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1948; Freeman, 1949; Cosbie Ross, 1960; and others). Suprapubic cystostomy as a
temporary measure is indicated only if a spinal cord injury is associated with direct injury
to the urethra or if the first urethral catheterization reveals a marked urethral stricture
which cannot easily be overcome. In later stages, suprapubic cystostomy may be indicated
in a case of urinary fistula which cannot be healed by conservative or surgical treatment.
The sooner suprapubic drainage is discontinued the better the prospect of checking
urinary infection and restoring a good capacity and satisfactory control of the bladder.
While we succeeded after the war, in a case of incomplete transverse lesion below Tio
with suprapubic cystostomy of 5 years and 4 months standing (Fig. 162), in establishing
a satisfactory bladder function with good capacity as shown in Fig. 162, this represents
an exception. In the great majority, we were able to discontinue suprapubic drainage with
in a year. While we did not experience major complications following spontaneous
closure of the suprapubic sinus, apart from repeated break down, serious complications
due to intraperitoneal extravasation including fatal peritonitis have been reported (Pate &
Bunts, 1948; Reite & Comarr, 1954; Bunts, 1958).
In cases in which suprapubic drainage has been continued for long periods, healing
of the suprapubic wound is always delayed, and even if the tract has been excised surgic
ally it still has a tendency to break down, even, as we found, after many years. Based on
personal experimental studies on catgut as an undesirable suture material for nerve
sutures (Guttmann, 1943), better healing results after excision of the suprapubic track
were obtained by using stainless steel wire, a procedure which has also been adopted
for surgical closure of urethral fistulas.
In conclusion, the view expressed by Ogier Ward & Riches (1944) that, in cases of
complete transverse lesion of the spinal cord, a properly conducted cystostomy opening
is infinitely preferable to an automatic bladder, and their strong recommendation that
suprapubic drainage should continue in such cases, has not been confirmed by the
experience gained in this Centre and by other workers in this field. Actually, the view
held that suprapubic cystostomy as an immediate or early treatment of the paralysed
bladder is only indicated in very exceptional cases, as mentioned above, is now generally
accepted in this country and abroad.
Cutaneous vesicostomy
In recent years, suprapubic drainage as early urological management of paraplegic
patients has been revived in the form of the tubeless or what is called, cutaneous vesi
costomy in the U.S.A. by Blocksom (1957), Lapides
el al.
(1960, 1962,1964), Arduino &
Miller (1960), Felton & Read (1960), Leal, Scributis & Lloyd (1963), Bernstein-Hahn
(1965), Rosenthal
et al.
(1967) and others. However, strong criticisms have been made
by American and other physicians and surgeons, in particular those with extensive
experience in paraplegia (Bors, Comarr, Ebel, Habib, Susset, Talbot, 1963; Guttmann &
Frankel, 1966; Gibbon
et al.,
1969; Cibeira, 1970; Bors & Comarr, 1971). Comarr, in
particular, has dissociated himself immediately fromLapides' statement that 'if the bladder
does not come around within 2 weeks after injury this is the indication to do it'. It may
be noted that Lloyd, who himself was in favour of cutaneous vesicostomy instead of the
