RAILROADING

Refer the patient if you can.

INDICATIONS (1) A severely displaced prostate immediately after the injury. (2) Failure to pass urine after 3 weeks of conservative treatment with suprapubic catheter’drainage. (3) increasing residual urine after attempted conservative treatment.

INVESTIGATIONS If possible, do an ascending urethrogram, and a micturating cystourethrogram. Use the suprapubic tube to get the contrast medium into the patient’s bladder. Fill his bladder as full as you can, and then get him to pass urine as a film is taken.

ANAESTHESIA Give him a general anaesthetic with a relaxant, and lie him supine. Have blood cross–matched.

USING CATHETERS FOR RAILROADING

Lubricate the patient’s urethra and try to pass a 16 or 18 Ch soft rubber catheter. If this passes immediately after the injury, your diagnosis was at fault. Remove it at once but leave the suprapubic catheter in for the full 3 weeks.

If a Foley catheter fails to enter his bladder, make a lower midline incision to expose and open his bladder with a suprapubic cystotomy as in Section 68.2. Make a fairly large vertical incision in his bladder. An opening of a reasonable size will make the procedure much easier. The catheter will present in his pelvis through the torn lower end of his urethra. If necessary, use ‘finger dissection’ deep in his retropubic space. Finding it may not be easy, and there may be a lot of clot to be swept away. Pass another larger 24 Ch catheter down through his bladder, into his internal urinary meatus and then through into his retropubic space. Bring it out into the wound. Remove its tip and eyes and push the end of the Foley catheter into it. If necessary, suture them together. Try to make a smooth join that will cause the minimum of trauma. Then pull the Foley catheter into his bladder.

If (in late cases) the Foley catheter fails to pass into his retropubic space, because there is too much fibrosis, you will have to use sounds.

USING SOUNDS FOR RAILROADING

EQUIPMENT Two curved metal sounds, apiece of rubber or plastic tube that will fit tightly over one of them, as in A, Fig. 68-5, and will not come off when you draw it through the patient’s uretha. A 20 Ch silicone latex Foley catheter.

SOUNDING If a rubber catheter does not pass, gently try to pass a curved Lister’s sound. If this does not pass, find where it is held up; see under difficulties’ below.

If all is well the sound should pass easily into the patient’s retropubic space. Pass another sound down through his bladder. You should feel a metallic ’clink’ as the sounds touch (B). If you don’t, mobilize the apex of his prostate a bit more and try to feel the ends of the two sounds in the wound. Or, ask your assistant to put his finger in the rectum and feel the ends of the two sounds.

Keeping the two sounds in contact with one another, use the upper one to guide the lower one into the bladder (C). Fix the piece of tube to the tip of the lower sound (D), and use it to draw this tube down through his urethra.

Alternatively, pass your finger through his prostatic urethra, try to feel the sound and guide it into his bladder, as in H, Fig. 68-5.

Stitch the tip of a Foley catheter snugly to the tube and use this to pull the catheter up into the patient’s bladder (E). If the tube and the catheter do not fit snugly, the join will further injure his urethra as it passes through.

WHEN THE FOLEY CATHETER IS IN PLACE stitch a stout monofilament suture to its tip, and bring this out through the patient’s abdominal wall (F).

Blow up the balloon of the Foley catheter, and close the patient’s bladder as usual (23.7). Keep the monofilament suture long, roll it round a swab and fix it to his abdominal wall. If the balloon bursts, you can use it to railroad another Foley catheter into place without doing a second laparotomy.

Send the patient back to the ward with the catheter on continuous drainage. If there was a tendency for the bladder to ’ride high’ far from the pelvic diaphragm, tie the distal end of the catheter (perhaps its side tube) with a long string to a 20 ml specimen bottle full of water. Lead this over the end of his bed; it will exert just enough traction to keep his prostate in place (G).

CAUTION! (1) Keep the balloon blown up. (2) Don’t exert too much traction, or you will pull the balloon out of the patient’s bladder into his retropubic space, or cause the base of his bladder to necrose. Most surgeons don’t exert any traction if the bladder doesn’t ’ride high’.

Keep up this gentle traction for 3 weeks. Then remove the catheter, and see if he can pass urine.

As soon as possible, bougie him with a large Lister bougie. Repeat it after 3 weeks, then 4, then 5 weeks until he is stable. He will certainly have a difficult stricture, so follow him up for life.

Alternatively insert a second Foley suprapubically, and drain his bladder through this. A Foley catheter which is exerting traction is not ideal for draining the bladder at the same time.

DIFFICULTIES WITH URETHRAL INJURIES

If the SOUND IS HELD UP IN THE PATIENT’S PERINEUM, cut down on its tip, as for external urethrotomy (23.9), and continue as for this operation.

If the SOUND IS HELD UP AT HiS PERINEAL MEMBRANE, remove it, and do a laparotomy as for Freyer’s prostatectomy (23.17), but with a lower midline abdominal incision. Open his retropubic space right down to his perineal membrane. Use the index fingers of both your hands to open up this space. Then open up his bladder as for Freyer’s prostatectomy. Find his internal meatus. You may be able to guide a Foley catheter past the obstruction into his bladder. If you fail, reintroduce the urethral sound, and pass another one down through his bladder and his internal urinary meatus as in B, Fig. 68-5.