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Case Report of Enormous Prostatic Adenoma
CASE REPORT OF ENORMOlJS PROSTATIC HENRY L. DOUGLASS Received for publication ::\Iarch 7, 1927
This case is reported merely because it illustrates the enormous so far size which prostatic tumors may sometimes reach. It as I have been able to find, the largest tumor of the prostate reported. The patient first presented himself at the office on the morning of November 28, 1926, suffering acutely from urinary retention. History. Mr. G. vV. G. is a white male, seventy-four years old. He is a farmer by occupation and a native of Tennessee. He was married fifty years ago. His wife is living and in good health. She has never been pregnant. During childhood patient had measles, mumps and whooping cough. At the age of seventeen he had typhoid fever. With that exception he has had no serious illness. His general health was good until ten years ago. The patient has never had venereal diseases. Patient began to have difficulty in urination about seventeen years ago. The urine was slow to start and he would have to strain a good deal to get it started. At that time he had some frequency. He would have to void three or four times at night. During urination the stream lacked force and he often noticed that it merely amounted to a dribble. There was no pain. He first noticed hematuria ten years ago. The urine would be bloody three to five times a year for the first six years. The bleeding has been more frequent and more profuse during the last four years. For many years his symptoms would get better and then recur. On the whole however he gradually got worse. During the past four years he found it at times impossible to urinate. At such times he got relief by catheterization. For the past three years he has suffered a great deal. He would have to void as often as twenty-five times some nights and the quantity voided each time would be so small as to afford no relief. The straining and effort to urinate caused great pain. There seemed to be no obstruction to the passage of a catheter. Failure never 115
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HENRY L. DOUGLASS
attended efforts at catheterization. He noticed that if he would go too long without urinating it usually resulted in inability to pass any urine at all. Eight or nine months ago he began to pass blood in the urine. Sometimes the blood would be bright red and terminal. Then again the entire urine would be colored by dark blood. The bleeding got worse and recently he has passed clots, some of which were rather large. In spite of this the patient has lost no weight and his general condition is good. During the early part of the night of November 27, 1926, he was taken with acute retention. The bladder filled during the night more rapidly than would be expected and his suffering was intense. His physician passed a soft rubber catheter into the bladder without much diffi_culty. No urine would come through the catheter, however, only a few blood clots. He was given morphine and brought to Nashville by automobile early the next morning, November 28, 1926. Family history. None of his immediate relatives had had cancer, tuberculosis or any serious urinary disturbances of any sort. Physical examination was carried out rather hurriedly at the office on the morning of November 28, because patient was suffering acutely. Patient's appearance is that of a man about seventy-five years old. He is well developed and walks in a stooped attitude because of pain in the lower abdomen. Abdomen: The abdomen is soft. There is a tumor in the hypogastric region, extending upward two inches above the umbilicus. The tumor is plainly visible. It is smooth and tense and lies in the midline. It is clearly an over-distended bladder. Rectal examination: The prostate is enormously enlarged. It is smooth and firm. It bulges into the rectum and the top of the gland cannot be felt. It is not malignant so far as can be determined by palpation. Extremities: The extremities are well developed. The reflexes are present and active. The extremities show no abnormalities. There is no evidence of loss of weight. A soft rubber catheter size 18 French was easily passed into the bladder, but no urine was obtained. A cystoscope, size 24 French, was then passed into the bladder without difficulty. A large clot came through the cystoscope which was a perfect cast of the instrument, but no urine. Attempts to irrigate through the cystoscope only washed out a few blood clots. A cystotomy was then deemed necessary for relief and the patient was carried to the hospital. Operation. The bladder was opened under local anesthesia by means of a suprapubic incision. About three quarts of dark bloody urine and
ENORMOUS PROSTATTC ADENOMA
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some blood clots were found in the bladder. When emptied the bladder walls collapsed against a very large mass which completely filled its cavity in the contracted state. There was barely enough room between the growth and the wall of the bladder to admit one finger for purposes of exploration. The tumor was firm but not hard and smooth except for one nodule, 1 inch by ½inch, at its apex. This nodule protruded through the incision in the dome of the bladder. The tumor was covered by the mucous membrane of the bladder. The internal meatus could not be located with certainty. A moderately soft rubber tube about onehalf inch in diameter was placed between the posterior wall of the bladder and the tumor and the wound closed. At first the exact nature of this tumor was not clear. The possibility of sarcoma was considered. However the consistency and smoothness of the growth led us to believe that it was an ordinary adenofibroma of the prostate. After cystotomy the patient reacted well and on the foulrth day his pulse rate and temperature were normal. Urinary drainage through the suprapubic tube was between forty-five and fifty ounces for each twentyfour hours. There was quite a lot of urinary drainage around the tube as well. During the first three or four days the patient appeared rather drowsy and there were occasional slight twitching of the muscles. On November 30, his blood chemistry was as follows: Non-proteinnitrogen, 46 mgm. per 100 cc.; urea, 60 mgm. per 100 cc., urea nitrogen, 28 mgm. per 100 cc., creatinine, 2 mgm. per 100 cc. All evidences of uremia promptly cleared up within five days. The blood in the urine gradually got less and on the fifth day the urine was clear. On the seventh day patient was allowed to sit up and on the eighth day the suprapubic tube was removed. On the eighth day the patient's condition was very good but the urine was slightly bloody again. Examination of the urine at this time was as follows: Color, red; acid, albumen 4 plus; sugar, negative; red blood cells, 4 plus; pus, negative; casts, negative. On the same date the blood chemistry was: Non-proteinnitrogen, 33 mgm. per 100 cc.; urea, 36 mgm. per 100 cc.; urea nitrogen, 16.8 mgm. per 100 cc.; creatinine, 1.5 mgm. per 100 cc . Blood grouping: The patient is type 4. Prostatectomy was thought advisable at this time and the operation was set for the following day. The bleeding which had been noticed earlier during the day continued. The amount of blood in the urine was barely enough to be seen grossly and his blood pressure was not affected by it. On the following morning the patient began to bleed profusely. Bright red blood ran both from the suprapubic wound and from the
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HEXRY L. DOUGLASS
urethra. Blood pressure dropped from 150/90 to 120/70. As the blood pressure reached 120 the bleeding stopped as suddenly as it begun. Preparations for transfusion were made but in the interval morphine and saline by hypodermoclysis were given and his blood pressure began to rise. Transfusion was not done and the patient was kept quiet. His blood pressure was taken every hour until it reached 140/80. At seven o'clock in the evening his general condition seemed good and he was carried to the operating room. We planned to remove the growth under gas and parasacral anesthesia. After blocking the caudal hiatus and one-half sacral nerves with 1 per cent novocain 50 cc. the patient became nauseated and vomited several times. He became cold and clamy and was evidently seriously affected by the novocain. His pulse was very weak and rapid and the blood pressure was around 80 systolic but too low to be determined accurately. He was transfused at once and sent back to his room. He had a moderately severe reaction to the transfusion which passed off within a few hours after which improvement was rapid. He was kept in bed and given calcium chloride by mouth to increase the coagulability of the blood. In spite of all precautionary measures his urine continued to be bloody at intervals. On December 16th, his blood pressure was 144/90 and his general condition was again considered fairly satisfactory. Plans were made for prostatectomy under gas anesthesia. During the night two minor haemorrhages occurred. His blood pressure however was little affected. About eight o'clock the following morning a sudden haemorrhage occurred which was of such magnitude as to prove fatal within less than an hour. He died while his vein was being opened for transfusion. After death permission was given to remove the tumor. The mass was exposed by enlarging the suprapubic wound. An incision was then made through the mucous membrane covering the growth and the flaps deflected to either side. The tumor was encapsulated and its enucleation was easily carried out as far down as the brim of the true pelvis. Here it was very difficult to force the finger between the growth and the pelvic bones and further enucleation was extremely hard to accomplish. At length it was delivered in one piece, leaving an enormous cavity the diameter of which was practically that of the pelvic outlet. The growth was smooth with the exception of one nodule at its apex, firm and encapsulated. In the fresh state it weighed 23¾ ounces. The specimen was placed in formalin and carried to the pathological department of Vanderbilt 1J niversity where, after a certain amount
~ENORMOUS PROSTATIC ADEKOMA
FIG. 1
Fm. 2
119
120
HENRY L. DOUGLASS
of shrinkage, it was photographed and sectioned for study. Figures 1 and 2 are photographs of the specimen as removed. In figure 2 the lateral lobes are spread apart. After studying sections from various parts of the tumor, Dr. E. W. Goodpasture of the department of Pathology, Vanderbilt University made the following report : "Microscopic sections from various areas of the hypertrophic prostate demonstrate that the condition of enlargement is one of an irregular hyperplasia of the organ. The glandular hyperplasia proceeds from various centers of growth forming irregular acini, some dilated, others with infolded epithelial lining. About the gland there is a stroma composed of smooth muscle cells and fibrous
Fm. 4
:Fm. 3 FIG.
3.
THE ADENOMATOUS ELEMENT IS SHOWN MORE PROMINENT WITH FIBROUS GROWTH IN THE MINORITY
FIG,
4.
THE GREATER BULK SHOWS HYPERTROPHY AND HYPERPLASIA OF FIBRO-
MUSCULAR TISSUE.
SOME FEW HYPERPLASTIC GLANDS ARE PRESENT
tissue. A very striking feature is the presence of large areas of infarction. The areas of necrosis are very generally distributed, being present in many sections from various portions of the gland. Vascular changes immediately responsible for the necrosis were not detected. There is very little reaction about the infarcts, and inflammatory reaction in the gland elsewhere is not conspicuous. One section taken from a fairly circumscribed compact area at the periphery of the gland, measuring 2 cm. in diameter, is composed of smooth muscle arranged in bundles, and this area is interpreted as a leiomyoma. Diagnosis. Hyperplasia of the prostate with infarction Leiomyoma -0f prostate.
This case is reported merely because it illustrates the enormous so far size which prostatic tumors may sometimes reach. It as I have been able to find, the largest tumor of the prostate reported. The patient first presented himself at the office on the morning of November 28, 1926, suffering acutely from urinary retention. History. Mr. G. vV. G. is a white male, seventy-four years old. He is a farmer by occupation and a native of Tennessee. He was married fifty years ago. His wife is living and in good health. She has never been pregnant. During childhood patient had measles, mumps and whooping cough. At the age of seventeen he had typhoid fever. With that exception he has had no serious illness. His general health was good until ten years ago. The patient has never had venereal diseases. Patient began to have difficulty in urination about seventeen years ago. The urine was slow to start and he would have to strain a good deal to get it started. At that time he had some frequency. He would have to void three or four times at night. During urination the stream lacked force and he often noticed that it merely amounted to a dribble. There was no pain. He first noticed hematuria ten years ago. The urine would be bloody three to five times a year for the first six years. The bleeding has been more frequent and more profuse during the last four years. For many years his symptoms would get better and then recur. On the whole however he gradually got worse. During the past four years he found it at times impossible to urinate. At such times he got relief by catheterization. For the past three years he has suffered a great deal. He would have to void as often as twenty-five times some nights and the quantity voided each time would be so small as to afford no relief. The straining and effort to urinate caused great pain. There seemed to be no obstruction to the passage of a catheter. Failure never 115
116
HENRY L. DOUGLASS
attended efforts at catheterization. He noticed that if he would go too long without urinating it usually resulted in inability to pass any urine at all. Eight or nine months ago he began to pass blood in the urine. Sometimes the blood would be bright red and terminal. Then again the entire urine would be colored by dark blood. The bleeding got worse and recently he has passed clots, some of which were rather large. In spite of this the patient has lost no weight and his general condition is good. During the early part of the night of November 27, 1926, he was taken with acute retention. The bladder filled during the night more rapidly than would be expected and his suffering was intense. His physician passed a soft rubber catheter into the bladder without much diffi_culty. No urine would come through the catheter, however, only a few blood clots. He was given morphine and brought to Nashville by automobile early the next morning, November 28, 1926. Family history. None of his immediate relatives had had cancer, tuberculosis or any serious urinary disturbances of any sort. Physical examination was carried out rather hurriedly at the office on the morning of November 28, because patient was suffering acutely. Patient's appearance is that of a man about seventy-five years old. He is well developed and walks in a stooped attitude because of pain in the lower abdomen. Abdomen: The abdomen is soft. There is a tumor in the hypogastric region, extending upward two inches above the umbilicus. The tumor is plainly visible. It is smooth and tense and lies in the midline. It is clearly an over-distended bladder. Rectal examination: The prostate is enormously enlarged. It is smooth and firm. It bulges into the rectum and the top of the gland cannot be felt. It is not malignant so far as can be determined by palpation. Extremities: The extremities are well developed. The reflexes are present and active. The extremities show no abnormalities. There is no evidence of loss of weight. A soft rubber catheter size 18 French was easily passed into the bladder, but no urine was obtained. A cystoscope, size 24 French, was then passed into the bladder without difficulty. A large clot came through the cystoscope which was a perfect cast of the instrument, but no urine. Attempts to irrigate through the cystoscope only washed out a few blood clots. A cystotomy was then deemed necessary for relief and the patient was carried to the hospital. Operation. The bladder was opened under local anesthesia by means of a suprapubic incision. About three quarts of dark bloody urine and
ENORMOUS PROSTATTC ADENOMA
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117
some blood clots were found in the bladder. When emptied the bladder walls collapsed against a very large mass which completely filled its cavity in the contracted state. There was barely enough room between the growth and the wall of the bladder to admit one finger for purposes of exploration. The tumor was firm but not hard and smooth except for one nodule, 1 inch by ½inch, at its apex. This nodule protruded through the incision in the dome of the bladder. The tumor was covered by the mucous membrane of the bladder. The internal meatus could not be located with certainty. A moderately soft rubber tube about onehalf inch in diameter was placed between the posterior wall of the bladder and the tumor and the wound closed. At first the exact nature of this tumor was not clear. The possibility of sarcoma was considered. However the consistency and smoothness of the growth led us to believe that it was an ordinary adenofibroma of the prostate. After cystotomy the patient reacted well and on the foulrth day his pulse rate and temperature were normal. Urinary drainage through the suprapubic tube was between forty-five and fifty ounces for each twentyfour hours. There was quite a lot of urinary drainage around the tube as well. During the first three or four days the patient appeared rather drowsy and there were occasional slight twitching of the muscles. On November 30, his blood chemistry was as follows: Non-proteinnitrogen, 46 mgm. per 100 cc.; urea, 60 mgm. per 100 cc., urea nitrogen, 28 mgm. per 100 cc., creatinine, 2 mgm. per 100 cc. All evidences of uremia promptly cleared up within five days. The blood in the urine gradually got less and on the fifth day the urine was clear. On the seventh day patient was allowed to sit up and on the eighth day the suprapubic tube was removed. On the eighth day the patient's condition was very good but the urine was slightly bloody again. Examination of the urine at this time was as follows: Color, red; acid, albumen 4 plus; sugar, negative; red blood cells, 4 plus; pus, negative; casts, negative. On the same date the blood chemistry was: Non-proteinnitrogen, 33 mgm. per 100 cc.; urea, 36 mgm. per 100 cc.; urea nitrogen, 16.8 mgm. per 100 cc.; creatinine, 1.5 mgm. per 100 cc . Blood grouping: The patient is type 4. Prostatectomy was thought advisable at this time and the operation was set for the following day. The bleeding which had been noticed earlier during the day continued. The amount of blood in the urine was barely enough to be seen grossly and his blood pressure was not affected by it. On the following morning the patient began to bleed profusely. Bright red blood ran both from the suprapubic wound and from the
ll8
HEXRY L. DOUGLASS
urethra. Blood pressure dropped from 150/90 to 120/70. As the blood pressure reached 120 the bleeding stopped as suddenly as it begun. Preparations for transfusion were made but in the interval morphine and saline by hypodermoclysis were given and his blood pressure began to rise. Transfusion was not done and the patient was kept quiet. His blood pressure was taken every hour until it reached 140/80. At seven o'clock in the evening his general condition seemed good and he was carried to the operating room. We planned to remove the growth under gas and parasacral anesthesia. After blocking the caudal hiatus and one-half sacral nerves with 1 per cent novocain 50 cc. the patient became nauseated and vomited several times. He became cold and clamy and was evidently seriously affected by the novocain. His pulse was very weak and rapid and the blood pressure was around 80 systolic but too low to be determined accurately. He was transfused at once and sent back to his room. He had a moderately severe reaction to the transfusion which passed off within a few hours after which improvement was rapid. He was kept in bed and given calcium chloride by mouth to increase the coagulability of the blood. In spite of all precautionary measures his urine continued to be bloody at intervals. On December 16th, his blood pressure was 144/90 and his general condition was again considered fairly satisfactory. Plans were made for prostatectomy under gas anesthesia. During the night two minor haemorrhages occurred. His blood pressure however was little affected. About eight o'clock the following morning a sudden haemorrhage occurred which was of such magnitude as to prove fatal within less than an hour. He died while his vein was being opened for transfusion. After death permission was given to remove the tumor. The mass was exposed by enlarging the suprapubic wound. An incision was then made through the mucous membrane covering the growth and the flaps deflected to either side. The tumor was encapsulated and its enucleation was easily carried out as far down as the brim of the true pelvis. Here it was very difficult to force the finger between the growth and the pelvic bones and further enucleation was extremely hard to accomplish. At length it was delivered in one piece, leaving an enormous cavity the diameter of which was practically that of the pelvic outlet. The growth was smooth with the exception of one nodule at its apex, firm and encapsulated. In the fresh state it weighed 23¾ ounces. The specimen was placed in formalin and carried to the pathological department of Vanderbilt 1J niversity where, after a certain amount
~ENORMOUS PROSTATIC ADEKOMA
FIG. 1
Fm. 2
119
120
HENRY L. DOUGLASS
of shrinkage, it was photographed and sectioned for study. Figures 1 and 2 are photographs of the specimen as removed. In figure 2 the lateral lobes are spread apart. After studying sections from various parts of the tumor, Dr. E. W. Goodpasture of the department of Pathology, Vanderbilt University made the following report : "Microscopic sections from various areas of the hypertrophic prostate demonstrate that the condition of enlargement is one of an irregular hyperplasia of the organ. The glandular hyperplasia proceeds from various centers of growth forming irregular acini, some dilated, others with infolded epithelial lining. About the gland there is a stroma composed of smooth muscle cells and fibrous
Fm. 4
:Fm. 3 FIG.
3.
THE ADENOMATOUS ELEMENT IS SHOWN MORE PROMINENT WITH FIBROUS GROWTH IN THE MINORITY
FIG,
4.
THE GREATER BULK SHOWS HYPERTROPHY AND HYPERPLASIA OF FIBRO-
MUSCULAR TISSUE.
SOME FEW HYPERPLASTIC GLANDS ARE PRESENT
tissue. A very striking feature is the presence of large areas of infarction. The areas of necrosis are very generally distributed, being present in many sections from various portions of the gland. Vascular changes immediately responsible for the necrosis were not detected. There is very little reaction about the infarcts, and inflammatory reaction in the gland elsewhere is not conspicuous. One section taken from a fairly circumscribed compact area at the periphery of the gland, measuring 2 cm. in diameter, is composed of smooth muscle arranged in bundles, and this area is interpreted as a leiomyoma. Diagnosis. Hyperplasia of the prostate with infarction Leiomyoma -0f prostate.