Cutting for the stone: A historical perspective on the rectovesical approach

Louis Joseph Sanson (1790-1841) was perhaps the brightest of Dupuytren’s (1777-1835) pupils and succeeded him after his death in 1835. At the age of only 27, he devised a new method for the extraction of stones from the bladder by “rectovesical incision”.

He described it in the most famous of his many works: “Des moyens de parvenir à la vessie par le rectum, etc.” (“Means of reaching the bladder through the rectum”) and carried out quite successfully a certain number of lithotomies by his new method at the Hôtel-Dieu.

Berlinghieri’s blessing The new and rather revolutionary approach was blessed and practised by some Italian surgeons among whom the most important was Andrea Vaccà Berlinghieri (1772-1826). Berlinghieri was the founder of the School of Surgery of Pisa, who modified, improved, perfected and advocated the approach in three essays: “Nemoria sopra il metodo di estrarre la pietra dalla vescica orinaria per la via dell’intestino retto” (Essay on the method for the extraction of the stone from the urinary bladder via rectum) (Pisa, 1821); “Memoria seconda, etc.” (Second essay, etc,) (Pisa, 1822) and “Memoria terza sul taglio retto-vescicale, etc.” (Third essay on the rectovesical incision) (Pisa, 1823).

Scarpa’s essay In 1823 Antonio Scarpa (1752-1832) entered into a heated debate with Vaccà Berlinghieri, by writing and publishing “Saggio di osservazioni sul taglio retto-vescicale per l’etrazione della pietra dalla vescica orinaria” (“An essay of observations about the rectovesical approach for the extraction of stones from the urinary bladder”). He dedicated it to his Swiss friend Théodore Maunoir (1806-1869), who had asked him: “Does the rectovesical approach still have supporters in Italy? How has it been improved? What is your opinion?”

A dedicatory letter comes first and contains a brief summary of the whole “Essay”. Scarpa opposed the rectovesical approach rather violently for many more or less well-grounded reasons. In his opinion it could not avoid a lot of drawbacks:

1. The operated patients generally “led a really wretched life for a rather long time making dreg urine and urinous faeces”;
2. Although this disaster could be warded off, oftentimes the surgeon could nonetheless not avoid “lopping off sometimes the left, sometimes the right seminal duct that are joined with the corresponding deferent ducts and seminal vesicles”;
3. The bridles of the scar that forms after the lancing of either the tip of the prostate or one side of the verumontanum may divert the fistulized orifice of the common seminal duct so that, in spite of being still open and wide, it does not correspond any more to the inlet of the urethra” as the case of a “thirty years old man…proves”.

After the extraction of a bladder stone by rectovesical approach “he observed that on the one hand he was prevented from ejaculating…; on the other hand the sperm flowed like a dribble from the urethral orifice after each sexual intercourse…In addition he also observed that he did no more enjoy the pleasure of the orgasm that generally precedes and follows ejaculation”.The post-mortem of this patient revealed “a scar at the tip of the verumontanum, whose bridles had diverted the natural orifices of the common seminal ducts from their right path so that they were turned towards the neck of the bladder instead of going straight towards the urethral orifice”.

Scarpa summarises the content of the whole dedicatory letter and concludes rather venomously; “I think that whenever one carries out research and most of all, whenever one suggests the introduction of innovations in the field of surgery, one should have the good idea of considering and mulling in advance over the precept ‘should what we are doing not be useful?”.

The full version of this article and references are published in the May-June 2012 issue of EUT>