F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
371
rent, the danger of massive postoperative bleeding has been greatly reduced, and the
functional results regarding the elimination of the obstruction have been very satisfactory.
Other surgeons have confirmed the good results, amongst them Bors & Comarr, Walsh
and others. This procedure, which may be indicated in certain upper and lower motor
neurone lesions does not interfere with the sexual function as far as erections are con
cerned. It results, of course, in incontinence but this disturbance of the hydrodynamics
is, as a rule, less dangerous to the upper urinary tract than retention and stagnation of
urine.
(a) 2: Open operations
Surgical procedures by open operation to eliminate or reduce urethral resistance are
Young's (1953) Y-V plasty of the vesical neck which is mainly used in children, or the
perineal membranous urethroplasty introduced by Semans (1949, 1960). This latter
operation consists in freeing and transecting the membranous urethra and re-uniting
the prostatic apex with the pelvic diaphragm. However, any operation within the perineal
region of paraplegics and tetraplegics may facilitate the development of pressure sores
later and this method is not practised in this country as the method of choice in eliminat
ing urethral resistance in spinal paraplegics and tetraplegics. Although Bunts (1961)
considered membranous urethroplasty in 3 of 12 operated cases as a necessary adjunct
to trans-urethral resection, and in 5 cases a feasible alternative to transurethral resection,
in 4 patients transurethral resection became necessary afterwards. Moreover, urinary
infection remained in all patients.
(a) 3: Transurethral resection of the bladder neck
This operation, first introduced by Emmett (1945), has proved from all experiences to be
the most important surgical method in the treatment of urinary retention due to obstruc
tion at the vesico-urethral junction be it caused by hypertrophy of the bladder neck or
spasticity. At Stoke Mandeville this operation has been carried out successfully for many
years, and our results are in accordance with the experiences of many other surgeons in
both upper and lower motor lesions. Fig. 163 shows the result of TUR in a case of
complete lesion below T5 who, about 5 years after injury, developed a profound bladder
distension due to hypertrophy of the bladder neck. However, authors still differ as to
whether the resection should be done round the clock (Emmett, 1959) or not. Bors (1957);
Cosbie Ross (1960), Gibbon
et al.
(1965) favour limited resection, a view shared by Walsh.
Bors & Comarr (1971) resect the vesical neck in areas where tissue is prominent, usually
the posterior lip and the lateral folds. This means a resection from 3 through 9 o'clock.
Only if this fails is the resection of the anterior lip included. While the amount of resected
tissue has varied widely throughout the years, there has been a trend in recent years not
to resect more than 2-4 grammes. Baker
et al.
(1950) and Burns & Kettridge (1958)
extended the resection to the proximal margin of the external sphincter. The instrumental
technique of TUR varies. While Gibbon
et al.
(1965) employ the cold punch, probably the
majority of surgeons are using diathermy.
With regard to the time when TUR is indicated, there is also difference of opinion
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