Special Surgical Procedures II
LESSON 3: Procedures in Genitourinary Surgery
Section Iv: operations on the bladder and prostate
3-22
Section IV. OPERATIONS ON THE BLADDER AND PROSTATE
3-22. OPEN OPERATIONS ON THE BLADDER
a. General. The urinary bladder may be opened to remedy acute retention; relieve obstruction and distention; control hemorrhage; remove stones, tumors, or foreign bodies; or repair congenital or traumatic defects. Other radical procedures are performed to treat cancer. Total cystectomy requires permanent urinary diversion.
b. Definitions.
(1) Cystotomy. A procedure in which the bladder is cut open.
(2) Cystolithotomy. A procedure in which the bladder is opened to remove stones.
(3) Cystostomy. A procedure in which an opening is made into the bladder for continuous drainage.
(4) Cystectomy (total). A procedure in which the bladder and adjacent structures are excised.
c. Patient Preparation.
(1) To facilitate identification and dissection, the bladder is usually drained of urine and filled with a sterile irrigating or antiseptic solution as a part of the preoperative preparation. Equipment and instruments for catheterization and irrigation should be prepared, in addition to the surgical setup. Irrigating solutions should be sterile, isotonic, and at body temperature.
(2) The patient lies in the supine position for most open operations of the bladder. The Trendelenburg position may be desired, since it tilts the pelvis high and offers good visualization of the pelvic organs, including the bladder. The patient may be draped with a nonabsorbent disposable skin drape and a fenestrated laparotomy sheet.
d. Sterile System for Bladder Irrigation.
(1) Each hospital has its own system for bladder irrigation. Suitable solutions should be specified by the surgeon.
(2) The system may consist of prepackaged irrigating solutions and sterile sets of connecting tubing, or it may be a flask, rubber tubing, and connector set such as the Valentine irrigator, which is prepared and sterilized by the operating room personnel as part of the instrument setup. With the Cotter system, the irrigating fluids are usually mixed and poured by the operating room personnel. Sterile pitchers or other containers for mixing and pouring will then be needed.
e. Operative Procedure (Suprapubic Cystotomy and Cystostomy).
(1) The bladder is distended preoperatively with the prescribed irrigating solution instilled via catheter. A vertical or transverse suprapubic incision is made through the skin and subcutaneous layers to the muscle using a scalpel, thumb forceps, and scissors. Bleeding vessels are controlled with hemostats and ligated. Wound towels and retractors are placed. The rectus muscle is incised or split by blunt dissection and retracted. The prevesical fat and peritoneum are retracted upward with Deaver retractors.
(2) The top of the bladder is dissected free, using thumb forceps and Metzenbaum scissors. The wall of the bladder is grasped on either side of the midline with Allis forceps. Two traction sutures of number 0 chromic gut may be placed through the bladder wall and held with straight Halsted hemostats. The muscle of the bladder is spread by blunt dissection with the tip of a clamp or scissors until the mucosa is seen. Two Allis clamps are placed, and the bladder is
incised with a sharp blade. At this point the distended bladder may be emptied via the urethral catheter, which is unclamped under the drapes by the circulating member of the team, or a suction tube may be introduced through the stab wound to remove the fluid as the bladder mucosa is incised.
(3) The bladder opening is extended with scissors. Bladder retractors are placed, and the bladder is explored for diverticula, calculi, or tumor. Removal of the pathological area or other corrective procedure is carried out and wound closure begun. A Malecot catheter may be used to drain the bladder suprapubically and a Foley retention catheter to drain through the urethra. The prevesical space may be drained with Penrose tubing.
(4) The bladder is sutured in two layers. A continuous suture of catgut is used on the mucosa and interrupted stitches of chromic catgut on the muscle layer. The abdominal muscle fascia and subcutaneous tissue are closed with catgut. Tension sutures of nylon or silver wire may be needed for some patients. A suture is placed around the cystostomy tube and affixed to the skin. The skin may be closed with silk or stainless steel wire.
(5) The wound is dressed with bulky dressings. The wound and cystostomy tube are held in place by adhesive tape strips.
