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Lowsley Retractor (Prostatic Tractor)

The Lowsley retractor, also called the Lowsley prostatic tractor, is a transurethrally passed instrument with hinged distal wings that open inside the bladder. Designed by Oswald Swinney Lowsley in the early 20th century as the central instrument of perineal prostatectomy, it persists on the modern reconstructive tray for two specific roles: assisted suprapubic-tube placement (especially in the neurogenic-bladder / hostile-abdomen patient) and as an anastomotic-tension reducer at the vesicourethral anastomosis during laparoscopic / robotic prostatectomy.[1][2]

Design​

  • Long curved shaft matching the male urethral curve.
  • Two hinged wings at the distal tip that lie flush during transurethral passage and open / close via the proximal handle mechanism.
  • Solid stainless steel, reusable, autoclavable.
  • Reusable wing-control handle with thumb-actuated open / close action; some variants include a locking mechanism.

Reconstructive-Urology Uses​

Lowsley-Assisted Suprapubic Cystostomy​

The most relevant contemporary use. The retractor is passed transurethrally into the bladder, the wings are opened and rotated anteriorly to tent the anterior bladder wall against the abdominal wall, the surgeon palpates (or directly visualizes) the tip subcutaneously, and a small skin incision is made over the palpable tip. The retractor is then advanced through the abdominal wall to externalize the tip, the SPT catheter is loaded onto the tip, and the entire assembly is withdrawn back through the bladder and out the urethra — leaving the SPT in place.[1]

Why this matters reconstructively:

  • Neurogenic-bladder patients — Edokpolo and Foster (2011) report a 44-patient series with mean OR time ~ 20 min, no intraoperative complications, and no incorrect catheter placements. NLUTD patients carry a disproportionate risk of bowel injury with blind percutaneous SPT because of small-capacity / thick-walled / scarred bladders, abdominal-wall scarring from prior diversion / channel surgery, and high BMI.[1]
  • Hostile abdomen / prior pelvic surgery — the transurethral starting point and direct tactile guidance reduce the bowel-injury risk inherent to blind percutaneous SPT (up to ~ 2.4% in pooled series).[3]
  • Underfillable bladder — when the bladder will not accept the volume required for safe percutaneous SPT, the Lowsley approach does not depend on a distended bladder for orientation.

See Suprapubic Tube / Suprapubic Cystostomy for the catheter side of the procedure, and Bladder Scanner for the volume-decision rule that triggers SPT.

Vesicourethral-Anastomotic Tension Reduction​

After the prostate is removed during laparoscopic / robotic radical prostatectomy (or — by extension — at the vesicourethral anastomosis of a complex revision in a post-radiation / post-prostatectomy reconstructive case), the Lowsley tractor is passed up the urethral stump, the wings are opened in the pelvis, a posterior bladder-neck traction stitch is grasped between the wings, and the bladder neck is drawn down to the urethral stump. This reduces anastomotic tension and prevents urethral mucosal tear during knot-tying.[4]

Reconstructive translation: the same maneuver applies to the vesicourethral re-anastomosis at redo bladder-neck reconstruction and at the second stage of two-stage rendezvous urethroplasty for membranous urethral disruption, when the proximal segment will not reach the distal urethra without traction.

Other Reconstructive-Adjacent Uses​

  • Bladder-anchoring during transvesical fistula or diverticulum repair — wings opened inside the bladder maintain the anterior bladder wall against the cystotomy.
  • Tactile guidance during open or laparoscopic salvage SPT when prior abdominal surgery has obliterated the percutaneous corridor.

Historical Context — Perineal Prostatectomy​

The Lowsley tractor was developed by Oswald Swinney Lowsley (1884–1955) as the central instrument of perineal prostatectomy (both simple and radical), passed transurethrally to engage and elevate the prostate into the perineal operative field for dissection.[2][5] The radical perineal approach has been largely supplanted by retropubic, laparoscopic, and robotic prostatectomy and falls outside WARWIKI's reconstructive scope. The instrument has nevertheless persisted because the tip-out-of-the-urethra mechanic is uniquely suited to the SPT and anastomotic-tension applications above.[6]

Technique Pearls — Lowsley-Assisted SPT​

  1. Empty the bladder per urethra with a Foley, then partial-fill (~ 200 mL saline) only if needed for orientation — full distention is not required.
  2. Pass the retractor with wings closed along the urethral curve into the bladder. Confirm bladder entry by urine return through the instrument's lumen (if applicable) or tactile loss of resistance.
  3. Open the wings, rotate the handle anteriorly, and palpate the tip subcutaneously in the midline ~ 2–3 cm above the pubic symphysis. If not palpable, do not blindly incise — reposition or convert to ultrasound-guided / open SPT.
  4. Small transverse skin incision over the palpable tip; advance the retractor through the abdominal wall under direct vision.
  5. Load the SPT catheter onto the tip, withdraw the assembly back into the bladder and out the urethra, leaving the catheter in place. Inflate the balloon.
  6. Cystoscopy confirmation of intravesical balloon position before securing.

Safety and Contraindications​

  • Inability to pass the retractor per urethra — significant stricture, false passage, or pelvic-fracture urethral disruption is an absolute contraindication; use ultrasound-guided percutaneous SPT or open cystostomy.
  • Active urethral infection or recent urethral instrumentation with mucosal trauma — risk of false-passage creation by the rigid instrument.
  • Anticoagulated patient — abdominal-wall hematoma risk; reverse or hold per institutional protocol before the skin incision.
  • Acutely thickened / trabeculated NLUTD bladder — the Lowsley approach still works, but cystoscopy beforehand to identify mucosal landmarks is prudent.

Lowsley vs Alternatives for Suprapubic-Tube Placement​

TechniqueBest fitBowel-injury risk
Lowsley-assistedNeurogenic / hostile abdomen / underfillable bladder; mean OR time ~ 20 min[1]Low — tactile and direct guidance
Percutaneous (blind / Stamey-type kit)Distensible bladder, virgin abdomenUp to ~ 2.4% bowel injury in pooled data[3]
Ultrasound-guided percutaneousDefault for elective SPT in a fillable bladderLower than blind percutaneous; the modern standard[3]
Open cystostomyFailed less-invasive attempts, fixed pelvis, or planned concomitant abdominal procedureLowest (direct vision) but highest morbidity

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