F • CLINICAL ASPECTS OF SPINAL CORD INJURIES
365
use of a permanent suprapubic mushroom catheter in the
occasional
case only when such
form of bladder drainage becomes necessary, made his view abundantly clear: 'to do
frequent and routine cutaneous vesicostomy early in the course of paraplegia is inexcus
able'. Kyle (1968) calls cutaneous vesicostomy 'an unreasonably traumatic procedure,
hard to manage and necessitating the wearing of complex and expensive apparatus'.
Krahn
et al.
(1964) stated that all their 7 patients undergoing the Lapides' vesicostomy
were failures and required intubated drainage later. Laskowski & Brantley Scott (1965)
performed the Lapides' vesicostomy in 45 patients, 44 of them with spinal cord lesions,
who (i) were unable to empty the bladder effectively, (2) required prolonged tube
drainage and (3) had a poor prognosis for neurological recovery (no detailed information
was given about the meaning of this point). Although there were no deaths, wound
infection was the most common early postoperative complication (8 cases), the others
being necrosis of the distal part of the bladder flap (5), prolonged urinary leakage (2),
atelactasis (i), paralytic ileus (i). The most common late complications were: technical
difficulty with the collecting device (8 cases) encrustations of skin flap due to growing
hair (4), bladder calculi (4), tight stoma (3) renal calculi (2) and vesical eversion (i).
Moreover, squamous metaplasia was found in all 13 cases where biopsies were performed
and cystitis glandularis occurred in 2 patients. These tissue changes may, as is known,
lead later to carcinomatous development. Yet, incredible as it may seem, in spite of all
these results the authors consider the incidence of postoperative complications as
acceptable. Karafin & Kendall (1966) reported one death. These experiences clearly contra-
indicate Lapides' view (1964) to employ cutaneous vesicostomy as a 'standard treatment
in paraplegics within a week or two after injury'. This concept ignores so profoundly
the natural forces of physiological adjustment in the spinal cord including the return of
bladder function. This procedure represents a grave mistake and is a serious retrograde
step in the early management of paraplegics and tetraplegics as it adds a considerable local
damage to the bladder wall in addition to its neurogenic lesion. It would result in most,
if not all, of the unhappy consequences of tubed suprapubic cystostomy of 30 years ago
and would create a very serious situation, especially if this surgical procedure were
followed up by workers with little experience with the complex problem of paraplegia and
tetraplegia. In this connection, the quoted reports published by Krahn
et al.
and Las
kowski & Brantley Scott are highly significant. It is therefore, gratifying that this method
is rejected by urologists and other workers concerned with the treatment and rehabili
tation of paraplegics and tetraplegics, including those who unfortunately still adhere
to the method of urethral drainage by indwelling catheter as initial and early treat
ment of these patients because of lack of staff or other reasons, to carry out intermittent
catheterization.
Closed methods of suprapubic catheterization
The old technique using a trocar and canula for the introduction of a self-retaining
catheter of a larger size, has been generally abandoned, and during the Second World
War it was replaced by Riches' method of suprapubic catheterization (Riches, 1943),
employing a very small catheter (i6F) fixed to a trocar. Whatever closed technique is
