Choice of procedure in cases of prostatic obstruction

CHOICE

OF PROCEDURE

PROSTATE N. P.

IN CASES

OF

OBSTRUCTION * RATHBUX,

M.D.

BROOKLYN, N. Y.

S

OME

of the recent contributions on the subject of prostatic hypertrophy, particularIy those reIating to cystoscopic resection, have, in a measure, reopened the whoIe subject of prostatism and prostatectomy. For a period of severa years before this new era, sporadic papers appeared here and there but they often seemed a bit trite. Meetings, such as this one, covering a period of three or four days, wouId often assembIe and disperse without a word on the subject. In other words, with the exception of a few perhaps minor technica variations, we were a11 pretty much in accord. The great majority of operators throughout the country were empIoying more or Iess as a standard procedure the two-stage suprapubic operation; a few, notabIy Hunt whiIe at The Mayo CIinic, favored the one-stage suprapubic procedure, feeIing that the better visuaIization meant more accurate contro1 of bIeeding and an added factor of safety. Young and a few others, mostIy those trained under him, were doing most of their cases by the perinea1 route and showing perhaps better mortaIity statistics than any of us. CauIk was standing braveIy and practicaIIy aIone with his cautery punch. And may I say in passing that when the Iast word is finaIIy said on the subject of cystoscopic resection and we are trying to give credit where credit is due, the name of John CauIk wiI1 Ioom large on the Iist. The merit of any surgica1 procedure stands or faIIs not so much on technica variations as it does upon the proper appreciation of the underIying pathoIogica1 condition. I beIieve that CauIk has based his attitude upon a proper appreciation of this factor and to that extent has been right. I shaI1

discuss this point a IittIe more at Iength Iater on in my paper. However, I repeat, with a few minor technica variations, we were a11 more or Iess in agreement. We had a11 of us seen and perhaps taken a smaI1 part in the gradua1 evoIution of these probIems. We had seen the frightfu1 mortaIity and morbidity of the earIy days of the present century reduced to aImost a negIigibIe factor, IargeIy because of painstaking attention to the detaiIs of seIection, preparation and after care of our cases rather than to any increase in ski11 or improvement in operative technique. In other words, we were graduaIIy settIing into an attitude of smug compIacency, which of course was not a heaIthy attitude. In the Iast few years we have had presented to us: accurate suturing of the bIadder neck foIIowing suprapubic enucIeation; one-stage suprapubic prostatectomy with compIete cIosure of the bIadder without drainage as suggested by Lower, radica1 resection of the bIadder neck for fibrotic prostate as suggested by Crabtree, and finaIIy, and perhaps most dramatic of aI1, the cystoscopic resection of a11 types of prostatic obstruction as so abIy advocated by Davis, McCarthy and others. These contributions, a11 of them extremeIy vaIuabIe, have, as I say, reopened the whoIe subject and brought about a thoroughIy heaIthy and desirabIe state of affairs. When these newer methods have been properIy evaIuated and have been subjected to the acid test of time they wiI1, of course, inevitabIy gravitate to their proper pIaces as more or Iess important additions to the armamentarium avaiIabIe for handIing this important group of cases.

* Read before the North CentraI Branch of the American UroIogicaI Association, Detroit, Mich., Oct. 28, 1932.

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AI1 of these recent contributions, particularly those deahng with cystoscopic have been tinctured by the resection, I say enthusiasm of t,heir advocates. this in no spirit of criticism but as a statement of a IogicaI and commendabIe fact. No forward step can be taken unIess it is backed by a high degree of enthusiasm on the part of its advocates. This wouId seem an appropriate time to take stock of our present position. It wouId seem, too, appropriate that this task might be modestIy undertaken by an average uroIogist (which I like to consider myserf) working in an average cIinic, obtaining average resuIts and entertaining no brief for any particuIar pIan of procedure. I am basing my paper, as I aIso base my present attitude, in part upon a study of 125 consecutive cases recentIy admitted to my cIinic (covering approximateIy the period during which cystoscopic resections have become popuIar), in part upon a carefu1 study of the recent Iiterature and in no smaI1 measure upon a more or Iess phiIosophica1 contempIation of the whole probIem, growing out of a professiona Iifetime spent in uroIogica1 work. May I at this time state my attitude, which is the most important point, perhaps the onIy point in my paper. I beIieve that we shouId make every effort, and now particuIarIy when we have so many weapons at our command, to fit our procedure to the particuIar requirements of each individua1 case, rather than fit the patient to the operation. This sounds Iike a very trite statement and it might we11 be said that there can be no argument on that score. This is freeIy admitted and yet in actual practice how often does it happen that the most obvious things are apparentIy o\,erIooked. The choice of procedure in cases of prostatism depends upon severa factors, first and foremost of course upon the fundamenta1 underIying disease: the type and character of obstruction. There are, however, numerous other factors of aImost equal importance which enter into the

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problem in many cases, such as the degree of obstruction, the absence or presence and degree of infection, the amount of discomfort existing, the age and genera1 ph)-sical condition of the patient, his economic status, his habits, his occupation and e\‘en the location in which he Iives. AII or any of these ratter items may be the deciding factor in determining whether a given patient shouId be subjected to any form of operative treatment. In my group of 125 cases recentIy studied (excIuding cases of carcinoma) in a11 of which the patients were admitted to the hospita1 for probabIe operation, there were 16 upon whom no form of operation was done; one because he was moribund, 2 because their various tests, which are ordinariIy employed, did not measure up to required standard of operabiIity, 4 who were operabIe but refused operation and 9 others who were perfectIy good operative risks and requested operation and yet who in our opinion couId be maintained perhaps indefiniteIy in comfort without any form of surgery. I see many other patients in my office (not included in this study group) who beIong in this same category; patients who are referred for and expect surgery, who are apparentIy perfect.17 good surgica1 risks and yet, in shouId not be operated my opmion, upon. Given a robust man in the early in the business or prosixties, active fessional worId, who has a moderate degree of prostatic enIargement, who has 2 ounces or a Iittle more of cIear residua1 urine, who voids once or twice at night and whose stream is sometimes a IittIe sIo\l- in starting, such a man should not, in my opinion, be subjected to the risk (and there is aIways a risk) of an! form of surgica1 operation, provided that: he is inteIIigent and is made thoroughI? famiIiar with his condition and prospects, provided too that he is abIe and wiIIing to compIy with obvious hygienic reguIations, incIuding the carefuI avoidance of excesses, aIcohoIic, dietary and otherwise, provided aIso that neither his business

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nor habits are such as to remove him for Iong periods of time from ready access to skiIIed surgical attention and finaIIy provided that he wiI1 report at reasonabIe intervaIs for a check on his progress. The same course of reasoning appIies under simiIar conditions to men in the middIe eighties, perhaps retired from business, reasonabIy good operative risks, if operation were indicated and yet whose span of Iife expectancy is 0nIy two or three years at the best. This attitude may seem uItraconservative but I beIieve it is correct. I think that those of us who draw our patients from a comparativeIy smaI1 radius and are therefore abIe to keep in more intimate touch with them are prone to entertain a more conservative attitude than exists in a few of the Iarger cIinics, many of whose patients come from great distances. I am quite sure that many patients are operated upon, and quite properIy so, in some of the Iarger cIinics who wouId be treated expectantIy by some of us who do our work in smaIIer cIinics. Most of these patients do not require nor are they benefited by any form of treatment other than the hygienic measures aIIuded to. There are, however, a few patients who are very def?niteIy benefited by simpIe IocaI measures. The man with a moderate degree of obstruction, cIear urine and a Iarge soft, boggy, eIastic prostate may, not infrequentIy, be much improved and operation indefiniteIy deferred by simpIe massage. PIease do not infer from this that I recommend or practice this poIicy as a I do maintain that in routine procedure. properIy seIected cases it is of definite vaIue and this is based upon a sound pathoIogica1 background. It is my understanding that the histoIogica1 changes in the ordinary case of prostatic hypertrophy, the so-caIIed adenomatous hyperpIasia, begin as a fibrosis surrounding the prostatic ducts near their exit. These changes have usuaIIy been interpreted as inflammatory in nature. I am convinced from a series of studies conducted

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at our clinic, which consisted in carefu1 sections of a Iarge number of prostates removed at operation pIus aIso a carefu1 study of prostates removed at autopsy from patients of a11 ages dying from various CardiovascuIar Iesions and which showed a striking similarity, that these evidences of earIy fibrosis are primariIy vascuIar in origin. I have discussed this at some Iength in another paper.’ At any rate fibrosis is foIIowed by constriction of the ducts and gross overdistention of the prostatic acini, which constitutes the buIk of the enIargement in the early stages. This being the case: the histoIogica1 picture being one of vascuIar deterioration, fibrosis, duct stricture, and acini overdistended with the products of secretion, it IogicaIIy foIIows that improvement cIinicaIIy and histoIogicaIIy shouId foIIow massage. I am sure that this is true in a smaI1 number of carefuIIy seIected cases. This histoIogica1 conception provides aIso a rationa background for the work which CauIk has been doing and his pubIished results over a period of severa years. He cIaims that foIIowing the remova of reIativeIy smaI1 portions of the prostate at the bIadder neck and floor of the deep urethra, the remainder of the gIand atrophies or shrinks. ExactIy the same conception may of course be appIied to the newer methods of resection. However, I do not think that this part of the probIem is by any means settIed as yet. And now that we have considered briefly that smaII group of cases that can be handIed conservativeIy, Iet us proceed to a consideration of that much Iarger group of cases wherein the degree of obstruction and severity of symptoms demand some form of surgical reIief. Here the choice of procedure wiI1 depend, or shouId depend, first and foremost upon the type of prostatic disease with which we are deaIing and secondariIy upon the physica vigor and operabiIity of the individua1. Without making an attempt to be too scientific or to express this thought with any degree of mathematica1

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I think it is safe to say that accuracy, the great majority of cases of prostatism wiI1 faI1 under the head of what may roughIy be caIIed genera1 prostatic enIargement. I beheve that the majority of these cases are best handIed by means of the two-stage suprapubic operation. That I am sure is my own attitude and I see no present reason for changing it. In the present series of cases studied, out of 93 operations performed (excIuding cystotI omies onIy), 65 were of this type. realize that there are a number of exceIIent operators who prefer and practice aImost routineIy the one-stage suprapubic operation, cI&ming the added advantage of better visuaIization, more accurate remova1 of a11 obstructing eIements and more accurate contro1 of hemorrhage. This is a11 true in a measure aIthough I do not personaIIy subscribe to some of the more or Iess compIicated methods of suture of the bIadder neck and prostatic bed foIIowing suprapubic prostatectomy. I think that these advantages, if they are advantages, are far more than baIanced by the disadvantage of Iess adequate preIiminary drainage and proIonged time of operation and I am sure that added time, even with bIock anesthesia, is a factor to some of these oId men. There is very IittIe difference in the Iength of hospitaIization for the two groups, and right here I shouId Iike to make another point and I cannot stress my attitude on this point too vigorousIy. I do not think that the eIement of time shouId enter very IargeIy if at a11 into our consideration when eIecting our choice of procedure. After aI1, what difference does a few weeks, a few more hospita1 days and a few extra dressings mean to our oId patient if, by trying to cut corners, we add even one iota to the risk invoIved. I have no quarre1 with the men who prefer to practice more or Iess routineIy perinea1 prostatectomy. Their mortaIity statistics wouId appear to be a shade better and their end resuIts probabIy just as good. One cannot be too extravagant in praise of the work done

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by Young in developing the technique of perinea1 prostatectomy and pIacing it upon a sound anatomica basis. There is onIy one comment which I wouid stress in comparing the two operations and that is the matter of genera1 appIicabiIity. It wouId seem to me that all cases of the type under consideration are suitabIe for suprapubic attack whiIe there are a few, incIuding the huge intravesica1 growth, which I do not beIieve that even the most ardent perinea1 prostatectionist would consider approaching by this route. I can best sum up my persona1 attitude toward these two operations by saying that if I had to have my own prostate removed and it were to be done in a clinic where perinea1 prostatectomy was more or Iess of a routine procedure, I shouId expect and hope that it wouId be done through the perinea1 route. On the other hand, if it were to be done in most of the cIinics in this country, I shouId expect and most ardently hope that it wouId be done suprapubicaIIy. In my own smaI1 group there were one perinea1 prostatectomy and 5 one-stage suprapubic operations. It is my feeIing that the great majority of cases, comprising this group which I have roughIy cIassified as ordinary prostatic enIargement, are being handIed, and properIy so, by means of one form or another of forma1 prostatectomy. It is my feeIing too that this attitude shouId and wiI1 persist for a Iong time, perhaps indefiniteIy and that other methods of treatment shouId be reserved for a smaIIer group of carefuIIy seIected cases. Time aIone can teI1 how broad or narrow this group may be. Let us now proceed to a consideration of the most recent and most dramatic contribution of transurethra1 operations. I think this has been one of the most important contributions to urology made in recent years and that men like CauIk, Stern, Davis, McCarthy, AIcock and others are entitIed to no end of credit for the vast amount of work which they have done in deveIoping and perfecting this

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method. Yet on the other hand I frankIy fee1 that they have been over-enthusiastic in their attitude and have stretched their indications beyond the Iimits of rationa surgery. This attitude is perhaps commendable in a way for the time being since it is onIy by means of such enthusiasm that new ideas may be carried forward and their merit properIy evaIuated. However if this attitude is persisted in without an occasiona soft peda1 appIied here and there, I beIieve it wiI1 actuaIIy do harm and retard progress. May I at this time interpoIate one thought. The papers we read and the discussions which we contribute at these meetings accompIish two ends, one immediate, the other more remote. First we thresh out many mooted points and cIarify many obscure situations among and for ourseIves and out of our differences evoIve that which speIIs progress. SecondIy, our concIusions, sometimes a bit immature, are immediateIy adopted as a soIemn text by hundreds of occasiona operators whose resuIts are never pubIished and whose mortaIity statistics are buried with their patients. If for no other reason than that, it behooves us to be very conservative in our concIusions. I think that AIcock is doing a spIendid piece of work. You are of course a11 famiIiar with it. He has for over a year now, with his great weaIth of materia1, empIoyed the eIectrotome to the excIusion of a11 other methods. He has approached the probIem with an open mind and is doing his job with the avowed purpose of evaIuating for himseIf and of course for uroIogists everywhere the merits and demerits of the procedure. You are referred to his paper for exact statistics. It is interesting to note that his mortaIity for his first 30 cases was excessiveIy high, whiIe that of his Iater cases was very Iow. This wouId seem to indicate that the mortaIity depended in Iarge measure upon the degree of technica skiI1. It wouId aIso seem to indicate that, in the near future, many Iives wiI1 be sacrificed upon the altar of uroIogica1 education. AI1 of

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us, of course, have our ear to the ground waiting for AIcock’s end-resuIts, as we have for the end resuIts of Davis, McCarthy and others who are using this method extensiveIy. In our own smaI1 series there were 12* cases of eIectrotome resections, with one death directIy attributabIe to the operation. In this case there was intraperitonea1 rupture of the bIadder. The operation was done under spina anesthesia, which according to McCarthy is contraindicated in these cases. Of course it is too earIy to venture any predictions as to our end-resuIts. The immediate resuIts appear satisfactory. The pIace which this new procedure wiI1 eventuaIIy occupy wiI1 depend very IargeIy upon two factors, the operative risk and the end-resuIt. As I said before I do not beIieve that the number of hospita1 days is entireIy a vaIid factor. WhiIe the pubIished reports of some of the pioneers might Iead one to beIieve that the operative risk is a negIigibIe factor, I have a feeIing that when further returns are in, the average mortaIity may we11 be comparabIe with that of forma1 prostatectomy as now done in most of our cIinics. We have aIready AIcock’s high mortaIity in his earIy cases, my own death in a very smaI1 series and there have been a few others which have come to my attention (unoffIciaIIy; so to speak), cases operated upon in smaI1 hospitaIs by “occasiona1” operators. These cases of course wiI1 never be pubIished. It is aItogether too earIy to form any concIusions as to end-resuIts. I could make this Iast statement without fear of contradiction except for one thing and that is the work of CauIk. WhiIe the technique of his operation differs somewhat from that of the newer methods, the operations are practicaIIy identica1 and he has been working Iong enough, foIIowed his cases and pubIished his resuIts to *At the present writing, November I, 1932, 12 more cases have been operated upon by this method, with no mortatity and no morbidity and with excelLent primary results.

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the end that his conchrsions are of dehnite vaIue and, we must admit, lend support to the attitude of some of the other enthusiasts. I do not know what to say to this other than that, perhaps, we need even more time and experience. My own attitude is that, in the Iight of our present knowIedge and experience, the erectrotome shouId be reserved for smaI1 median Iobe hypertrophies and Iarge thick hyperpIastic median bars. This has been my practice, therefore the few cases in my own series were of that group. For the fibrotic median bars and minor degrees of obstruction sometimes noted after prostatectomy and caused either by scar tissue or smaI1 nubbins of prostate which have been overIooked or have recurred, I much prefer the CauIk technique to any other form of procedure. The removal of a smaI1 amount 0nIy of tissue is required, two or three bites being normaIIy ampIe. The apparatus is much Iess compIicated, the technique is simpIe, the entire operation can be compIeted quickIy, safeIy and positiveIy and the resuIts in my hands have been uniformIy exceIIent. There were 6 of these operations in my group. I have reserved for fina consideration a group of cases which have unti1 recentIy given me more troubIe than any of the others. I refer to the smaI1 fibrotic prostate, scIerosis of the bIadder neck if you Iike, associated with a high degree of obstruction and compIicated, as they frequentIy are, by prostatic caIcuIi. I have operated in a great many of these cases by various methods and have not unti1 recent years had a singIe case in which I was entireIy satisfied with my resuIts. I was far from satisfied with the resuIts of transurethral procedures and it had been my practice to approach most of my cases by means of a one-stage suprapubic operation for the purpose of securing good exposure, ease of approach and good visuaIization. I have toiIed IaboriousIy with my finger, my finger nai1 and various types of punch forceps and have had to show for my

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prolonged efforts a few insignificant bits of tissue, a IittIe grave1 and a raggedlooking bladder neck. I am sure that many of you wiI1 recaI1 simiIar experiences. I have aIways felt, at the end of such an operation, that I had done a very unsatisfactory and a very unsurgical sort of a job and the Iater rest&s have invariabIy warranted that attitude. My patients ha1.e reported Iater at the offrce or clinic with t,heir residua1 urine markedly reduced but stiI1 present in fair amount, the character of their stream much improved but far from satisfactorv and, most important of aI1, the dysuria and frequency much the same as before operation. In other words, an entireIy unsatisfactory resuIt. I beIieve that the answer to this very trying probIem consists in radica1 resection of the prostate and scIerosed bIadder neck by the perinea1 route as recommended by Crabtree. This operation is based upon sound surgica1 and anatomical principIes and, in my judgment, Crabtree has made a contribution quite as important as the much-heralded transurethra1 resection. For some reason or reasons, however, this operation does not appear to have caught the imagination or engaged the attention of uroIogists in genera1 and has not been accorded the consideration to which it is entitled. I beIieve there are two reasons for this attitude: first, the fear of technica difficulties and secondIy, the dread of incontinence foIIowing operation. A Iarge number of uroIogists, perhaps the majority, have had very IittIe or no training m perineal surgery and they quite naturaIIy contempIate a careful, accurate dissection of the perineum with a certain amount of fear and trembIing. I can speak very feeIingIy on that subject since I formerIy belonged in that group myself. (There was 0nIy one perinea1 prostatectomy in my- present series.) This is however byno means an unsurmountabIe objection. I am sure that anyone with a fair degree of natural surgica1 skiI1, a carefu1 review of

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the anatomy, who has once seen the operation done, wiII have no specia1 d&uIties. That has been my experience and I consider myseIf onIy an average operator. In fact, strange as it may seem, I have found this operation much simpIer from a technica point of view than the ordinary perinea1 prostatectomy. I shaI1 make no effort at this time to describe the technique. That is ampIy covered in Crabtree’s papers, with which you are a11 famiIiar. And now on the second point: the fear of postoperative incontinence. I see no surgica1 or anatomica reason why, if the operation is properIy performed, this comphcation shouId enter very IargeIy into our consideration. WhiIe my own persona1 experience has been Iimited to 3 of these operations, and whiIe I reaIize that such a smaI1 group means IittIe or nothing from a statistica point of view, even so smaI1 a group is convincing to the individua1 operator. My resuIts have been exceIIent, there has been no incontinence and onIy one operative complication. This occurred in a man of fortyfour with a grossIy infected prostate and a high degree of obstruction. He had been subjected, before coming under my care, to three or four punch operations with no improvement in his condition. He had a marked degree of periprostatitis, the perinea1 dissection was moderateIy diffIcuIt and in the course of this dissection an accidenta wound was made in the rectum. This was repaired and the operaHis immediate convation compIeted. Iescence was compIicated by a breakdown in the recta1 wound and a feca1 fistuIa which finaIIy cIosed spontaneousIy and at the present time, one year after operation, he has an absoIuteIy perfect resuIt.

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Crabtree in a recent persona1 communication reports a tota of 26 cases operated upon by this method over a period of eight years. (This, by the way, is fair evidence that he is seIecting h’is cases carefuIIy.) There was no mortaIity; there was one case of partial incontinence Iasting three or four months and eventuaIIy going on to compIete recovery; one case was “doubtfu1.” AI1 the others had perfect resuIts with no incontinence and no residua1 urine. Of course it wiI1 take a Iong time and the experience and resuIts of many operators before the indications and merits of this operation can be finaIIy determined. I am confident, however, that it wiI1 eventuaIIy occupy an important pIace. In concIusion, I should Iike once more to stress the one point which I have attempted to make in this paper. Prostatism provides us with a wide variety of probIems; we have avaiIabIe a wide variety of methods of treatment; and it devoIves upon us to make every effort to erect the procedure which is best adapted to each individua1 case. I reaIize that my paper might be more convincing if it were boIstered with a mass of statistica evidence. It has not, however, been a statistica1 paper but rather a more or Iess phiIosophica1 contempIation of the whole probIem, an expression of my personal views, for what they are worth upon a few of the mooted points and an effort to provide a suitabIe groundwork upon which to base what I trust may be a profitabIe discussion. REFERENCES

I. RATHBUN, N. P. Some of the renaI compIications of Drostatism. J. thol., 26: no. I, Jan., 1931. 2. CRABTREE, G. Surgery oi fibrous prostate-operation for tota excision of gIand. AM. J. SURG., n.s. 8: 958-969, 1930.