The author, having to treat a boy, nine years of age, in whom the urethra opened in the peri neum, without a vestige of a urethra throughout the penis, while the imperforate glans penis was bound down to the perineum, adopted with success the following operative method : I. A thread was passed through the glans penis to control the glans and facilitate traction upon it ; then the fraenum bind ing down the glans was cut across by an incision which was carried through the skin entirely around the penis, not too close to the corona, the prepuce on the dorsum being thus divided by the circular sweep. The tip of a finger, inserted into the gaping wound in the concavity of the penis, felt for any bands which still bound it down, and these, as felt, were divided with suc cessive cuts with scissors, which were freely used until the penis was quite released and could be drawn out straight. There was then a great length of raw surface exposed between the opening of the urethra in the perineum and the glans, along which the median sulcus between the corpora cavernosa was deepened by further careful dissection and the removal of the remains of the longitudinal fibrous bands already divided.
II. The glans was then perforated by a tenotomy knife thrust through its substance close to the under surface; by incising freely towards the dorsum a capacious channel through the substance of the glans was constructed.
III. Two longitudinal incisions through the skin of the penis Iii. Two longitudinal incisions through the skin of the penis were then made, one on each side of the raw surface, running about one-third of an inch, or less, from its margin, starting near to the perineal opening of the urethra, and carried forward, al ways parallel to the cut margin, over to the dorsum of the penis till they met (Fig. 1, E, E'). By this incision a strip of prepuce was marked out which surrounded the penis in a manner closely resembling a clergyman's stole. This strip of skin was loosened from its connections everywhere except at its extremities, and the free loop was slipped over the end of the penis ; it was then manipulated so that the cutaneous surfaces were apposed and the raw surfaces turned outward. Forceps, passed through the chan nel in the glans, then seized the loop and pulled it through; the redundant portion of the loop was then cut off, and the two lateral portions of the new urethra were fixed in position by stitches at the meatus.
IV. The skin-flaps to cover in the raw surfaces behind the corona and along the under surface of the body of the organ were then adjusted and sutured. On the dorsum the procedure was as simple as in circumcision ; on the under surface of the body, the presenting edges of the turned-in strip, E, E', which formed the walls of the new urethra, were included in the sutures, each suture thus traversed four cutaneous edges. (Fig. 2.) The sutures did not fully pierce the edges of the new urethral strips, but caught them on the raw surface close to the edge, so that the edges of the urethral strips were somewhat inverted as the sutures were tied. The deeper edges of the new urethral strips were adjusted in the mesial sulcus between the corpora cavernosa and did not require any suturing. At the spot where the perineal urethra became continuous with the new penile urethra a pucker ing caused a nipple-like projection of the skin, which was snipped off with scissors. The sutures having been tied, a narrow bandage of iodoform gauze was wound round the organ and left undis turbed for several days. No rod of any kind was placed in the new urethra thus formed.
V. A suprapubic cystotomy was then done, and after the insertion of a drain to carry off the urine, the closure of the perineal opening was proceeded with. The author advises, how ever, that this final step be deferred until after sound healing of the penile wounds has been secured. He thinks that, although success finally crowned his own effort, it would have been more easily and certainly secured if he had made the operation in two stages, separated by an appreciable interval.
The closure of the perineal fistula was the most difficult part of the whole procedure. He found it necessary to define accurately the ridge marking the union of the urethral mucosa with the skin of the perineum ; the separation between the two at that point was accomplished by cutting off the crest of this ridge all the way round with a delicate pair of scissors. The edges of the urethra now fell naturally together when the thighs were approxi mated, and did not need to be sutured. The skin of the perineum was undercut slightly and approximated by a few sutures. After a fortnight, the suprapubic drain was dispensed with. The ulti mate result was highly satisfactory. British Medical Journal, November 17, 1900.