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Experimental Combination of Electroresection and cryosurgery for Prostatectomy Clinical Appliance of Cryosurgery as a Tool for Better Prostatic Electroresections
Vol. 105, June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
EXPERIMENTAL COMBINATION OF ELECTRORESECTION AND CRYOSURGERY FOR PROSTATECTOMY. CLINICAL APPLIANCE OF CRYOSURGERY AS A TOOL FOR BETTER PROSTATIC ELECTRORESECTIONS PANOS J. ROUVALIS The elimination of necrotic tissue following prostatic cryosurgery is a major problem. 1- 5 Nevertheless, serious complications also are associated with transurethral electroresection: 1) difficulty or even impossibility of resecting large glands in less than 1 hour, 2) hemorrhage accompanied by sudden elevation of blood pressure, 3) poor condition of patient or insufficient anesthesia necessitating completion of procedure as soon as feasible, 4) poor visualization and localization owing to profuse bleeding at end of procedure and 5) technical failures owing to inadequate reserve supplies and lack of experience. Occasionally the patient may have to be returned to the operating room for control of hemorrhage or for a multiple-stage operation. 6 It is not surprising that many surgeons prefer an open operation. We combined 2 methods of prostatectomy to achieve a more radical and safe procedure. We tried cryosurgery followed by resection and resection followed by cryosurgery. MATERIALS AND METHODS
Cryosurgery followed by resection. A midline
suprapubic incision was made in 10 dogs. The bladder was opened and the Linde CE-4 cryoprobe was placed transvesically to the prostatic urethra, after dilatation with sounds. 7 An average freezing time of 150 seconds at minus Accepted for publication September 1, 1970. Rouvalis, P.: Comparisons between plain cryosurgery, TUR, combined TUR and cryosurgery, and open surgery. Internat. Surg., 53: 4, 1970. 2 Rouvalis, P.: Der heutige Stand der Kaltechirurgie der Prostata. Urologe, 5: 279, 1970. 3 Gonder, M. J., Soanes, W. A. and Shulman, S.: Cryosurgical treatment of the prostate. Invest. Urol., 3: 372, 1966. 4 Jordan, W. P., Jr., Walker, D., Miller, G. H., Jr. and Drylie, D. M.: Cryotherapy of benign and neoplastic tumors of the prostate. Surg., Gynec. & Obst., 125: 1265, 1967. 5 Backer, 0. G. and Lund, F.: Kryoprost.atektomi. Apparatur og operationsteknik. Nord. Med., 77: 532, 1967. 6 Barnes, R. W., Bergman, R. T. and Hadley, H. L.: Encyclopaedia of Urology. Berlin: SpringerVerlag, vol. 6, 1959. 7 Soanes, W. A., Gonder, M. J. and Shulman, S.: 1
826
160C was necessary for complete freezing of the prostate. A small caliber Stern-::\IcCarthy electrotome was passed through the vesical opening into the cavity of the bladder. The vesical opening had been sutured in a purse-like manner around the sheath of the rcsectoscope in order to hold water with an average temperature of 20C. Resection was practically impossible for the first 10 minutes following freezing because the tissue was still hard. About 20 or 30 minutes post-freezing 2 pieces of tissue (the average length of which was 120 mm. and average depth 30 mm.), the resectoscope was placed within the prostatic urethra and tissue was resected from the section between 9 and 12 o'clock (fig. 1, A). No bleeding vessel was identified. It seemed that bleeding, although not excessive, came from the complete cut surface and it was difficult to control by means of electrocoagulation. Bleeding ceased spontaneously the next day. Tissue was softer in cutting due to prostatic edema.s- 9 A day later 3 pieces of prostatic tissue from the already cut section were resected. Bleeding was less this time. The tissue was more bluish-white and more sticky in cutting. Two days postoperatively 3 pieces of tissue were resected and no bleeding was encountered. Three days postoperatively 3 more pieces of tissue were resected, always from the same section, and again there was no bleeding (fig. 1, B). The verumontanum was not easily defined (edematous prostate). Because of difficulty in distinguishing the prostatic tissue from the capsule, perforation was done in 3 cases although later cuts were not as deep as previous ones. During prostatic resection the visual field was obscured with cloudy material (rnicrotissue of frozen prostate divided probably after Apparatus and technique for cryosurgery of the prostate. J. Urol., 96: 508, 1966. 8 Gonder, M. J., Soanes, W. A. and Smith, V.: Experimental prostate cryosurgery. Invest. Urol., 1: 610, 1964. 9 Gonder, M. J., Soanes, W. A. and Smith, V.: Chemical and morphologic changes in the prostate following extreme cooling. Ann. N. Y. Acad. Sci., 125: 716, 1965.
EXPERIMENTAL COMBINATION OF ELECTRORESECTION AND CRYOSURGERY
827
Frn. 1. Necrosis and hemorrhagic infiltration. A, piece resected 30 minutes after freezing. B, piece rcsected 3 days after freezing. electric vibration). Postoperatively there was no hemorrhage and the dogs were sacrificed in 6 days. Resection fallowed by cryosurgery. The prostatic gland of 10 animals was approached as previously described. The right side of the gland was partially resected, leaving the left side for comparison. The diathermy used was a Dovie model CSV on medium power cutting current. The Linde CE-4 cryoprobe was placed into the enlarged prostatic urethra and the remaining prostate was frozen at minus 160C for an average of 110 seconds. Bleeding in all cases was no more than that of the usual cryosurgical approach, (minimal1°), of equal density on the complete surface of the lumen and ceased spontaneously by 7 to 11 hours postoperatively. Postoperatively, there was no hemorrhage and the dogs were sacrificed in 6 days (figs. 2 and 3). Clinical study. We then did partial resections followed immediately by cryosurgery in 100 patients. The youngest patient was 56 years old and the oldest was 93 (table 1). All operations were done under low epidural anesthesia. Re-
sections were done at the more bulky point, or the point with the larger diameter the capsule to the central lumen), to achieve equal thickness between lumen and so that freezing was equally extended ~o all parts of the remaining tissue towards the In cases in which equal prostatic thickness vnts not achieved, complete freezing was helped by pressing the index finger at the thicker prostatic point the cryoprobe (precipitated freezing). We thoroughly resected the iutravesical part when possible so that accidental temporary of the ureternl orifices 11 was practically avoided. \Ve have been especially careful to avoid thoroug;h resection of the hypertrophied tissue near the bladder neck and the anterior lobe because both arc critical points to cryoperforation and tbeir anatomical positions do not favor digital palpation duriu1; freezing (in order to check (table 2). In 8 cases in which blood pressure elevation was difficult to control, resection vrns stopped at an earlier stage and cryosurgery wac-; clone
10 Ortved, W. E., O'Kelly, F. M., Todd, I. A. D., Maxwell, J. B. and Sutton, M. R.: Cryosurgical prostatectomy: a report of 100 cases. Brit. J. U rol.,
11 Roberts, l'v1., Longo, F. and Lattimer, J. surgery of ureteral orifices in
39: 577, 1967.
551, 1968.
828
ROUVALIS
Cryosurgery has been used mainly for hemostatic purposes in 6 additional cases of grades 1 and 2 prostate resection. In these cases necessary freezing time has not exceeded 0.3 to 0.5 minutes at minus 160C. Vasectomy was performed routinely. RESULTS
Fm. 2. A, resected pieces and specimen. B, drawing of specimen.
Surgical stress has been minimized in our cases since the combined procedure of transurethral resection and cryosurgery has not exceeded 1 hour. There has been no need for transfusion and we had no mortalities. Hospitalization has been slightly longer than that following resection but much shorter than that following cryosurgery (table 3). Complications included epididymitis in 3 patients who responded to antibiotic therapy. One patient experienced mild incontinence which ceased 15 days postoperatively. Meatal strictures in 2 cases were surgically corrected. In 1 patient secondary hemorrhage occurred 20 days postoperatively but ceased after catheter insertion and washing. 1. Age distribution (100 cases)
TABLE
immediately. The same was done in 6 patients with tendency to shock, in whom blood pressure was maintained with stronger vasopressors. In cases in which the apex was indistinct and the probe was difficult to localize we calculated the anatomical position of the apex by the rigidity of the prostatic bed, the remaining curves of lateral lobes, the anterior lobe and the bladder neck margin. We fixed our index finger at that point and inserted the probe into the prostatic urethra until each nib reached our index finger. In cases in which the diameter of the prostatic fossa was larger than the probe, we palpated digitally to achieve complete fixation of the wider fossa around the probe. During cryosurgery following resection we have been careful not to raise the probe's holding part, because its freezing end would move downward, the lower part of the bladder neck would be pressed and freezing process to this would be dangerous because of its relation to the bowel. Preventively, we have placed all patients in a slight Trendelenburg's position. The probe has not been moved in and out since such movements would probably cause bladder neck overfreezing.
Age (yrs.)
No. Cases
50-59 60-69 70-79
9 35 37 19
80 or more
TABLJ,
2 No. Cases
Prostate: Grade 3 Grade 4 Resected tissue:* 25-35 gm. 35-70 gm. Freezing time of remaining tissue :t ~"2 to lVi mins. l};a to Hi mins.
59
41 34 66 56
44
* Resection completed in less than 1 hour.
t Minus 160 degrees. TABLE
3. Days of catheter removal
No. Days
No. Cases
5 6-7 8
36 39 17
EXPERIMENTAL COMBINATION OF ELECTRORESECTION AND CRYOSURGERY
829
FIG. 3. A, periphery of damaged area after 6 days. Some cells at basement membrane of gland survived. necrosis and hemorrhagic infiltration. C, necrosis and hemorrhagic infiltration-bigger vessel lumen. ghost of glands. E, periphery-slight leukocytic infiltration, capsule intact.
/l/ljl/l/l[lll/1/1/ljlll/l/l/ljl/1/lllll\l\lllllll\l\l\l\l\l\1\
0
'I
2
3
FIG. 4. Fragments of necrotic tissue voided spontaneously. A, following combined TUR and cryo-surgery. B, following plain cryosurgery.
830
ROUVALIS
In most cases pyuria persisted for 30 to 60 days. Although no protective solutions have been used, absorptive complications have not been encountered since we have not resected completely towards the periphery (location of large lumen veins and sinuses). Thorough followup of cases has not revealed malignant development to date. Local hardness in some cases has been proved histologically to be a benign reaction. 12- 14 Nineteen of our patients had carcinoma of the prostate. There must be a minimal vascular spread of malignant cells when cryosurgery is done as the second part of the procedure. 15 DISCUSSION
Cryosurgery followed immediately or during the first postoperative days by resection is difficult to perform and there is danger of perforation because of the changing characteristics of tissue post-freezing. Thorough hemostasis by electrocoagulation has proved difficult. There is the disadvantage of the 2-stage operation. Cryosurgery followed in 15 days by resection has been attempted by others as well as by us. These procedures are easy to perform at that period but there is always the disadvantage of a 2-stage operation. Resection followed immediately by cryosurgery is applicable and easy to perform. No changes other than those usually seen after cryosurgery have been noted in the histology of the margin of the resected lumen or in any other section of the remaining tissue. Because of the safety secured by cryosurgery in case of uncontrollable hemorrhage during resection, we prefer quick cutting for thorough hemostasis; therefore, we are able to resect more grams of prostatic tissue in 1 hour, thus surpassing our standard. This combined procedure increases the extent of radicality and, therefore, enables operation per urethram on bigger glands. The volume of necrotic tissue which remains after cryosurgery following resection is less than 12 Ehrlich, R. M., Tannenbaum, M., Roberts, M. and Lattimer, J. K.: Experimental prostate cryosurgery: a study utilizing radioautography and electron microscopy. J. Urol., 101: 890, 1969. 13 Soanes, W. A. and Gonder, M. J.: Cryosurgery in benign and malignant diseases of the prostate. Intern. Surg., 61: 104, 1969. 14 Soanes, W. A., Gonder, M. J., Albin, R. J., Maser, M. D. and Jagodzinski, R. V.: Clinical and experimental aspects of prostatic cryosurgery. J. Cryosurgery, 2: 23, 1969. 16 Soanes, W. A. and Gonder, M. J.: Use of cryosurgery in prostatic cancer. J. Urol., 99: 793, 1968.
that following cryosurgery alone. Its elimination through the tunnel left by transurethral resection (fig. 4) is easier and the danger of a focus for sepsis and septicemia (2 per cent fatal in cryosurgery only) is much less. 16 The resected pieces of tissue allow more accurate biopsy results than those of the needle biopsy, which we use to take preliminary tests when performing cryosurgery alone. Usually we do not resect the most hemorrhagic points, that is the region of the bladder neck (entrance of urethral group of arteries-division of prostatic artery17) and towards the capsule, by the end of the procedure (contraction of capsular arteries) but we approach them by cryosurgery so that loss of blood is minimized. Postoperative bleeding following cryosurgery after resection has been minimal, as it is after cryosurgery alone, and much less than that following resection alone. Frequently, towards the end of resection, surgeons believe that bleeding is well controlled, but later it is obvious that they must repeat a coagulation, which is difficult because narcosis has passed and clots obscure prostatic fossa and bleeders. In such cases quick freezing under local anesthesia18 can prove of great value as shown in our 6 additional cases. SUMMARY
We first experimented with cryosurgery followed immediately by resection and then with resection followed immediately by cryosurgery. We found the latter combination easier to perform and have used it in 100 cases. There has been no mortality and only few complications which have been easy to prevent or control. The combination of transurethral electroresection followed immediately by cryosurgery minimizes the disadvantages of each method when applied separately. Dr. Maurice J. Gonder taught us the cryoprostatic technique and Dr. Nicos Papacharalampous made the photomicrographs.
100 Vasilissis Sofias Avenue, Athens 610, Greece 16 Rouvalis, P.: Cryosurgical prostatectomies, our modifications and results. In: 22nd Tagung der Deutschen Gesellschaft fur Urologie. Berlin, October 23-26, 1968. Wiesbaden: Carl Ritter & Co., p. 87, 1969. 17 Flocks, R.H.: The arterial distribution within the prostate gland: its role in transurethral prostatic resection. J. Urol., 37: 524, 1937. 18 Rouvalis, P.: Cryosurgery of the prostate under local anesthesia. J. Urol., 102: 244, 1969.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
EXPERIMENTAL COMBINATION OF ELECTRORESECTION AND CRYOSURGERY FOR PROSTATECTOMY. CLINICAL APPLIANCE OF CRYOSURGERY AS A TOOL FOR BETTER PROSTATIC ELECTRORESECTIONS PANOS J. ROUVALIS The elimination of necrotic tissue following prostatic cryosurgery is a major problem. 1- 5 Nevertheless, serious complications also are associated with transurethral electroresection: 1) difficulty or even impossibility of resecting large glands in less than 1 hour, 2) hemorrhage accompanied by sudden elevation of blood pressure, 3) poor condition of patient or insufficient anesthesia necessitating completion of procedure as soon as feasible, 4) poor visualization and localization owing to profuse bleeding at end of procedure and 5) technical failures owing to inadequate reserve supplies and lack of experience. Occasionally the patient may have to be returned to the operating room for control of hemorrhage or for a multiple-stage operation. 6 It is not surprising that many surgeons prefer an open operation. We combined 2 methods of prostatectomy to achieve a more radical and safe procedure. We tried cryosurgery followed by resection and resection followed by cryosurgery. MATERIALS AND METHODS
Cryosurgery followed by resection. A midline
suprapubic incision was made in 10 dogs. The bladder was opened and the Linde CE-4 cryoprobe was placed transvesically to the prostatic urethra, after dilatation with sounds. 7 An average freezing time of 150 seconds at minus Accepted for publication September 1, 1970. Rouvalis, P.: Comparisons between plain cryosurgery, TUR, combined TUR and cryosurgery, and open surgery. Internat. Surg., 53: 4, 1970. 2 Rouvalis, P.: Der heutige Stand der Kaltechirurgie der Prostata. Urologe, 5: 279, 1970. 3 Gonder, M. J., Soanes, W. A. and Shulman, S.: Cryosurgical treatment of the prostate. Invest. Urol., 3: 372, 1966. 4 Jordan, W. P., Jr., Walker, D., Miller, G. H., Jr. and Drylie, D. M.: Cryotherapy of benign and neoplastic tumors of the prostate. Surg., Gynec. & Obst., 125: 1265, 1967. 5 Backer, 0. G. and Lund, F.: Kryoprost.atektomi. Apparatur og operationsteknik. Nord. Med., 77: 532, 1967. 6 Barnes, R. W., Bergman, R. T. and Hadley, H. L.: Encyclopaedia of Urology. Berlin: SpringerVerlag, vol. 6, 1959. 7 Soanes, W. A., Gonder, M. J. and Shulman, S.: 1
826
160C was necessary for complete freezing of the prostate. A small caliber Stern-::\IcCarthy electrotome was passed through the vesical opening into the cavity of the bladder. The vesical opening had been sutured in a purse-like manner around the sheath of the rcsectoscope in order to hold water with an average temperature of 20C. Resection was practically impossible for the first 10 minutes following freezing because the tissue was still hard. About 20 or 30 minutes post-freezing 2 pieces of tissue (the average length of which was 120 mm. and average depth 30 mm.), the resectoscope was placed within the prostatic urethra and tissue was resected from the section between 9 and 12 o'clock (fig. 1, A). No bleeding vessel was identified. It seemed that bleeding, although not excessive, came from the complete cut surface and it was difficult to control by means of electrocoagulation. Bleeding ceased spontaneously the next day. Tissue was softer in cutting due to prostatic edema.s- 9 A day later 3 pieces of prostatic tissue from the already cut section were resected. Bleeding was less this time. The tissue was more bluish-white and more sticky in cutting. Two days postoperatively 3 pieces of tissue were resected and no bleeding was encountered. Three days postoperatively 3 more pieces of tissue were resected, always from the same section, and again there was no bleeding (fig. 1, B). The verumontanum was not easily defined (edematous prostate). Because of difficulty in distinguishing the prostatic tissue from the capsule, perforation was done in 3 cases although later cuts were not as deep as previous ones. During prostatic resection the visual field was obscured with cloudy material (rnicrotissue of frozen prostate divided probably after Apparatus and technique for cryosurgery of the prostate. J. Urol., 96: 508, 1966. 8 Gonder, M. J., Soanes, W. A. and Smith, V.: Experimental prostate cryosurgery. Invest. Urol., 1: 610, 1964. 9 Gonder, M. J., Soanes, W. A. and Smith, V.: Chemical and morphologic changes in the prostate following extreme cooling. Ann. N. Y. Acad. Sci., 125: 716, 1965.
EXPERIMENTAL COMBINATION OF ELECTRORESECTION AND CRYOSURGERY
827
Frn. 1. Necrosis and hemorrhagic infiltration. A, piece resected 30 minutes after freezing. B, piece rcsected 3 days after freezing. electric vibration). Postoperatively there was no hemorrhage and the dogs were sacrificed in 6 days. Resection fallowed by cryosurgery. The prostatic gland of 10 animals was approached as previously described. The right side of the gland was partially resected, leaving the left side for comparison. The diathermy used was a Dovie model CSV on medium power cutting current. The Linde CE-4 cryoprobe was placed into the enlarged prostatic urethra and the remaining prostate was frozen at minus 160C for an average of 110 seconds. Bleeding in all cases was no more than that of the usual cryosurgical approach, (minimal1°), of equal density on the complete surface of the lumen and ceased spontaneously by 7 to 11 hours postoperatively. Postoperatively, there was no hemorrhage and the dogs were sacrificed in 6 days (figs. 2 and 3). Clinical study. We then did partial resections followed immediately by cryosurgery in 100 patients. The youngest patient was 56 years old and the oldest was 93 (table 1). All operations were done under low epidural anesthesia. Re-
sections were done at the more bulky point, or the point with the larger diameter the capsule to the central lumen), to achieve equal thickness between lumen and so that freezing was equally extended ~o all parts of the remaining tissue towards the In cases in which equal prostatic thickness vnts not achieved, complete freezing was helped by pressing the index finger at the thicker prostatic point the cryoprobe (precipitated freezing). We thoroughly resected the iutravesical part when possible so that accidental temporary of the ureternl orifices 11 was practically avoided. \Ve have been especially careful to avoid thoroug;h resection of the hypertrophied tissue near the bladder neck and the anterior lobe because both arc critical points to cryoperforation and tbeir anatomical positions do not favor digital palpation duriu1; freezing (in order to check (table 2). In 8 cases in which blood pressure elevation was difficult to control, resection vrns stopped at an earlier stage and cryosurgery wac-; clone
10 Ortved, W. E., O'Kelly, F. M., Todd, I. A. D., Maxwell, J. B. and Sutton, M. R.: Cryosurgical prostatectomy: a report of 100 cases. Brit. J. U rol.,
11 Roberts, l'v1., Longo, F. and Lattimer, J. surgery of ureteral orifices in
39: 577, 1967.
551, 1968.
828
ROUVALIS
Cryosurgery has been used mainly for hemostatic purposes in 6 additional cases of grades 1 and 2 prostate resection. In these cases necessary freezing time has not exceeded 0.3 to 0.5 minutes at minus 160C. Vasectomy was performed routinely. RESULTS
Fm. 2. A, resected pieces and specimen. B, drawing of specimen.
Surgical stress has been minimized in our cases since the combined procedure of transurethral resection and cryosurgery has not exceeded 1 hour. There has been no need for transfusion and we had no mortalities. Hospitalization has been slightly longer than that following resection but much shorter than that following cryosurgery (table 3). Complications included epididymitis in 3 patients who responded to antibiotic therapy. One patient experienced mild incontinence which ceased 15 days postoperatively. Meatal strictures in 2 cases were surgically corrected. In 1 patient secondary hemorrhage occurred 20 days postoperatively but ceased after catheter insertion and washing. 1. Age distribution (100 cases)
TABLE
immediately. The same was done in 6 patients with tendency to shock, in whom blood pressure was maintained with stronger vasopressors. In cases in which the apex was indistinct and the probe was difficult to localize we calculated the anatomical position of the apex by the rigidity of the prostatic bed, the remaining curves of lateral lobes, the anterior lobe and the bladder neck margin. We fixed our index finger at that point and inserted the probe into the prostatic urethra until each nib reached our index finger. In cases in which the diameter of the prostatic fossa was larger than the probe, we palpated digitally to achieve complete fixation of the wider fossa around the probe. During cryosurgery following resection we have been careful not to raise the probe's holding part, because its freezing end would move downward, the lower part of the bladder neck would be pressed and freezing process to this would be dangerous because of its relation to the bowel. Preventively, we have placed all patients in a slight Trendelenburg's position. The probe has not been moved in and out since such movements would probably cause bladder neck overfreezing.
Age (yrs.)
No. Cases
50-59 60-69 70-79
9 35 37 19
80 or more
TABLJ,
2 No. Cases
Prostate: Grade 3 Grade 4 Resected tissue:* 25-35 gm. 35-70 gm. Freezing time of remaining tissue :t ~"2 to lVi mins. l};a to Hi mins.
59
41 34 66 56
44
* Resection completed in less than 1 hour.
t Minus 160 degrees. TABLE
3. Days of catheter removal
No. Days
No. Cases
5 6-7 8
36 39 17
EXPERIMENTAL COMBINATION OF ELECTRORESECTION AND CRYOSURGERY
829
FIG. 3. A, periphery of damaged area after 6 days. Some cells at basement membrane of gland survived. necrosis and hemorrhagic infiltration. C, necrosis and hemorrhagic infiltration-bigger vessel lumen. ghost of glands. E, periphery-slight leukocytic infiltration, capsule intact.
/l/ljl/l/l[lll/1/1/ljlll/l/l/ljl/1/lllll\l\lllllll\l\l\l\l\l\1\
0
'I
2
3
FIG. 4. Fragments of necrotic tissue voided spontaneously. A, following combined TUR and cryo-surgery. B, following plain cryosurgery.
830
ROUVALIS
In most cases pyuria persisted for 30 to 60 days. Although no protective solutions have been used, absorptive complications have not been encountered since we have not resected completely towards the periphery (location of large lumen veins and sinuses). Thorough followup of cases has not revealed malignant development to date. Local hardness in some cases has been proved histologically to be a benign reaction. 12- 14 Nineteen of our patients had carcinoma of the prostate. There must be a minimal vascular spread of malignant cells when cryosurgery is done as the second part of the procedure. 15 DISCUSSION
Cryosurgery followed immediately or during the first postoperative days by resection is difficult to perform and there is danger of perforation because of the changing characteristics of tissue post-freezing. Thorough hemostasis by electrocoagulation has proved difficult. There is the disadvantage of the 2-stage operation. Cryosurgery followed in 15 days by resection has been attempted by others as well as by us. These procedures are easy to perform at that period but there is always the disadvantage of a 2-stage operation. Resection followed immediately by cryosurgery is applicable and easy to perform. No changes other than those usually seen after cryosurgery have been noted in the histology of the margin of the resected lumen or in any other section of the remaining tissue. Because of the safety secured by cryosurgery in case of uncontrollable hemorrhage during resection, we prefer quick cutting for thorough hemostasis; therefore, we are able to resect more grams of prostatic tissue in 1 hour, thus surpassing our standard. This combined procedure increases the extent of radicality and, therefore, enables operation per urethram on bigger glands. The volume of necrotic tissue which remains after cryosurgery following resection is less than 12 Ehrlich, R. M., Tannenbaum, M., Roberts, M. and Lattimer, J. K.: Experimental prostate cryosurgery: a study utilizing radioautography and electron microscopy. J. Urol., 101: 890, 1969. 13 Soanes, W. A. and Gonder, M. J.: Cryosurgery in benign and malignant diseases of the prostate. Intern. Surg., 61: 104, 1969. 14 Soanes, W. A., Gonder, M. J., Albin, R. J., Maser, M. D. and Jagodzinski, R. V.: Clinical and experimental aspects of prostatic cryosurgery. J. Cryosurgery, 2: 23, 1969. 16 Soanes, W. A. and Gonder, M. J.: Use of cryosurgery in prostatic cancer. J. Urol., 99: 793, 1968.
that following cryosurgery alone. Its elimination through the tunnel left by transurethral resection (fig. 4) is easier and the danger of a focus for sepsis and septicemia (2 per cent fatal in cryosurgery only) is much less. 16 The resected pieces of tissue allow more accurate biopsy results than those of the needle biopsy, which we use to take preliminary tests when performing cryosurgery alone. Usually we do not resect the most hemorrhagic points, that is the region of the bladder neck (entrance of urethral group of arteries-division of prostatic artery17) and towards the capsule, by the end of the procedure (contraction of capsular arteries) but we approach them by cryosurgery so that loss of blood is minimized. Postoperative bleeding following cryosurgery after resection has been minimal, as it is after cryosurgery alone, and much less than that following resection alone. Frequently, towards the end of resection, surgeons believe that bleeding is well controlled, but later it is obvious that they must repeat a coagulation, which is difficult because narcosis has passed and clots obscure prostatic fossa and bleeders. In such cases quick freezing under local anesthesia18 can prove of great value as shown in our 6 additional cases. SUMMARY
We first experimented with cryosurgery followed immediately by resection and then with resection followed immediately by cryosurgery. We found the latter combination easier to perform and have used it in 100 cases. There has been no mortality and only few complications which have been easy to prevent or control. The combination of transurethral electroresection followed immediately by cryosurgery minimizes the disadvantages of each method when applied separately. Dr. Maurice J. Gonder taught us the cryoprostatic technique and Dr. Nicos Papacharalampous made the photomicrographs.
100 Vasilissis Sofias Avenue, Athens 610, Greece 16 Rouvalis, P.: Cryosurgical prostatectomies, our modifications and results. In: 22nd Tagung der Deutschen Gesellschaft fur Urologie. Berlin, October 23-26, 1968. Wiesbaden: Carl Ritter & Co., p. 87, 1969. 17 Flocks, R.H.: The arterial distribution within the prostate gland: its role in transurethral prostatic resection. J. Urol., 37: 524, 1937. 18 Rouvalis, P.: Cryosurgery of the prostate under local anesthesia. J. Urol., 102: 244, 1969.