Ashhurst reviews all the 20 cases of eversion of the bladder that had been so far treated by operation, 14 of which by Ayres, Holmes, Wood, Maury and Barker were successful, 3 by IIolmes and Wood failures, and 3 by Richard, Pancoast and Wood with fatal terminations. In 2 of the last cases the fatal result is said to have been unconnected with the opera tion.
But all these operations with inverted flaps are liable to the disadvan tage that the hairy growth will lead to continual deposits of salts. For this reason, and because injury to the peritoneum is very possible between the recti muscles, and the flaps when of large size readily mortify, Thiersch has abandoned this method. He proposed to cover the orifice with sim ple side flaps. Each flap is to be large enough to cover the entire opening in the fresh state. The inner margin of the lower flap follows the inner margin of the rectus muscle closely above, and is accurately attached to the margin of the bladder. The outer border is parallel to it, and goes down to or beyond Poupart's ligament. This entire band of tissue is attached above and below, but is entirely free underneath.
To secure the necessary amount of blood, the sheath of the rectus, the tendons of the external oblique and the fascia lata, must be denuded. The flaps may then be allowed to granulate in situ, or a plate of ivory or glass may be placed under the flaps, to keep the granulations short and healthy. After three weeks the upper connection of the flap is to be cut diagonally from below and within to above and outwards; the whole is then turned over the lower part of the bladder, the opposite edge of that organ is freshened to the symphysis, and stitched to the edge of the flap. The somewhat shrunken flap now covers the lower two-thirds of the bladder. In all his six cases Thiersch, only then fixed his flaps over the bladder, and brought the surface of the wound into per manent contact with the urine, where stationary granulation had set in in the flap. When the union of this lower flap is complete, he proceeds' to close the upper part of the bladder. The second flap is taken from the other side, stretches from the inner incision to the point of origin of the lower flap; and the external incision is not carried so deeply as in the first case. At the same time the skin to the width of to 1 inch is t,o be carefully loosened from the recti muscles at the upper margin of the bladder, to get a granulating surface, which, like the granu lations of the flap, must be kept from becoming exuberant. In 3 to 4 weeks the upper end of the flap is to be divided as described, and the flap turned square over the bladder. Its lower margin is then in contact with the upper margin of the first flap; its freshened end is sewn to a freshened place in the skin lying opposite to it, its granulating surface covers the upper portion of the vesical mucous membrane, but also projects beyond it over the granulating surface which was formed at the upper margin of the bladder. Then, after freely freshening them again, the contiguous edges of both flaps are united by deep and superficial sutures. Hence forward the urine can only flow below, and a short silver catheter should be introduced.
In the male subject the plastic treatment of glans and scrotum takes twelve weeks more, so that Thiersch takes a whole year to completely close the male bladder. Then by using a compressorium to the glans the patient can retain urine to the amount of six ounces. Thiersch lays special stress upon the importance of making the flaps as long and broad as possible, since he found that the capacity of the bladder increased the less resistance there was from the anterior wall. The compressorium must therefore have a hollow, concave capsule attached to it, to permit the anterior bladder wall to dilate.
In girls Thiersch's operation may be done more simply and in shorter time. Although even when the closure of the bladder is almost com plete, continence cannot well be attained, since it is impossible to supply a sphincter, yet slight pressure with an instrument will in time e,ause a certain dilatation of the bladder under urinary pressure. That alone is of great benefit to the patient. She can keep herself dry, does not always smell of urine, does not get sore, does not sunr continual pain from the irrit,ation of the mucous membrane—advantages which would certainly decide most of these patients to submit to an operation which does not in itself involve any danger.
Vogt's attempt ' to construct an entire bladder of mucous membrane, by loosening it at its attachment to the anterior abdominal wall, uniting its edges, and then covering it with a flap of skin, was not successful.
Billroth's method is simpler than that of Thiersch. He loosens two broad flaps, leaving them attached above and below, and in 10 to 14 days, when the under surface is granulating freely, unites them in the middle line. If the flaps are broad enough, no lateral stitches are needed; the side openings closing of themselves in 5 to 6 weeks. The bladder is thus completely covered, but a small fistula is left at the navel, through which the urine is passed until the urethra is completely closed below. The fistula then heals spontaneously, or is closed by freshening and sutures.
In two of the rare cases of epispadia, which have been above described, the patients were cured by K. SchrOder operatively, so that they could retain their urine four hours. In the case figured by Frommel, the whole surface freshened was of the shape of an equilateral triangle, the apex being at the mons veneris, and the sides running down to the lateral halves of the clitoris. From these latter points the line of denudation ran to the lateral borders of the urethral opening. The skin was dis sected from the triangle; and to make a urethra a small ne3dle was passed from below the urethral opening into the wound, and then carried out on the other side of the urethra from the freshened surface to near the edge of the wound. Four such stitches formed a urethra to inch long in addition to what was already there. While the sutures were being applied a metallic catheter lay in the urethra. Then the two sides of the triangle were united by superficial and deep sutures. The wound healed per primam. From the beginning the patient could pass her urine spon. taneously; catheterism was not necessary, and she got well.