the operation for perineorrhaphy (see [p. 128]), is passed antero-posteriorly, thus reducing the size of the raw area and making a solid support in the median line. The raw edges are then brought together by sutures. The catheter should be passed every eight hours for three days, and then the patient should be allowed to micturate on her hands and knees.
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Fig. 45. Stoltz’s Operation for Cystocele. The oval surface has been
denuded and the circumferential suture passed but not tied.
1,1',2,3. The four points first selected as boundaries for denudation. s. Suture, the arrows denoting the direction in which it is passed. sp. Retractor. t. Tenaculum. u. Urethral orifice. |
(2) Stoltz’s operation. The instruments necessary are: a No. 8 male bladder sound; two tenacula; hooked forceps; sharp-pointed angular scissors, and a needle-holder (Schauta’s for preference).
The patient is placed in the lithotomy position and the parts are exposed by means of an Auvard’s speculum. A silver wire or tenaculum is passed through the posterior lip of the cervix, by means of which downward and backward traction may be exerted. Four points must be selected: two lateral (Fig. 45, 1, 1'), fixing the external boundaries of the surface to be denuded; one immediately behind the orifice of the urethra (2); and a fourth in front of the cervix (3). These four points should be capable of close approximation. They are carefully joined by curved incisions so that the area to be denuded is almost oval in shape. The bladder sound is now passed, and the mucous membrane of the vagina kept on the stretch by pressure on its point. The process of denudation should be carried out with a scalpel or pointed curved scissors. It will be found that bleeding rarely gives any trouble. The point of the needle threaded with silk is inserted on the operator’s right side of the urethral orifice and a little below it; it pierces the mucous membrane on the left side of the median line, and again appears upon the surface. By an in-and-out stitch all the way round the circle which has been pared, the point finally issues on the operator’s left side of the urethra and below it: by traction on these two ends the edges of the denuded surface are drawn together and the prolapsed bladder is sutured in its normal situation. A puckered cicatrix results. This method is valuable for prolapsus uteri when combined with the operation of posterior colporrhaphy.