In cases where there has been difficulty in removing a large stone through the supra-pubic incision, much damage to the bladder from ineffectual attempts to extract might have been averted by making, in addition, an incision as for median cystotomy, by which the position of the stone could be altered with the finger from the perineal wound, while the forceps were applied through the supra-pubic opening.
Supra-pubic cystotomy has proved of much value in the treatment of stones where the operator was of opinion that they were too large for removal by crushing or in any other way. It is impossible to define by measurements what is meant by a very large stone. The term must be regarded somewhat as a relative one, in which the ex perience of the operator, the state of the urethra, the size of the pros tate, and the condition of the bladder have to be taken into consider ation. An ounce-and-a-half stone, for instance, complicated with an obstructive prostate, might, in the opinion of the operator, require a supra-pubic opening; whereas, if it had not been so complicated, a calculus twice this size, or even larger, could be dealt with by crushing. Again, the probable composition of the stone, whether a hard or a soft one, will influence the decision of the surgeon. In the same manner a conclusion may be arrived at in the case of male chil dren; the size and nature of the calculus, coupled with the practi tioner's own experience in these operations, will determine whether crushing or cutting should be undertaken.
Sacculated stones, or the possibility of such a condition, would point to the selection of the high operation. Mr. Vincent Jackson '" reports an apt illustration bearing upon this point, where supra pubic lithotomy was successfully performed for the removal of a litMe-acid calculus, weighing over fifty grains, which was fixed in a sacculus at the base of the bladder. Removal had previously been attempted by perineal lithotomy.
Where stone in the bladder is complicated with an enlarged pros tate, and the patient is more or less dependent on the catheter by reason of atony, there are good grounds for the selection of supra pubic cystotomy. By this means not only may the stone as well as the obstruction be removed, but the function of the bladder may be re stored. It is in cases of this kind, where the patient is, or becomes, absolutely dependent on the use of the catheter after lithotrity, that cal culous recurrence so frequently takes place. There can be no doubt that a complete power of contraction and evacuation is an important consideration in the selection of lithotrity. When performing supra pubic cystotomy it is well to see that the external meatus of the ure thra is not unnaturally limited, and if this is the case it should be di vided. I have known an instance where such an obstruction retarded
the healing of the supra-pubic incision, in the same way that an urethral stricture does, and where before the wound healed it was necessary to divide the meatus with some freedom.
Instances are occasionally met with where, for some reason, the supra-pubic opening does not close as rapidly as could be desired, and a more or less troublesome fistula results. It may merely be a case of delay, where healing can be promoted by the use of nitrate of silver, the wire of the cautery, or even the simple expedient, if the hole is a small one, of requiring the patient to exercise firm pressure over it with the finger each time urine is voluntarily passed. The retention of a soft catheter in the urethra for a few days, or the fre quent passing of a catheter, are also expedients which have proved successful. In two instances where the fistula looked as if it were going to be permanent I passed a grooved staff into the bladder, punctured the membranous urethra, and put a drainage-tube into the bladder. By incontinently and continuously draining the urine in this way for some days, the fistula healed, as did subsequently the perineal puncture on the withdrawal of the drainage-tube. This plan has also been adopted as a primary pai:t of the operation for supra pubic cystotomy. The drainage thus provided has enabled the sur geon to close the anterior wound by superficial and deep sutures, and primary union has in this way been obtained.
The supra-pubic operation has been used in cases of stone in women with advantage, and also in both sexes for the removal of some calculi, formed on such irregular foreign bodies as hair-pins and wires which have been introduced into the urethra. Under the latter circumstances, lithotrity would be out of the question, as such attempts to extract, after breaking down the phosphatic mass covering the bodies, have been attended with serious and fatal consequences. By a supra-pubic incision less difficulty and risk may be anticipated, as should it be necessary the nucleus may be divided by a pair of cutting pliers or bone-forceps. The bladder can in women be kept moderately distended with water by the pressure of a finger on the line of the urethra until it is opened from the front. The high opera tion has been utilized for plastic operations, as in the case of some varieties of vesico-vaginal fistulae.
The scar left after supra-pubic cystotomy sometimes causes in convenience and spasms by preventing the bladder contracting down as the contents of the viscus escape. Where the scar tissue is very thick and hard the annoyance is sometimes considerable, but in other cases matters gradually adapt themselves.