Skip to main content

Lowsley Retractor (Prostatic Tractor)

The Lowsley retractor, also called the Lowsley prostatic tractor, is a transurethrally passed instrument with hinged distal jaws that can grasp a catheter or traction suture. Developed in the era of perineal prostatectomy, it has documented roles in inside-out suprapubic-tube placement in selected patients with transurethral access and posterior vesicourethral-anastomotic traction in a laparoscopic-prostatectomy technical report.[1][2][4][7]

Design​

  • Long curved shaft matching the male urethral curve.
  • Two hinged wings at the distal tip that lie flush during transurethral passage and open or close via the proximal handle mechanism.
  • Reusable metal instrument in documented operative practice; confirm the specific manufacturer's construction, cleaning and sterilization and jaw-control instructions before use. For example, Avalign's Lowsley IFU specifies flush-port or lumen cleaning and advises against ultrasonic cleaning of that device; it does not govern other models.[9]
  • Proximal jaw-control handle, with variant details dependent on the available model.

Reconstructive-Urology Uses​

Lowsley-Assisted Suprapubic Cystostomy​

In the described inside-out cutdown, the retractor is passed transurethrally into the bladder with its jaws closed, the tip is brought against the anterior bladder or abdominal wall, and a cutdown exposes the palpable tip. A catheter is secured in the opened jaws and drawn back into the bladder, where its balloon is inflated; the catheter is released and the retractor alone withdrawn through the urethra. Confirm the balloon is intravesical. This maneuver does not itself rule out interposed bowel.[1][7][8]

Why this matters reconstructively:

  • Neurogenic-bladder patients with suitable urethral access. Edokpolo and Foster reported 49 primary placements in 44 people; operative time 20.2 ± 5.5 min was documented for only 19 cases, with no intraoperative complications or misplaced catheters in that selected retrospective series and one next-day significant hematuria. This is not a comparative bowel-safety trial.[1]
  • Prior lower-abdominal surgery or possible interposed bowel. The palpable tip does not eliminate bowel-injury risk. Review operative history and anatomy and consider contemporaneous ultrasound by a trained operator or open exposure according to the revised BAUS guideline; avoid treating a hostile abdomen as an automatic indication for Lowsley.[3][7][8]
  • Poorly distensible bladder. Direct exposure or image-guided planning may help when a trocar corridor is unsafe; a Lowsley cutdown still needs a safe path and adequate transurethral passage.[7]

See Suprapubic Tube / Suprapubic Cystostomy for the catheter side of the procedure, and Bladder Scanner for noninvasive volume assessment. A scanner number alone does not establish a safe catheter track.[7]

Vesicourethral-Anastomotic Tension Reduction​

In the laparoscopic radical prostatectomy technique report, a Lowsley is passed through the urethral stump. A posterior bladder-neck traction stitch is grasped with its jaws and pulled toward the urethra while the 6-o'clock anastomotic suture is tied; 4- and 8-o'clock stitches are placed before release. In this technique report, the authors state that the maneuver moves tension from the posterior urethra to the bladder neck, preventing urethral tears and posterior-wall gaps, while the open anterior anastomosis preserves vision.[4]

Application to redo bladder-neck reconstruction or staged repair of membranous urethral disruption requires its own anatomy- and tissue-specific plan; Garrett's initial prostatectomy description does not validate these extensions.[4]

Other Reconstructive-Adjacent Uses​

  • Transvesical exposure and tactile localization may be possible in selected fistula or diverticulum repairs or planned open SPT; the instrument does not exclude interposed bowel.

Historical Context — Perineal Prostatectomy​

The Lowsley tractor is associated with Oswald Swinney Lowsley (1884–1955) and the historical perineal prostatectomy, passed transurethrally to help expose the prostate in the perineal field.[2][5] Retropubic, laparoscopic and robotic approaches have displaced much of that practice. The same jaw-control and tactile-localization principles explain its later selected SPT and traction uses, not a unique or universally safer indication.[4][6][7]

Technique Pearls — Lowsley-Assisted SPT​

  1. Plan a safe route after reviewing lower-abdominal operations, bleeding risk and possible interposed bowel; image or expose the path when indicated. Do not assume a palpable tip makes blind incision safe.[7]
  2. Pass with jaws closed only when urethral passage is safe and atraumatic; verify intravesical position by the operative method, not an assumed lumen or urine-return feature of every Lowsley model.
  3. Press the curved tip against the anterior bladder wall and identify it through a deliberate suprapubic cutdown, protecting intervening structures. If the tip or pathway cannot be confirmed, change the approach.[7][8]
  4. Secure the catheter tip in the opened jaws before controlled withdrawal of the retractor into the bladder; check for slippage. Inflate the balloon intravesically, release the catheter and remove the retractor per urethra.[7][8]
  5. Confirm intravesical catheter or balloon position, with cystoscopy when feasible, before securing; monitor for bleeding or signs of visceral injury.[7][8]

Safety and Contraindications​

  • Inability to pass the retractor safely per urethra. Stricture, false passage or suspected disruption calls for another drainage route; an SPT itself may be appropriate in urethral trauma, but the transurethral Lowsley path is not.[7]
  • Active urethral infection or recent urethral instrumentation with mucosal trauma; risk of false-passage creation by the rigid instrument.
  • Bladder cancer or undiagnosed hematuria, abdominal-wall sepsis, or a subcutaneous vascular graft in the suprapubic region are listed by BAUS as contraindications to SPC insertion.[7]
  • Bleeding disorder or anticoagulation. The BAUS SPC guideline lists uncorrected bleeding disorder or anticoagulation treatment among contraindications and advises that anticoagulant and antiplatelet medication should, as a general rule, be discontinued, following local guidelines.[7]
  • NLUTD bladder and altered abdominal anatomy. Assess bladder distension, autonomic-dysreflexia risk when relevant, interposed bowel, instrument reach and catheter position; cystoscopy alone cannot exclude intervening bowel.[7]

Lowsley vs Alternatives for Suprapubic-Tube Placement​

TechniqueBest fitBowel-injury risk
Lowsley-assisted cutdownSelected patient with safe transurethral passage and confirmed path; permits larger catheter[1][7]Bowel injury remains possible; no comparative rate established
Percutaneous trocar / SeldingerDistensible palpable bladder and no high-risk track, with trained operator[7]For SPC insertion overall, older series reported 2.4–2.7% bowel injury and later series 0–0.2%; Hall et al. found 11/1,490 (0.7%) in a published-series meta-analysis and one bowel injury among 11,473 insertions in a UK national audit, and recommend quoting a risk below 0.25% when counseling low-risk patients.[7][10]
Ultrasound-guided percutaneousImaging by a trained operator when the bladder is not palpable or the track is uncertain[7]Helps identify a safe pathway; comparative safety benefit is not formally established
Open cystostomyInterposed bowel/high-risk corridor or concomitant open operation[7]Direct visualization may mitigate injury but does not eliminate risk; wound/pain morbidity is greater

See also: Suprapubic Catheter, Van Buren Sound (tenting alternative when a Lowsley is not on the tray), Bladder Scanner, Stamey Needle.

Videos​

Suprapubic Tube Placement via the Lowsley Retractor
AUA Core Curriculum (2024)

References​

1. Edokpolo LU, Foster HE. "Suprapubic cystostomy for neurogenic bladder using Lowsley retractor method: a procedure revisited." Urology. 2011;78(5):1196–8. doi:10.1016/j.urology.2011.07.1393

2. Melman A, Boczko J, Figueroa J, Leung AC. "Critical surgical techniques for radical perineal prostatectomy." J Urol. 2004;171(2 Pt 1):786–90. doi:10.1097/01.ju.0000107834.23316.59

3. Jacob P, Rai BP, Todd AW. "Suprapubic catheter insertion using an ultrasound-guided technique and literature review." BJU Int. 2012;110(6):779–84. doi:10.1111/j.1464-410X.2011.10882.x

4. Garrett JE, LaGrange CA, Chenven E, Strup SE. "Use of Lowsley tractor during laparoscopic prostatectomy to reduce urethrovesical anastomotic tension." J Endourol. 2006;20(3):220–2. doi:10.1089/end.2006.20.220

5. Thrasher JB, Paulson DF. "Reappraisal of radical perineal prostatectomy." Eur Urol. 1992;22(1):1–8. doi:10.1159/000474713

6. Walther PJ. "Radical perineal vs. retropubic prostatectomy: a review of optimal application and technical considerations in the utilization of these exposures." Eur Urol. 1993;24 Suppl 2:34–8. doi:10.1159/000474386

7. Jane Hall S, Harrison S, Harding C, Reid S, Parkinson R. British Association of Urological Surgeons' suprapubic catheter practice guidelines — revised. BJU Int. 2020;126(4):416–22.

8. Karsh LI, Egerdie RB, Albala DM, Flynn BJ. The Transurethral Suprapubic endo-Cystostomy (T-SPeC): A Novel Suprapubic Catheter Insertion Device. J Endourol. 2013;27(7):880–85.

9. Avalign German Specialty Instruments. Instructions for Use and Reprocessing, INS_LBL-00010 Rev C. pp 1–4.

10. Hall S, Ahmed S, Reid S, et al. "A national UK audit of suprapubic catheter insertion practice and rate of bowel injury with comparison to a systematic review and meta-analysis of available research." Neurourol Urodyn. 2019;38(8):2194–2199. doi:10.1002/nau.24114