Skip to main content

Turner-Warwick Retractor

Turner-Warwick retractors are self-retaining ring-and-blade systems used for perineal exposure. Sontec catalogs 178- and 229-mm round frames and a 7 × 5-in oval frame with interchangeable blades; the selected frame and blades hold adjustable soft-tissue retraction without continuous handheld traction.[10]

The Turner-Warwick name also appears in staged urethroplasty for bulbar and membranous strictures; Reid reported outcomes in 60 patients treated with that operation.[2]

Design​

  • Frame. Circular metal ring that sits over the perineum, providing a stable platform for blade attachment.
  • Blades. Multiple interchangeable shapes and sizes (short and long, straight and curved, narrow and broad) clipped at any point along the ring with a tightening mechanism.
  • Self-retaining: blade tension is held by the clip, freeing surgical assistants from manual retraction.
  • Low profile. The ring sits close to the perineal skin so blades project into the field rather than the frame; minimizes interference with the surgeon's working space in the confined perineal corridor.
  • 360° positioning: blades can be placed at any clock position around the ring, so retraction can be tailored to the operative geometry and adjusted between phases of the case.
  • Material. Reusable metal components vary by set: Sontec lists a malleable copper blade in set 516-804. Check the component-specific reprocessing instructions before autoclaving.[11]

Reconstructive-Urology Uses​

The Turner-Warwick is purpose-built for the perineal urethral case and is most at home on the trays for:

  • Bulbar and membranous urethroplasty. Both single-stage (anastomotic, BMG ventral or dorsal onlay, augmentation) and multi-stage techniques, including the Turner-Warwick staged urethroplasty itself.[1][2][3]
  • Posterior urethroplasty. Perineal exposure for repair of pelvic-fracture urethral injuries or posterior urethral disruption (PFUI repair), including the trans-perineal approaches with progressive corporal separation, inferior pubectomy, and supracrural rerouting.
  • Perineal urethrostomy. Exposure of the bulb for the proximal anastomotic line of perineal urethrostomy and for late revision.
  • Perineal prostatectomy. Historical or occasional contemporary use.
  • Transperineal RUF repair. A perineal ring may support exposure when a transperineal approach, such as repair with gracilis interposition, is selected. York-Mason repair uses a separate posterior transsphincteric route.[8]
  • Trans-perineal complex BNC or VUAS reconstruction. Perineal reanastomosis after radical prostatectomy with severe BNC, perineal salvage exposures.
  • Open VVF and RVF repair via perineal approach. When the trans-perineal field is the chosen route.
  • Vaginal-cuff and post-radical-cystectomy salvage perineal exposures.

Why the Ring Design Works for Perineal Surgery​

The perineum is a narrow corridor bounded by the thighs laterally and the scrotum or vulva anteriorly. Handheld retraction in this field demands one or two assistants, and any movement by the assistant translates directly into a moving operative field. The Turner-Warwick's ring-and-blade architecture solves this:

  • Stable circumferential platform. The ring does not move once positioned and locked.
  • Per-blade tension control. Each blade applies tension independently; the surgeon adjusts the side that needs more exposure without compromising the rest of the field.
  • 360° re-positioning. During a posterior urethroplasty, the operative target shifts from the distal bulb to the proximal stump to the apex; ring-based retractors let the surgeon re-position blades clock-position by clock-position rather than re-prepping.
  • Frees the assistant's hands for suction, ties, traction or handing instruments, which is meaningful in lengthy reconstructive cases.[4][6]

Comparison to Adjacent Self-Retaining Systems​

RetractorFrameBlade attachmentBest fit
Turner-WarwickCircular metal ringMultiple clipped blades, 360°Perineal urethroplasty (BUS / membranous / posterior), perineal RUF
Perineal Bookwalter (Jordan)Ring + post / table-mountMultiple clipped blades, table-attachedPosterior urethroplasty
Lone StarDisposable plastic ringElastic stays with hook anchorsUrethroplasty, hypospadias, perineal, vaginal, anal — soft tissue traction without metal-blade pressure
Joshi-KulkarniSelf-retaining clampTissue compression at the penile basePenile urethroplasty[4]
Bookwalter (abdominal)Large ring + postMultiple bladesAbdominal / pelvic open RU work; designed for abdominal and retroperitoneal exposure, where a 4,000-application review reported large-bowel injury (4 cases) and one femoral neuropathy with blade tightening[7]

The Turner-Warwick is the dedicated perineal ring retractor, purpose-built for the geometry of the perineal urethroplasty case in a way no general-purpose abdominal retractor is.

Technique​

  • Positioning. Use procedure-appropriate lithotomy with pressure points protected. Standard lithotomy is routine for bulbomembranous anastomosis; some centers use exaggerated lithotomy for more direct perineal exposure, but it is not required by the retractor and is associated with lower-limb neuropraxia, rhabdomyolysis and acute renal failure. A beanbag without adequate gel padding and operations longer than 5 hours increase the risks associated with exaggerated lithotomy. Position the ring over the perineum after prep, draping and incision-line marking.[9]
  • Blade selection. Choose blade depth and curvature by tissue layer: short narrow blades for skin and superficial layers, long curved blades for deeper perineal exposure of the bulb and corpora.
  • Progressive tensioning: place anterior and lateral blades first to expose the perineum broadly; add posterior and deeper blades as the dissection advances toward the bulbar / membranous urethra.
  • Re-position as the case progresses: between mobilization, stricturotomy, anastomosis, and closure phases the ideal blade positions change; the ring's clip mechanism is designed for this iterative adjustment.
  • Neuropraxia avoidance. Longer time in lithotomy was associated with lower-extremity neuropathy in a prospective cohort. Limit lithotomy time and recheck leg position periodically.[12]

Outcomes Context​

Turner-Warwick's eponymous staged urethroplasty technique for complex bulbar and membranous strictures achieved approximately 90% overall success in Reid's series of 60 patients[2] and remains a foundational paradigm in modern urethroplasty practice.[5] The retractor was developed as part of this comprehensive operative system; whatever the contemporary technique (anastomotic, BMG, fasciocutaneous flap, staged Bracka, or trans-perineal posterior urethroplasty), the perineal exposure principles the Turner-Warwick was engineered for remain unchanged.

Historical Context​

Richard Turner-Warwick was a defining figure in 20th-century reconstructive urology, a pioneer of complex urethral reconstruction, a prolific instrument designer, and one of the founders of modern functional and reconstructive urology as a discipline. His name is attached to the staged urethroplasty that appears in mid-century stricture series.[2][3] The Turner-Warwick line of instruments on the urology tray includes:

  • Turner-Warwick perineal retractor.
  • Turner-Warwick Ryder needle holder. Elongated-shank modification of the Ryder for deep posterior urethroplasty and VUA reconstruction.
  • Turner-Warwick urethroplasty staged technique. The operative method the retractor was engineered to support.

See his profile in History & Lineage for the broader contribution.

See also: Perineal Bookwalter (Jordan), Lone Star, Turner-Warwick Ryder.

References​

1. Verla W, Oosterlinck W, Spinoit AF, Waterloos M. "A comprehensive review emphasizing anatomy, etiology, diagnosis, and treatment of male urethral stricture disease." Biomed Res Int. 2019;2019:9046430. doi:10.1155/2019/9046430

2. Reid RE. "Turner-Warwick urethroplasty and urethral stricture. Results in 60 patients." Urology. 1975;6(6):711–5. doi:10.1016/0090-4295(75)90802-x

3. Alexander RM, Spadaro JJ, Stripling JR, et al. "Surgical treatment of urethral stricture." South Med J. 1977;70(12):1405–6. doi:10.1097/00007611-197712000-00007

4. Flynn H, Joshi PM, Kulkarni SB, Desai D. "How to do a penile urethroplasty using a novel self-retaining penile retractor." ANZ J Surg. 2023;93(1–2):334–6. doi:10.1111/ans.18039

5. Dugi DD, Simhan J, Morey AF. "Urethroplasty for stricture disease: contemporary techniques and outcomes." Urology. 2016;89:12–8. doi:10.1016/j.urology.2015.12.012

6. Dorton HE. "New self-retaining retractor holder to facilitate surgical exposure." Am J Surg. 1981;141(2):306–8. doi:10.1016/0002-9610(81)90184-7

7. Noldus J, Graefen M, Huland H. "Major postoperative complications secondary to use of the Bookwalter self-retaining retractor." Urology. 2002;60(6):964–7. doi:10.1016/s0090-4295(02)01946-5

8. Dafnis G. "Transsphincteric repair of rectourethral fistulas: 15 years of experience with the York Mason approach." Int J Urol. 2018;25(3):290–296. doi:10.1111/iju.13518

9. Gomez RG, Scarberry K. "Anatomy and techniques in posterior urethroplasty." Transl Androl Urol. 2018;7(4):567–579. doi:10.21037/tau.2018.03.05

10. Sontec Instruments. Urology Selection (catalog), pp. 14–16. PDF.

11. Sontec Instruments. Urology Selection (catalog), pp. 14–16. PDF.

12. Warner MA, Warner DO, Harper CM, Schroeder DR, Maxson PM. "Lower extremity neuropathies associated with lithotomy positions." Anesthesiology. 2000;93(4):938–942. doi:10.1097/00000542-200010000-00010