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Prostatic Resection in Vitro and in Vivo1
PROSTATIC RESECTION IN VITRO AND IN VIV0 1 GEORGE 0. BAUMRUCKER From the Section on Urology, Veterans Administration, Indianapolis, Ind.
There has been a trend in recent urologic literature to place considerable emphasis on the impossibility of being a prostatic resectionist. Such aweinspiring phrases as "the resectoscope is a deadly instrument in the hands of some;" "resection is not easy for every one to do;" perfect co-ordination is a necessary physical quality to have to be a competent resectionist," etc., are only too familiar to many who have recently gone through or are going through their apprentice period in transurethral surgery. This precautionary advice has rightly served as a timely and reactionary restraint to the recent violent surge of resection enthusiasm. Coming as it does from those who are rightly recognized as our master resectionists, it should not be ignored, however, neither should it become a fear-inspiring admonishment. It should be encouraging · to the young resectionist to note that the sequence of events of trial, error and correction is fundamental human psychology which has governed the learning process of all surgeons, transurethral or otherwise. With these continually disturbing admonishments in mind, the following approach to the study of resection was attempted in the hope of answering one question, namely, can the young urologist become proficient enough in the technique of resection or the cold punch operation to merit the confidence of his fellow practitioners without going through a long initial period of trial and error-~hat period in which the greatest percentage of unsatisfactory results or resection occur? As a result of this study I have convinced at least myself that there are certain definite "practice" steps which can be taken by the resectionist-to-be to develop his ability, self-confidence and skill in transurethral surgery. Analyzed into its fundamental parts, the composite act of resection consists of several very definite and clear-cut procedures. We will begin with the assumption that the candidate has a thorough understanding of cystoscopic technique and an intimate knowledge of the normal and pathological appearance of the bladder and bladder neck. These must be the basis and necessary pre-requisites for any operative work with the resectoscope or punch instrument. First Step, familiarity with the instrument: In the first place the resectionistto-be, should be thoroughly familiar with the mechanics of the instrument he contemplates using. This should be taken apart and put together so often that it can be done with the eyes closed, so that during any emergency situation the necessary adjustments can be made immediately and without hesitation. Second Step, the resectoscope as a cystoscope: The instrument should be used as a cystoscope for visualization of the bladder neck whenever opportunity arises. There will be numerous patients whose urethras will allow the passage of an No. 28 F. instrument without difficulty during the course of a routine cystoscopic 1 Published with permission of the Medical Director, Veterans Administration who assumes no responsibility for the opinions expressed or the conclusions drawn. 660
PROSTATIC RESECTION IN VITRO AND IN VIVO
661
examination. This can be done under the usual technique of local urethral anesthetization (either with Diothane or ½ per cent cocaine solution). This will serve two purposes; first, it will accustom the observer to a view of the bladder neck and prostate gland through the foroblique lens rather than at the right angle of the cystoscopic lens and second, he will become accustomed to the use of the resectoscope with its manifold controls and adjustments. He ,vill
Fm. 1. Shows method of using the cutting current on pieces of meat in conjunction with the electro-surgical unit (step 3).
Fm. 2. Shows the resectoscope inserted into the rubber bladder holding the modeling clay prostate. Several holes in the rubber bulb will allow the clay to bulge through and serve to fix the "prostate" in place firmly during resection (step 4).
develop a technique of holding the instrument, of turning the water supply on and off, of moving the cutting element and of arranging the water supply tube and the wires for light and power. Thus when the time for the resection arrives all the mechanical and technical difficulties will have been mastered and there will be no accident or delay due to awkwardness. It is also helpful to move the loop.backwards and forwards engaging the prostate if any is present, to observe the extent of loop excursion in relation to the prostate.
662
GEORGE 0. BAUMRUCKER
Third Step, the cutting and coagulating currents: This step should consist in practice with the cutting current. This is best done on a piece of meat submerged in a pan of water (fig. 1). The inactive electrode is fastened to the meat and connected to the electrosurgical unit, the active electrode of course being attached to the cutting element. By adjusting the cutting and coagulating dials at different values on the unit, one can determine the best cutting or coagulating current and familiarize himself with the effects of the cutting current on the tissue. The active power-electrode and the light cord are attached to the instrument. The water flow tube is not necessary here. This step serves a multiple purpose :~first, it promotes coordination between the foot, hand and the eye; second, it accustoms the operator to the proper speed of pulling the cutting loop through the tissue; third, of establishing the right amount of cutting and coagulating current and, fourth, of feeling the amount of pressure necessary to resect a piece of "prostate." It also serves the purpose of allowing the
FIG. 3. This shows about 15 gm. of resected modeling clay prostate. is very similar in size and shape to real prostatic clippings.
It is noted that it
operator to see the effects of the current on the tissue through the telescope. An ordinary cut of beef or a beef heart, has been used for this purpose. The latter has a firmer body and will not fall apart under water so rapidly. Fourth Step, resection of models: This is the most interesting step of this analysis. It consists of resecting modeling clay prostates (figs. 2, 3, 4 and 5). The prostate consists of children's soft modeling clay; the "bladder" being a half of a rubber bulb from a bulb syringe. Using Randall's text "Surgical Pathology of Prostatic Obstruction," any type of prostate may be reproduced and modeled from his excellent photographs. This is a most realistic procedure to develop accuracy in cutting. It serves to further familiarize the resector with the foroblique and retrograde appearance of the different types of glands to be encountered before, during and following the resection. No cutting current is needed. The consistency of the clay is such that the loop can be pulled through the substance easily,~coincidentally with about the same resistance that a normal prostate has when resected. These "prostates" can be easily remodeled and resected again and again. There is no limit to the number of "patients"
PROSTATIC RESECTION IN VITRO AKD IN VIVO
663
the resectionist can resect. No water is needed for this procedure. It is "cut" dry. The only control cord that is needed is the one for the light. This illumi-
A
B
C D Frn. 4. Showing a progressive sequence in the resection of a modeling clay prostate. This one in particular is a reproduction of Randall's commissural lobe hypertrophy.
A
B
Fm. 5. A reproduction of the so-called bladder neck contraction or fibrosis. This one was modeled from a patient as it was observed suprapubically following the removal of three vesical calculi. The internal urethral orifice was so tight that the tip of the little finger could not be forced into it. Right, the amount actually rcsected from this patient was only 5 gm., which is shown at base of "bladder."
nates the artificial prostatic intrusion and posterior urethra. The resection of these clay prostates is done with the eye at the telescope. Although the putty prostate will not bleed, the procedure is fairly realistic, having the advantage that one may look into the "bladder" from the "inside" after each few
664
GEORGE 0. BAUMRUCKER
cuts to see if the resection is about where it was intended to be and where it was doing the most good. By trial and error in this way, one can avoid the same trial and error "in vivo." A mirror facing the resector and reflecting the image of the open end of the rubber "bladder" will facilitate this step. These steps cover every possible action necessary in the mechanics of resection except coagulation of the bleeders. However, if the loop can be maneuvered accurately enough to resect the different types of intrusions, it can be easily approximated to the real bleeders for coagulation when the time comes. This will cause no difficulty whatsoever if familiarity with the instrument is sufficient. There are listed in the bibliography articles which will be especially helpful in this study and which cover pre- and post-operative management as well as operative precautions. SUMMARY
A method of obtaining preliminary training for transurethral surgery 1s presented. REFERENCES ALCOCK, N. G.: Prostatic resection and surgical prostatectomy. J. A. M. A., 101: 13531358, 1933. BAUMRUCKER, GEORGE 0.: A double-acting clamp to facilitate bladder irrigations. J. Urol., 47: 741-5, 1942. BUMPUS, H. C.: Avoidance of complications of prostatic resection. Southwestern Med., 20: 85, 1936. BUMPUS, H. C., JR.: Complications following prostatic resection. Am. J. Surg., 38: 89, 1937. CABOT, HuGH: Infection, the central problem in the treatment of prostatic obstruction. Proceed. of the Staff Meet., Mayo Clinic, 6: 163-165, 1931. DAVIS, THEODORE M.: Technic of prostate resection. J. Urol., 37: 763, 1937. - - - : Transurethral prostatic resection. South. Med. J., 28: 693, 1935. EMMETT, JoHN L.: Recent developments in transurethral prostatectomy. Arch. Physical Therapy, 20: 473, 1939. FLOCKS, R.H.: The arterial distribution within the prostate gland; its role in transurethral prostatic resection. J. U rol., 37: 524-548, 1937. FOLEY, FREDERIC E. B.: Present status of transurethral resectionists, competent or otherwise. J. Urol., 43: 565, 1940. HUGGINS, CHARLES, AND VERMEULEN, CORNELIUS: Pre-operative and Postoperative treatment in urology. Arch. Surg., 40: 1185-1191, 1940. McCARTHY, JosEPH FRANCES: Endoscopic prostatic resection. Bull. N. Y. Acad. Med., 14: 554, 1938. MYERS, Hu C.: Status of transurethral prostatic resection. Arch. Physical Therapy, p. 342 (June) 1939. NESBIT, REED M.: The limitations of transurethral prostatectomy. J. Mich. State Med. Soc., 38: 770, 1939. OLSEN, PAUL F.: Expanding the scope of transurethral pros ta tic resection by means of a two-stage operation. J. Iowa State Med. Soc., 28: 47, 1938. PILCHER, F., JR., AND SHEARD, C.: Measurement on loss of blood during transurethral prostatic resection. Proceed. Staff Meet., Mayo Clinic, 12: 209-213, 1937. PLAGGEMEYER, H. W., AND WELTMAN, CARL G.: The limitations of transurethral resection of the prostate gland. J. Urol., 38: 389, 1937. RANDALL, ALEXANDER: Surgical Pathology of Prostatic Obstructions. Baltimore: Williams & Wilkins Co., 1931. THOMPSON, GERSHOM J.: Transurethral prostatectomy. Kew Orleans Med. and Surg. J., 90: 142, 1937. THOMPSON, RAYMOND: Mortality in prostatic surgery. Technique of prostatic resection by the Davis method; Analysis of 108 cases. South. Med. and Surg., 100: 251, 1938. TuRNER, B. WEEMS: Contra-indications and complications incident to transurethral prostatic resection. J. Urol., 37: 815, 1937. WHITE, EDWARD W]\,r., AND MURRAY, CHAS. A.: Prostatic electro-resection. Ill. Med. J., p. 35, (Jan.) 1941. YOUNG, HuGH H.: Some problems in surgical treatment of the prostate. J. A. M.A., 110: 280, 1938.
There has been a trend in recent urologic literature to place considerable emphasis on the impossibility of being a prostatic resectionist. Such aweinspiring phrases as "the resectoscope is a deadly instrument in the hands of some;" "resection is not easy for every one to do;" perfect co-ordination is a necessary physical quality to have to be a competent resectionist," etc., are only too familiar to many who have recently gone through or are going through their apprentice period in transurethral surgery. This precautionary advice has rightly served as a timely and reactionary restraint to the recent violent surge of resection enthusiasm. Coming as it does from those who are rightly recognized as our master resectionists, it should not be ignored, however, neither should it become a fear-inspiring admonishment. It should be encouraging · to the young resectionist to note that the sequence of events of trial, error and correction is fundamental human psychology which has governed the learning process of all surgeons, transurethral or otherwise. With these continually disturbing admonishments in mind, the following approach to the study of resection was attempted in the hope of answering one question, namely, can the young urologist become proficient enough in the technique of resection or the cold punch operation to merit the confidence of his fellow practitioners without going through a long initial period of trial and error-~hat period in which the greatest percentage of unsatisfactory results or resection occur? As a result of this study I have convinced at least myself that there are certain definite "practice" steps which can be taken by the resectionist-to-be to develop his ability, self-confidence and skill in transurethral surgery. Analyzed into its fundamental parts, the composite act of resection consists of several very definite and clear-cut procedures. We will begin with the assumption that the candidate has a thorough understanding of cystoscopic technique and an intimate knowledge of the normal and pathological appearance of the bladder and bladder neck. These must be the basis and necessary pre-requisites for any operative work with the resectoscope or punch instrument. First Step, familiarity with the instrument: In the first place the resectionistto-be, should be thoroughly familiar with the mechanics of the instrument he contemplates using. This should be taken apart and put together so often that it can be done with the eyes closed, so that during any emergency situation the necessary adjustments can be made immediately and without hesitation. Second Step, the resectoscope as a cystoscope: The instrument should be used as a cystoscope for visualization of the bladder neck whenever opportunity arises. There will be numerous patients whose urethras will allow the passage of an No. 28 F. instrument without difficulty during the course of a routine cystoscopic 1 Published with permission of the Medical Director, Veterans Administration who assumes no responsibility for the opinions expressed or the conclusions drawn. 660
PROSTATIC RESECTION IN VITRO AND IN VIVO
661
examination. This can be done under the usual technique of local urethral anesthetization (either with Diothane or ½ per cent cocaine solution). This will serve two purposes; first, it will accustom the observer to a view of the bladder neck and prostate gland through the foroblique lens rather than at the right angle of the cystoscopic lens and second, he will become accustomed to the use of the resectoscope with its manifold controls and adjustments. He ,vill
Fm. 1. Shows method of using the cutting current on pieces of meat in conjunction with the electro-surgical unit (step 3).
Fm. 2. Shows the resectoscope inserted into the rubber bladder holding the modeling clay prostate. Several holes in the rubber bulb will allow the clay to bulge through and serve to fix the "prostate" in place firmly during resection (step 4).
develop a technique of holding the instrument, of turning the water supply on and off, of moving the cutting element and of arranging the water supply tube and the wires for light and power. Thus when the time for the resection arrives all the mechanical and technical difficulties will have been mastered and there will be no accident or delay due to awkwardness. It is also helpful to move the loop.backwards and forwards engaging the prostate if any is present, to observe the extent of loop excursion in relation to the prostate.
662
GEORGE 0. BAUMRUCKER
Third Step, the cutting and coagulating currents: This step should consist in practice with the cutting current. This is best done on a piece of meat submerged in a pan of water (fig. 1). The inactive electrode is fastened to the meat and connected to the electrosurgical unit, the active electrode of course being attached to the cutting element. By adjusting the cutting and coagulating dials at different values on the unit, one can determine the best cutting or coagulating current and familiarize himself with the effects of the cutting current on the tissue. The active power-electrode and the light cord are attached to the instrument. The water flow tube is not necessary here. This step serves a multiple purpose :~first, it promotes coordination between the foot, hand and the eye; second, it accustoms the operator to the proper speed of pulling the cutting loop through the tissue; third, of establishing the right amount of cutting and coagulating current and, fourth, of feeling the amount of pressure necessary to resect a piece of "prostate." It also serves the purpose of allowing the
FIG. 3. This shows about 15 gm. of resected modeling clay prostate. is very similar in size and shape to real prostatic clippings.
It is noted that it
operator to see the effects of the current on the tissue through the telescope. An ordinary cut of beef or a beef heart, has been used for this purpose. The latter has a firmer body and will not fall apart under water so rapidly. Fourth Step, resection of models: This is the most interesting step of this analysis. It consists of resecting modeling clay prostates (figs. 2, 3, 4 and 5). The prostate consists of children's soft modeling clay; the "bladder" being a half of a rubber bulb from a bulb syringe. Using Randall's text "Surgical Pathology of Prostatic Obstruction," any type of prostate may be reproduced and modeled from his excellent photographs. This is a most realistic procedure to develop accuracy in cutting. It serves to further familiarize the resector with the foroblique and retrograde appearance of the different types of glands to be encountered before, during and following the resection. No cutting current is needed. The consistency of the clay is such that the loop can be pulled through the substance easily,~coincidentally with about the same resistance that a normal prostate has when resected. These "prostates" can be easily remodeled and resected again and again. There is no limit to the number of "patients"
PROSTATIC RESECTION IN VITRO AKD IN VIVO
663
the resectionist can resect. No water is needed for this procedure. It is "cut" dry. The only control cord that is needed is the one for the light. This illumi-
A
B
C D Frn. 4. Showing a progressive sequence in the resection of a modeling clay prostate. This one in particular is a reproduction of Randall's commissural lobe hypertrophy.
A
B
Fm. 5. A reproduction of the so-called bladder neck contraction or fibrosis. This one was modeled from a patient as it was observed suprapubically following the removal of three vesical calculi. The internal urethral orifice was so tight that the tip of the little finger could not be forced into it. Right, the amount actually rcsected from this patient was only 5 gm., which is shown at base of "bladder."
nates the artificial prostatic intrusion and posterior urethra. The resection of these clay prostates is done with the eye at the telescope. Although the putty prostate will not bleed, the procedure is fairly realistic, having the advantage that one may look into the "bladder" from the "inside" after each few
664
GEORGE 0. BAUMRUCKER
cuts to see if the resection is about where it was intended to be and where it was doing the most good. By trial and error in this way, one can avoid the same trial and error "in vivo." A mirror facing the resector and reflecting the image of the open end of the rubber "bladder" will facilitate this step. These steps cover every possible action necessary in the mechanics of resection except coagulation of the bleeders. However, if the loop can be maneuvered accurately enough to resect the different types of intrusions, it can be easily approximated to the real bleeders for coagulation when the time comes. This will cause no difficulty whatsoever if familiarity with the instrument is sufficient. There are listed in the bibliography articles which will be especially helpful in this study and which cover pre- and post-operative management as well as operative precautions. SUMMARY
A method of obtaining preliminary training for transurethral surgery 1s presented. REFERENCES ALCOCK, N. G.: Prostatic resection and surgical prostatectomy. J. A. M. A., 101: 13531358, 1933. BAUMRUCKER, GEORGE 0.: A double-acting clamp to facilitate bladder irrigations. J. Urol., 47: 741-5, 1942. BUMPUS, H. C.: Avoidance of complications of prostatic resection. Southwestern Med., 20: 85, 1936. BUMPUS, H. C., JR.: Complications following prostatic resection. Am. J. Surg., 38: 89, 1937. CABOT, HuGH: Infection, the central problem in the treatment of prostatic obstruction. Proceed. of the Staff Meet., Mayo Clinic, 6: 163-165, 1931. DAVIS, THEODORE M.: Technic of prostate resection. J. Urol., 37: 763, 1937. - - - : Transurethral prostatic resection. South. Med. J., 28: 693, 1935. EMMETT, JoHN L.: Recent developments in transurethral prostatectomy. Arch. Physical Therapy, 20: 473, 1939. FLOCKS, R.H.: The arterial distribution within the prostate gland; its role in transurethral prostatic resection. J. U rol., 37: 524-548, 1937. FOLEY, FREDERIC E. B.: Present status of transurethral resectionists, competent or otherwise. J. Urol., 43: 565, 1940. HUGGINS, CHARLES, AND VERMEULEN, CORNELIUS: Pre-operative and Postoperative treatment in urology. Arch. Surg., 40: 1185-1191, 1940. McCARTHY, JosEPH FRANCES: Endoscopic prostatic resection. Bull. N. Y. Acad. Med., 14: 554, 1938. MYERS, Hu C.: Status of transurethral prostatic resection. Arch. Physical Therapy, p. 342 (June) 1939. NESBIT, REED M.: The limitations of transurethral prostatectomy. J. Mich. State Med. Soc., 38: 770, 1939. OLSEN, PAUL F.: Expanding the scope of transurethral pros ta tic resection by means of a two-stage operation. J. Iowa State Med. Soc., 28: 47, 1938. PILCHER, F., JR., AND SHEARD, C.: Measurement on loss of blood during transurethral prostatic resection. Proceed. Staff Meet., Mayo Clinic, 12: 209-213, 1937. PLAGGEMEYER, H. W., AND WELTMAN, CARL G.: The limitations of transurethral resection of the prostate gland. J. Urol., 38: 389, 1937. RANDALL, ALEXANDER: Surgical Pathology of Prostatic Obstructions. Baltimore: Williams & Wilkins Co., 1931. THOMPSON, GERSHOM J.: Transurethral prostatectomy. Kew Orleans Med. and Surg. J., 90: 142, 1937. THOMPSON, RAYMOND: Mortality in prostatic surgery. Technique of prostatic resection by the Davis method; Analysis of 108 cases. South. Med. and Surg., 100: 251, 1938. TuRNER, B. WEEMS: Contra-indications and complications incident to transurethral prostatic resection. J. Urol., 37: 815, 1937. WHITE, EDWARD W]\,r., AND MURRAY, CHAS. A.: Prostatic electro-resection. Ill. Med. J., p. 35, (Jan.) 1941. YOUNG, HuGH H.: Some problems in surgical treatment of the prostate. J. A. M.A., 110: 280, 1938.