Perineal Urethrostomy

Perineal Urethrostomy (from French boutonniere—loop, boutonniere), an operation for creating a fistula in the urethra on the perineum (synonyms: perineal drainage of the bladder, or cystostomia perinealis). In modern urology, this operation is used only where it is necessary to create a permanent fistula in the urethra to allow urine to drain, i.e., in cases of extensive strictures or obstructions of the urethra and so on. Previously, this method was widely used for extracting stones from the bladder and draining it, for diverting urine, during plastic operations on the urethra in its pendulous part, etc. The patient is placed on the table with the pelvis elevated; the legs, bent at the knee and hip joints, are brought to the abdomen and held in this position to strongly protrude the perineum. An incision, 3-7 cm long, is made strictly along the midline and does not extend 1-3 cm to the anus. Where it is possible to introduce any metal instrument (bougie, itinerarium) into the urethra and protrude the perineal part of the urethra with it, orientation to the urethra is very easy. The layered incision of tissues proceeds in the following order: skin and connective tissue, raphe of the anus (raphe sphincteris ani), transverse muscle of the perineum (m. transversus perinei), bulbocavernosus muscle (m. bulbo-cavernosus), and finally, the bulbous part of the urethra, which is pulled somewhat upward, making it possible to bring the membranous part of the urethra out into the wound. The latter is incised longitudinally for a length of 3-4 cm, and the edges of the urethral wound are sutured with silk threads to the skin wound. A thick catheter or drain is inserted into the bladder and fixed with an uncut thread from one of the nearest sutures. The catheter remains in the bladder until the urethral incision heals to the skin wound. The main task of the perineal urethrostomy operation is to create the fistula as close as possible to the anal opening so that during urination, urine does not spray the scrotum and does not cause eczema. On the other hand, the opening must be wide enough for free passage of urine.