When the pain and frequency of uri nation become unbearable and fail to respond to treatment, it will be necessary to perform suprapubic cystotomy for the purpose of drainage; at the same time it may be possible to remove it, if super ficial, by means of a curette. The rest afforded by prolonged drainage of the bladder is one of the most potent factors in aiding to bring about a cure. It is always a difficult matter to decide when the suprapubic opening may be allowed to close in cases that progress favorably. In general, this should not be until the evidences of cystitis have disappeared.
Epispadias.
Epispadias, or absence of the roof of the urethra, is occasionally met with. It may be either complete or partial. The partial variety shows absence of the roof of a portion of the urethra. In the complete variety the entire roof of the urethra is absent and there is also exstrophy or absence of the an terior wall of the bladder and the over lying portions of the abdominal wall; so that the mucous membrane of the pos terior wall of the bladder presents in the hypogastric region. In the latter condi tion there is, of course, complete inconti nence of urine.
Treatment. — In the partial forms of epispadias of sufficient extent to demand relief it is proper to advise closure of the defect by operation. If there is plenty of material the edges may be freshened and brought together over a catheter by means of sutures. If this method is not available, a flap may be taken from the anterior abdominal wall and turned downward to form the new roof of the urethra.
Thiersch's operation is performed in four stages. The first is the formation of that portion of the canal which nor mally is situated in the glans. An in cision is made on either side of the me dian furrow through about three-fourths of the thickness of the glans. The central portion is depressed, while the two lateral portions are freshened and brought together over a short piece of catheter or rubber tubing.
The second stage is the formation of the remainder of the roof of the urethra. For this purpose two flaps are made from the integument on the dorsum of the penis. In length these flaps correspond to the amount of the defect in the ure thra. The base of one flap corresponds to the margin of the urethral groove, while the free edges of the other flap cor respond to the opposite margin of the groove. A catheter is now introduced
into the bladder and made to lie in the urethral groove. The flap with its base next to the catheter is turned over the latter so that its raw surface is outward, while the free edge is held by transfix sutures armed with a needle at either end which transfix the base of the sec ond flap. The latter is intended to cover over the raw surfaces presented by in verting the first.
The third step aims to close the small space between the two previous opera tions. For this purpose the prepuce is incised transversely and the glans slipped through this incision. The Margins of the defect are next freshened, the pre puce made to cover this, and the raw edges sutured to close the opening.
Fourth step: This consists in the closure of the space which still exists be tween the posterior portion of the new urethra and the orifice leading to the bladder. For this purpose a triangular flap is made, the base of which is placed to the left of the normal urethral orifice. This flap is inverted so that the raw sur face is uppermost. A second quadri lateral flap with its base in the inguinal region is made to cover the inverted first flap, and the wound closed by sutures.
A sufficient period of time should be allowed between each of these steps for perfect healing.
Method of treating epispadias which has personally given good result. The operation consists in refreshing the edges of the penile furrow, extending it till the abdominal parietes are reached, then ex cising two parallel strips of skin corre sponding in size to the freshened penile portion. Bringing the penis on the ab domen, the denuded portions come in con tact, and the penis is sutured in place, the penile furrow being converted into a urethra running from below upward. A second act, at a later period, consists in dissecting the penis out of its new bed, and with it a strip of skin of the proper size continuous with the glans and di vided in the direction of the umbilicus. This flap is now turned down and the two raw surfaces united to each other. Rosen berger (Belt. z. klin. Chin, B. 15, H. 3, p. 735).
The method of operating for ex strophy of the bladder is described under that heading.