FUKUYAMA, KENSHIRO

HARADA, NAOHIKO

IWADE, TIZUKO

NARIKAWA, YASUO

ODA KAZUO

SANO, NOBUO

SAWADA, SOZO

TSUDA, TOSHINOBU

Kyoto University Research Information Repository

TitleNEW SURGICAL APPROACH TO THE URETHRA :SUPRA-AND ANTE-PUBIC URTHROTOMYAuthor(s)HARADA, NAOHIKO; SANO, NOBUO; SAWADA, SOZO;NARIKAWA, YASUO; TSUDA, TOSHINOBU; IWADE,TIZUKO; FUKUYAMA, KENSHIRO; ODA KAZUOCitation日本外科宝函 (1957), 26(5): 767-774Issue Date1957-09-01URL http://hdl.handle.net/2433/206406RightType Departmental Bulletin PaperTextversionpublisherKyoto University臨床NEW SURGICAL APPROACH TO THE URETHRA: SUPRA-AND ANTE-PUBIC URTHROTOMY NAOHIKO HARADA, NoBuo SANO, Sozo SAWADA, YAsuo N ARIKA w A, TosHINOBU TsuDA, T1zuKo I w ADE, KENSHIRO FuKUY AMA and KAzuo OoA Department of Surgery, Osaka City University Medical School (Director : Prof. Dr. YAE:11os SmRAHA) 767 The correction of urethral obturation which is caused by・ urolithiasis,injur色sand inflammation is directed toward removal of the obstruction and re-establishment of the continuity of the urethra. The simplest procedure which can fulfil these objectives is a insertion of an urethral catheter. But, generally, a catheter can not be passed easily in cases of deformed male urethra. In such a case, one has to incise both the suprapubic region and the perineum. A catheter is passed through the external orifice of the urethra toward its lesion, and if, after exposure of the lesion, the catheter can be directed into the proximal segment of the urethra and on in加the bladder, only this is necessary・ (Figg. 1 & 2). However, it is often impnssible 句 findthe proximal segment of the urethra, and in such instances a catheter has 句 bepassed retrograde into the posterior urethra to the lesion transvesically through a suprapubic incision. When the two ends of the urethra have been identi-fied, the two catheters are connected (Fig. 3), and the catheter in distal portion from the lesion is drawn into the bladder. By this procedure, it is inconvenient that 2 teams of operators, that is, a suprapubic-and a perineal・team,work simul-taneously. However, it is often necessary to use this procedure in practice. Therefore, if a urethral catheter can be passed through by・ only one incision, its practical value would be enormous. Recently, we have devised a new surgical approach to the urethra named supra” and ante-pubic urethrotomy (Figg. 4, 5, & 6). We wish to describe in details the technique of this operation and our clinical experiences in this paper. 1. AN ANATOMICAL ILLUSTRATION OF THE TECHNIQUE Posterior half of the urethra is generally’apt to be a百ectedby various causes (Fig. 1). An obturation of this portion has been ordinarily handled bγ 加ththe external and the suprapubic transvesical urethrotomy. However, we have .devised a procedure of aces・ to the urethra by’the supra-and ante-pubic approach (Fig. 4, 768 l- 1~外科宝V.r~ ~白川巻第 5 ~｝ 5, & 6) ・The approach needs only a suprapubic incision, and has the油 meadvantage th~t has been forrr it lお rema1、kablethat the approach combined with the ト；ymphysectom.¥・ i日capab1 eto present a wider field for operation, even though the posterior urethra ma,¥・ he deformed seriously. But the approach is not recommended for lesions in the short urethra of the female (Fig. 7). 2. OPI<~RATIVE TECHNIQUE 1) Position of the patient ：ふ itis unnec弘首ryto inci問 the perineum and to divide the operators into two teams, the patient is placed in an ordinal Trende・lenburε’s position (Fig. 8). 2) Anesthesia : The spinal anesthesia is recommend and sufficient. 3) Incision：λlong suprapubic mid line incision is made and extended clown-ward to the caudal, passing over the anterior surface of the pubic 冷・m1】h,¥・sis,round the root of the penis, and reaches the midpoint of the scrotum at the median raphe. The penile suspensory Iiεament should not he incised carefully (Fig. 9.) 4) Dissection of the Bladder : The incision is carried out serialy through the skin, subcutaneous tissue, the fascia of the rectus muscle, and the muscle itself. Then the location of the peritoneal reflection is recognized and this is displaced upward (Fig. 10). Thus the superior wall of the bladder i8 exposed, and is incised sharply. As the bladder is usually expanded with large quantity of stagnated mine at the time of urethral obturation, dissection of the bladder is easy t,o practise. When the urine is sucked up through the bladder opening, the patient is apt to feel well being and his general condition is recovered immediately (Fig. 11). 5) Observation of the Urethra and its Lesion : Inside of the bladder, especially the trigone, should beρbserved carefully. In case of urethral obturation, the ureters demonstrate a strong peristalsis, and the urine springs from their orific邸 :;tctively,and the internal urethral orifice is extremely expanded. 人 catheter is then inserted into the urethra retrogradely, until it arrives at the affected area. This will incli-cate the orientation of tbe injured portion. 6) Ex卯sureof the Urethra : a) The anterior Urethra : The area between the spennatic cord and the l淀川lesupcnsor.¥・ ligament is developed lη・ blunt dissection, until the bulb of urethra is ex卯sec!in the field at the root of the median raphe. The resistance of the urethral catheter can he palpated along the anterior urethra in both cor卯racavernosum. b) The Posterior l!rethra : The posterior urethra is so di百icultof acce鉛because of its anatomical situation that either トザmphysectom.¥・or symphyseotom，＼・iメ・necessan・ to reach the a古田te!area. The 町・mphysishas 4 feet (Fig. 12). The cutting lines of these 4 feet must加 placed白earthe medial side in order to di町田ta portion as samll as possible. The penile suspensor.＼’ligament, puboprostatic ligament, and levator 'ani muscle need not to be cut, when the resection is subperiostally applicated. But, when two inferior feet which run lateropo日teriorly,are cut o汀，SUPRA-AND ANTE-PUBIC URTHROTOMY 769 the fibres of the levator ani muscle are sometimes severed. Cares should be taken to denude the inner layer of the priost in order to prevent the side-injuries. After the periostal denudation of the pubic bone, symphysectomy is easily done with a saw, and the posterior urethra can be demonstrated under direct vision in the space where the可mphysishad been situated (Figg. 13 & 14). It is preferable that the resected S：＇＼・mphJ叫日 isput back and fixed with suture in the original place after the completion of intrapelvic procedures. However, its defect would never cause such complications as deformity of the pelvis, disturbance of gait or impossibility’ of erection of the penis. If the resected bone is abandoned, the attached point of these ligamenb弓has旬 beanchored with silk suture at both the inner and the outer layer of the remnant periost, in order加 increaseits strength and to promote regeneration of the bone from it. 7) Removal of the Obturating Agent : After the obturated lesion of the ur-ethra is exposed, the obturating agent is removed by urethrotomy or b：＇＼’ urethrectomy. 8) Reconstruction of the Continuity of the Urethra : The catheter which is inserted in the urethra retrogradely is connected with another one normogradeLy inserted at the lesion where the obturating agent has been found, and the catheter is pulled into the bladder in such a manner that the retrograde catheter would be utilized as a guiding catheter (Fig. 15). A metal sound for the catheter is convenient as a guide. 9) Closure : The urethra is sutured with fine silk and the wound of the abdominal wall is also closed. The bladder and the antepubic space are drained after this procedure. One of the authors (Sawada) devised an e百ectfuldrainage. Namely, the urethral catheter is drawn out through the suprapubic fistula and several holes are made on the side wall of its intravesical portion. Then both ends of the catheter are connected with a suction. This looped drainage is convenient to prevent an accidental falling (Fig. 16). 10) Postoperative Treatment : The urine must not be laid 卯olin the baldder. If the suction is effective, the sutured wound will be dry and clean. The loop-drain should be left in situ more than 3 week日 1x>stoperatively,but the antepubic drain can be drawn out earlier. 3. CASE REPORT 1) K. :¥I., age 61, Japanese male; The patient has been complaining of a urinar~· obturation, and admitted to our hospital, on August 24, 1956. He had SU百erectfrom gonorrheal urethritis 40 years ago. For the last 20 years, he has been treated frequent！γfor dysuria and a sense of suprapubic expansion by external urethrostomies. For 2 da~·s, he could not micturate urine on account of the urethr-al stenosis. Clinical Findings: The suprapubic region was expanded extremely, and the urethra complete！~’ obturated at the point of 6 cm from the glans. The ventral side of the penis had a hard cicatrical induration. The urethra was not palpated, 770 日本外科宝間第26巻第5号but a urethral stone wa日 palpated.。i-ieration: The bladder ＂’as opened with a suprapubic incision, and about 900 cc of urine was sucked up through the opening. 人目oundwa:-: inserted retrograde-ly from the internal urethral orifice to demonstrate the urethral stone (Fig. 17). Then a supra-and ante-pubic urethrotom.＇’ which is reported b.＇’ the authors in the paper was performed. Thus the stone in the urethra was taken out and a urethral catheter was inserted for the I・e-establishmentof the injured urethra. About 110 <la.＇’日 wa日necesar.'・ postoperatively to close the urethra. Discussion : This case had a stone with a stenosis in the urethra as a result of the former operation. Csually, in routine, surgeon prefers to an external urethra-tom.'・ in such a case. But the thick cicatrical tissue made the authors give up to take an ordinary procedure, and selected our new technique in the area where there wa日 noscar. 2) H. G., age 28, Japane刈 male; The patient had been complaining of a stenosis of the urethra, and was admitted to our hospital, on February 11, 1955. He had a trauma at the perineum and was submitted to external urethrotomy 10 years ago. After the first operation, a fine urethroperineal fistula was built and could not be closed with dyspareunia and leakage of urine. Since then he had been operated 7 times and his urine was not clear. 。inicalFinding日： Thepatient had a wide cicatrical surface on the abdomen, perineum, and penis shaft. The urethra had a stricture at the membranous portion and his bladder was extremely expanded. Operation : The abdominal skin and fascia was incised. The tissue of the lesion had been changed into a thick scar and adhered to the可mphysis.We could expose the pubis with much e百ort, an【lcut o町 thepubic bone, demonstrating a retropubic periurethral abscess due to the injury on the posterior urethra (Fig. 18). The ahsce州 wascleaned, and pla日t≫ of the urethra was performed. A catheter was passed through the full length of the urethra with a guide-catheter. The bladder was close〔l. ,¥ drainage catheter was left in the Retzius' space. Af旬r60 days following the operation, the patient was recovered completely. Discussion : External urethrotomy and sectio alta are not preferable in such a case as there is a retropubic periurethral abscess. But one could find the abscess 同・日.＇・mphysectomy. It was another convenient advantage that we could get a wider operating白klin the retropubicぉpaceIJy this approach with s.'・mphysec加my.C'Ol"¥（‘LUSIO.l¥ The authors give a report on the details of their new operative technique for deformed urethra, named supra- and ante-pubic urethrotom.'', and its clinical application on a few cases, discu出ingib『日pecialadvantages. REFERENCES 1 J Baird, S. S.: Urethrectomy subsequent to total cystectomy. J. Urol., 74; 621: 1955. 2) Comarr, A. E. : An ~djunct in the manage-ment of the peno呂crotalabscess. J. Urol., 74; 818: 1955. SUPRA-A'.¥JD A:¥TE-PFBH‘URTHROTO:'IIY Fig・. 2. A catheter can be directed into the proximal se宮mentof the urethra. Fig-. 5. Supra-and ante-pubic approach to the urethra. Fig・, 6. Supra and ante-pubic approach to the urethra. 771 772 111~1ト手、γ友f者 ;,r¥・_2；，とE沼5§・ Fig. 7. Female・日 shorturethra. 一 一＿）~＿／「－－ eノ一二土可て三ラ戸rr--/ . .－－－，：；－~ .~－－－· ノFig. 8. Trendelcnbuq.（行 position.、同町乞Fig. 9. A long suprapubic 111idlinc’ incision is made. ， Fig・. 10. The peritoneal reflection i ~ displaced upv.’ard. F'ig. 11. The superior wall of the bladder is incised sharply. SUPRA-A父J)A:¥'fF.-PじBICUHTHROT<J:¥IY 773 Fig・. 12. The symphsis has ・Ifeet. Fig. 13. The posterior urethra can be demonstrated under direct visi-on in the space where the symphysis was situated Fig・. 14. Symphysectumy is easily 《loneand the po日leriorurethra can be clemonstratecl. Fig. 15. The normogra<le catheter is pulled into the bladder in such a manner that the retrograde catheter would be utilized as a guide-one. Fig. 16. The both ends of the catheter are connected with a suction. This looped drainage is convenient to prevent an accidental falling. 774 iJ ,j.：外利’iよ山 第26巻 第HJ・Fig・. 17. An urethral stone was demon~lrated. Fig・. 18. A retropubic periurethral abscess clue to the injury on the posterior urethra was disco¥・ered. 手口文抄録恥骨上恥骨前尿道切開術大阪I".lL；大学医＇.j：創」外科ψ教室（王'.f：白羽弥右衛門教授j原因 直彦・佐野信雄・沢田蘇応三・成川 康夫津田 利信 ・岩出千鶴子・福山川四郎・小田 和夫従来，以i旦によjすら外科的進入路としてはp 外尿道 おいてはp すべての{9!jにおいてP 1つの手術野で手術切開術p 続尿道進路， 耳［骨後五進路，ならびに経路脱 今遂行することができる利点があり，さらに，必要に的進路の4者があった.cくに尿道の変形が甚しい症 応じてはp 手術野中に露出している恥J骨縫合を切除す例においてはp 経勝統的進人路とP 外尿道切開術との るここによってP 後部！ポ道のすべてをi直視下に露出す，合併術式が多く用いられてきた．しかしP この術式 るここ もでさる．bこは，術者・を 2分しなけれはならない欠点がある． 私達は，この付。I式の詳細と，その臨床応用例とを こ最近，私達はp 耳；己骨前から尿道に達する術式をと’辛 こに報告した．しP Jf［.，骨」これ骨前尿道切開休？と名づけた．このtf;j式に

恥骨上恥骨前尿道切開術

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恥骨上恥骨前尿道切開術

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