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The Bladder in Prostatism: An Operation for Excessive Bladder Hypertrophy1
THE JOURNAL OF UROLOGY
Vol. 60, No. 4, October 1948 Prin
THE BLADDER IN PROSTATISM: AN OPERATION FOR EXCESSIVE BLADDER HYPERTROPHY1 E.G. CRABTREE (Deceased) ANDS: RICHARD MUELLNER From the Department of Urology, Beth Israel Hospital, Boston, Mass.
The attention of the urologist is quite naturally focused on the obstructive factor in prostatism. It is obstruction of the bladder outlet which is responsible for the symptoms of prostatism and it is the removal of this obstruction which results in clinical relief. There are, however, rare instances when surgical removal of all the obstructing tissue is not followed by a restoration of normal micturition. In such instances the patient either cannot void at all, despite the prostatectomy or he continues to retain very large residuals of urine in his bladder. Such a poor clinical result is often puzzling, and has tempted surgeons to further excisions of tissue in the posterior urethra or at the bladder neck. The failure to restore normal micturition in cases of this sort, however, is not due to continued obstruction but rather to a changed bladder muscle. The detrusor in such cases is markedly scarred and much of its smooth muscle is replaced by connective tissue. Such a detrusor cannot contract adequately to expel all of the bladder contents. Where scar tissue replacement has been very marked the patient cannot void at all. If, on the other hand, the process is not too extensive, he may be able to expel small quantities of urine at frequent intervals, nevertheless retaining a large bladder residual. These observations are not new and have been commented on as far back as 1818 by John Hunter. 2 The clinical picture produced by this type of bladder was quite thoroughly discussed at a meeting of the American Association of Genito-Urinary Surgeons in 1911 following the presentation of 3 such cases by Binney. 3 His patients had persistent urinary retention, despite a thorough prostatectomy, and in the absence of neurogenic vesical disturbance. Binney recommended prolonged catheter drainage of the bladder for the relief of the urinary retention. A similar case was reported at that meeting by Fuller, whose patient had to be maintained on catheter drainage for a few years, before he was able to resume voluntary micturition. Persistent bladder atony after adequate prostatectomy was ascribed by early investigators to "ageing" of the bladder muscle or to sclerosis of the vesical arteries. Sugimura, 4 Caspar,5 and Hermann,6 however, correctly pointed out 1 Read by invitation at meeting of Western New York and Ontario Urological Society of Central Section, American Urological Association, Saranac, N. Y., September 6, 1947. 2 Hunter, J.: A Treatise on the Venereal Disease. London: Sherwood, Neeley and Jones, 1818, 2nd ed. 3 Binney, H.: Bladder atony and prostatectomy. Tr. Am. Assoc. Genito-Urin. Surg., 6: 98-112, 1911. 4 Sugimura, S.: Uber die Entstehung der sogenannten echten Divertikel der Harnblase, insbesondere des Blasengrundes, nebst Beitragen zur Lehre von der Pathologie der Muskulatur und elastischen Gewebe in der Harnblase. Virchows Arch., 204: 349-372, 1911. 6 Casper, L.: Ueber ungewoehnliche Faelle dauernder Harnverhaltung. Berl. klin. Wchnschr., 47: 425-426, 1910. 6 Herrmann, H.: Ueber die Substitution der Muskulatur der Harnblase durch Bindegewebe. Centralbl. f. allg. path. u. path. Anat., 35: 417-426, 1925. 593
594
E. G. CRABTREE AND S. RICHARD MUELLNER
that the failure of the detrusor to regain its tonus ,vas due to marked proliferation of fibrous tissue at the expense of the smooth muscle. Hermann's findings are more in accord with our own. He described two major histologic changes commonly associated with this type of bladder failure: an increase in the pre-existing fibrous tissue which normally surrounds the muscle bundles, so as to make the
Fm. 1. Case 2. Light areas between muscle bundles consist of fibrous tissue. increase in thiclmess of fibrous septa.
Fm. 2. Case 4.
Note
Note islands of muscle tissue in areas of dense scar
septa considerably thicker, and also new areas of connective tissue which replace muscle either wholly or in part. These areas of scar are interspersed with many islands of good muscle tissue. The nuclei of the muscle cells are often swollen and vacuolated and the chromatin is clumped, indicating muscle degeneration as the basis of this fibrosis (figs. 1 and 2). An excessively hypertrophied and scarred detrusor is usually quite large, and may retain up to 2 or 3 liters of urine. Its wall can measure 2½ cm. in thickness. It has a leathery consistency and its cut surface is gritty and streaked with
EXCESSIVE BLADDER HYPERTROPHY
i
595
yellowish or whitish fibers. When the bladder is emptied by catheter it does not contract to obliterate its cavity, but collapses into large thick folds, having lost a great deal of its contractile power. Clinically patients who have such a bladder have painless over-distention as a result of which they have excessive frequency of urination, dribbling and overflow incontinence. The cause of unusual scarring of the bladder in rare instances of prostatism is not clear. Age, arteriosclerosis and infection do not seem to be factors in its genesis. The youngest patient in our series -was 33 years old. The ease with which such a bladder can be rehabilitated depends in large measure upon the extent of the scarring of the bladder musculature. If this is not too severe a fair degree of recovery can be expected after prolonged catheter drainage. In one patient of this group the period of drainage appears to have been considerably shortened by the administration of large doses of testosterone
Fm. 3. Case 1. Note smooth outline of bladder 9 years postoperatively
propionate intramuscularly. This was used because in previous studies it was found effective in enhancing the tonus of the bladder muscle. 7 This patient was able to abandon his catheter and voided with a residual which had decreased from 500 cc to 150 cc after 2 weeks of the above therapy. In the other patients of this series the bladder changes were found to be far too advanced to expect any benefit from such a regime. Bearing in mind the occurrence of islands of normal smooth muscle tissue within the great mass of scar, it seemed reasonable to excise much of the scar tissue with the hope that the islands of smooth muscle would regenerate, since the bladder muscle is known to have remarkable recuperative powers. For this reason an operation was carried out in -which the bladder was exposed through a midline suprapubic incision, and extraperitonealized. After thorough mobilization, two-thirds of the mobile portion of the bladder was excised. The small bladder which remained was closed around a cystotomy tube. The obstructive factor was dealt with means appropriate to the individual case. 7 Muellner, S. R. and Hamilton, J.B.: The effect of testosterone propionate on the tonus of the urinary bladder. J. Urol., 52: 139-148, HJ44.
596
E. G. CRABTREE AND S. RICHARD MUELLNER
Following excision of much of the scarred portion of the bladder, it ,vas surprising to find how well the remainder recovered. It eventually expanded to a nearly normal capacity and assumed a smooth, rounded outline in the cystogram instead of the ragged and irregular shape it had before (fig. 3). It was hardly to be expected that a bladder so markedly altered histologically, -would entirely recover, and permit normal micturition; but it was gratifying to find that the patients, whose only alternative was permanent drainage by cystotomy tube or catheter, recovered sufficiently so that they voided fairly normal quantities of urine at infrequent intervals and had comparatively small residuals. CASE ABSTRACTS
The follmving brief case abstracts will illustrate some of the points brought out in this paper. Case 1. William P., aged 67, was admitted to the Phillip's House on February 5, 1937 complaining of nocturia for many years. The urine was uninfected. The prostate was small. The Wassermann test -was negative. Studies revealed a very large bladder, bilateral diverticula and a contracted vesical neck. At operation on February 23, 1937 the bladder wall was 1 cm. thick and light in color. The bladder was extraperitonealized and both diverticula and a large portion of the bladder were excised. The bladder neck was punched out with Young's punch instrument. Microscopic sections of bladder wall showed "hypertrophy with fibrosis." Postoperatively, the patient voided well and had a residual of 60 cc (fig. 3). His residual fluctuated in size. When last seen on June 5, 1946 the residual was 120 cc. Case 2. Felix F., aged 70, was admitted to the Beth Israel Hospital on February 13, 1947. An abdominal mass which was discovered accidently proved to be a large bladder. The prostate was large. The urine on admission was uninfected. After two -weeks of drainage he voided 200 cc and had residual of 1800 cc. A cystogram shmved 2 diverticula. At operation the bladder wall was 2 cm. thick. The peritoneal surface of the bladder appeared to be more scarred than the rest. The bladder was extraperitonealized, mobilized and twothirds of it excised. The pathological diagnosis was fibrosis and muscular hypertrophy of the bladder wall (fig. 1). The patient died of slowly increasing uremia, the nonprotein nitrogen rising from 42 to 130 mg. per cent. Case 3. Edgar B., aged 56, was admitted to the New England Baptist Hospital on January 10, 1946. He had a long history of dysuria and a massive bladder residual. The prostate was small. An operation was done on January 16, 1946. The bladder wall was 2½ cm. thick, scarred and noncontractile. The vesical neck was contracted. The bladder was extraperitonealized, mobilized, and two-thirds of it excised. On January 29, 1946 the bladder neck was resected transurethrally. He voided with good control. The residual urine was 60 cc. Case 4- John S., aged 78, was admitted to the New England Baptist Hospital on February 9, 1947. He had prostatism for 2 years and urinary retention
EXCESSIVE BLADDER HYPERTROPHY
597
2 weeks before admission to the hospital. The prostate was small. The urine sediment contained 10-15 white blood cells per high power field. A cystogram showed a bladder stone. At operation on February 24, 1947 the bladder wall was found to be thick and leathery. The bladder was mobilized and a large portion of the dome was excised. The contracted vesical neck was punched out with a Young's punch instrument. The pathological diagnosis was fibrosis of the bladder. When checked on April 9, 1947 he voided with a good stream. The residual urine was 45 cc (fig. 2). Case 5. William O'N., aged 33, was admitted to the New England Baptist Hospital on September 25, 1945. He had frequency and nocturia for many years, becoming more marked in recent months. His stream lacked force and he had to strain to void. The bladder was large; the prostate small and firm. The urine was uninfected. At operation on October 11, 1945 the bladder wall was found to be 2 cm. thick. The bladder was mobilized, extraperitonealized and two-thirds of the mobile portion excised. The contracted vesical neck was resected. On July 12, 1946, he voided well with a "small residual." Case 6. Frank F., aged 90, was admitted to the New England Baptist Hospital on March 18, 1947. Many years ago he underwent suprapubic prostatectomy elsewhere, following which he was unable to void. Within recent years he had had one or two transurethral resections as well, but was still unable to void. He was admitted with an indwelling catheter. The bladder was large and atonic and collapsed into thick folds like "wet leather" when emptied. The bladder residual was 1500 cc. Because of the patient's advanced age and poor general health he was advised to continue with the indwelling catheter drainage. Case 7. Hyman U., aged 80, was admitted to Beth Israel Hospital in August 1945. He had a 10-year history of prostatism with increasing frequency and decreasing size of his stream. For a few months before admission, he noticed considerable dribbling. The bladder was palpable at the umbilicus. The urine was uninfected. The prostate was moderately enlarged. At cystotomy, the bladder wall was found to be very thick. His incision healed well after suprapubic prostatectomy. He voided small amounts of urine, but the residual urine was 500 cc. The indwelling catheter was replaced and he was given 100 mg. of testosterone propionate weekly. After 2 weeks' treatment he voided easily, had a good stream, and the residual urine was reduced to 150 cc. Case 8. Joseph H., aged 92, was admitted to the Boston City Hospital in acute retention. He had had prostatism for 30 years. He had a large prostate (200 gm.) and a large bladder. The bladder at cystotomy was 2.5 cm. thick. The bladder wall was fibrous and its cut edge was streaked with whitish fibers. The bladder was markedly trabeculated and sacculated and contained a large, smooth, hard stone. The urine was infected. Postoperatively the patient voided small amounts and retained considerable residual. The fistula reopened on two occasions. After 3 months' catheter drainage, however, the fistula healed securely, the patient voided fairly well. The amount of the residual was not recorded.
598
E. G. CRABTREE AND S. RICHARD MUELLNER CONCLUSIONS
A detrusor, which in rare instances of prostat.ism becomes markedly scarred, and thus loses a great deal of its contractile and expulsive power, is responsible for large bladder residuals and inability to void, despite adequate prostatectomy. Satisfactory micturition can be achieved in such patients by an operation wherein about two-thirds of the scarred bladder is excised. Following such an excision the remainder of the bladder tends to regenerate to normal size, and will empty fairly satisfactorily.
520 Beacon St., Boston,
Jl,f ass.
Vol. 60, No. 4, October 1948 Prin
THE BLADDER IN PROSTATISM: AN OPERATION FOR EXCESSIVE BLADDER HYPERTROPHY1 E.G. CRABTREE (Deceased) ANDS: RICHARD MUELLNER From the Department of Urology, Beth Israel Hospital, Boston, Mass.
The attention of the urologist is quite naturally focused on the obstructive factor in prostatism. It is obstruction of the bladder outlet which is responsible for the symptoms of prostatism and it is the removal of this obstruction which results in clinical relief. There are, however, rare instances when surgical removal of all the obstructing tissue is not followed by a restoration of normal micturition. In such instances the patient either cannot void at all, despite the prostatectomy or he continues to retain very large residuals of urine in his bladder. Such a poor clinical result is often puzzling, and has tempted surgeons to further excisions of tissue in the posterior urethra or at the bladder neck. The failure to restore normal micturition in cases of this sort, however, is not due to continued obstruction but rather to a changed bladder muscle. The detrusor in such cases is markedly scarred and much of its smooth muscle is replaced by connective tissue. Such a detrusor cannot contract adequately to expel all of the bladder contents. Where scar tissue replacement has been very marked the patient cannot void at all. If, on the other hand, the process is not too extensive, he may be able to expel small quantities of urine at frequent intervals, nevertheless retaining a large bladder residual. These observations are not new and have been commented on as far back as 1818 by John Hunter. 2 The clinical picture produced by this type of bladder was quite thoroughly discussed at a meeting of the American Association of Genito-Urinary Surgeons in 1911 following the presentation of 3 such cases by Binney. 3 His patients had persistent urinary retention, despite a thorough prostatectomy, and in the absence of neurogenic vesical disturbance. Binney recommended prolonged catheter drainage of the bladder for the relief of the urinary retention. A similar case was reported at that meeting by Fuller, whose patient had to be maintained on catheter drainage for a few years, before he was able to resume voluntary micturition. Persistent bladder atony after adequate prostatectomy was ascribed by early investigators to "ageing" of the bladder muscle or to sclerosis of the vesical arteries. Sugimura, 4 Caspar,5 and Hermann,6 however, correctly pointed out 1 Read by invitation at meeting of Western New York and Ontario Urological Society of Central Section, American Urological Association, Saranac, N. Y., September 6, 1947. 2 Hunter, J.: A Treatise on the Venereal Disease. London: Sherwood, Neeley and Jones, 1818, 2nd ed. 3 Binney, H.: Bladder atony and prostatectomy. Tr. Am. Assoc. Genito-Urin. Surg., 6: 98-112, 1911. 4 Sugimura, S.: Uber die Entstehung der sogenannten echten Divertikel der Harnblase, insbesondere des Blasengrundes, nebst Beitragen zur Lehre von der Pathologie der Muskulatur und elastischen Gewebe in der Harnblase. Virchows Arch., 204: 349-372, 1911. 6 Casper, L.: Ueber ungewoehnliche Faelle dauernder Harnverhaltung. Berl. klin. Wchnschr., 47: 425-426, 1910. 6 Herrmann, H.: Ueber die Substitution der Muskulatur der Harnblase durch Bindegewebe. Centralbl. f. allg. path. u. path. Anat., 35: 417-426, 1925. 593
594
E. G. CRABTREE AND S. RICHARD MUELLNER
that the failure of the detrusor to regain its tonus ,vas due to marked proliferation of fibrous tissue at the expense of the smooth muscle. Hermann's findings are more in accord with our own. He described two major histologic changes commonly associated with this type of bladder failure: an increase in the pre-existing fibrous tissue which normally surrounds the muscle bundles, so as to make the
Fm. 1. Case 2. Light areas between muscle bundles consist of fibrous tissue. increase in thiclmess of fibrous septa.
Fm. 2. Case 4.
Note
Note islands of muscle tissue in areas of dense scar
septa considerably thicker, and also new areas of connective tissue which replace muscle either wholly or in part. These areas of scar are interspersed with many islands of good muscle tissue. The nuclei of the muscle cells are often swollen and vacuolated and the chromatin is clumped, indicating muscle degeneration as the basis of this fibrosis (figs. 1 and 2). An excessively hypertrophied and scarred detrusor is usually quite large, and may retain up to 2 or 3 liters of urine. Its wall can measure 2½ cm. in thickness. It has a leathery consistency and its cut surface is gritty and streaked with
EXCESSIVE BLADDER HYPERTROPHY
i
595
yellowish or whitish fibers. When the bladder is emptied by catheter it does not contract to obliterate its cavity, but collapses into large thick folds, having lost a great deal of its contractile power. Clinically patients who have such a bladder have painless over-distention as a result of which they have excessive frequency of urination, dribbling and overflow incontinence. The cause of unusual scarring of the bladder in rare instances of prostatism is not clear. Age, arteriosclerosis and infection do not seem to be factors in its genesis. The youngest patient in our series -was 33 years old. The ease with which such a bladder can be rehabilitated depends in large measure upon the extent of the scarring of the bladder musculature. If this is not too severe a fair degree of recovery can be expected after prolonged catheter drainage. In one patient of this group the period of drainage appears to have been considerably shortened by the administration of large doses of testosterone
Fm. 3. Case 1. Note smooth outline of bladder 9 years postoperatively
propionate intramuscularly. This was used because in previous studies it was found effective in enhancing the tonus of the bladder muscle. 7 This patient was able to abandon his catheter and voided with a residual which had decreased from 500 cc to 150 cc after 2 weeks of the above therapy. In the other patients of this series the bladder changes were found to be far too advanced to expect any benefit from such a regime. Bearing in mind the occurrence of islands of normal smooth muscle tissue within the great mass of scar, it seemed reasonable to excise much of the scar tissue with the hope that the islands of smooth muscle would regenerate, since the bladder muscle is known to have remarkable recuperative powers. For this reason an operation was carried out in -which the bladder was exposed through a midline suprapubic incision, and extraperitonealized. After thorough mobilization, two-thirds of the mobile portion of the bladder was excised. The small bladder which remained was closed around a cystotomy tube. The obstructive factor was dealt with means appropriate to the individual case. 7 Muellner, S. R. and Hamilton, J.B.: The effect of testosterone propionate on the tonus of the urinary bladder. J. Urol., 52: 139-148, HJ44.
596
E. G. CRABTREE AND S. RICHARD MUELLNER
Following excision of much of the scarred portion of the bladder, it ,vas surprising to find how well the remainder recovered. It eventually expanded to a nearly normal capacity and assumed a smooth, rounded outline in the cystogram instead of the ragged and irregular shape it had before (fig. 3). It was hardly to be expected that a bladder so markedly altered histologically, -would entirely recover, and permit normal micturition; but it was gratifying to find that the patients, whose only alternative was permanent drainage by cystotomy tube or catheter, recovered sufficiently so that they voided fairly normal quantities of urine at infrequent intervals and had comparatively small residuals. CASE ABSTRACTS
The follmving brief case abstracts will illustrate some of the points brought out in this paper. Case 1. William P., aged 67, was admitted to the Phillip's House on February 5, 1937 complaining of nocturia for many years. The urine was uninfected. The prostate was small. The Wassermann test -was negative. Studies revealed a very large bladder, bilateral diverticula and a contracted vesical neck. At operation on February 23, 1937 the bladder wall was 1 cm. thick and light in color. The bladder was extraperitonealized and both diverticula and a large portion of the bladder were excised. The bladder neck was punched out with Young's punch instrument. Microscopic sections of bladder wall showed "hypertrophy with fibrosis." Postoperatively, the patient voided well and had a residual of 60 cc (fig. 3). His residual fluctuated in size. When last seen on June 5, 1946 the residual was 120 cc. Case 2. Felix F., aged 70, was admitted to the Beth Israel Hospital on February 13, 1947. An abdominal mass which was discovered accidently proved to be a large bladder. The prostate was large. The urine on admission was uninfected. After two -weeks of drainage he voided 200 cc and had residual of 1800 cc. A cystogram shmved 2 diverticula. At operation the bladder wall was 2 cm. thick. The peritoneal surface of the bladder appeared to be more scarred than the rest. The bladder was extraperitonealized, mobilized and twothirds of it excised. The pathological diagnosis was fibrosis and muscular hypertrophy of the bladder wall (fig. 1). The patient died of slowly increasing uremia, the nonprotein nitrogen rising from 42 to 130 mg. per cent. Case 3. Edgar B., aged 56, was admitted to the New England Baptist Hospital on January 10, 1946. He had a long history of dysuria and a massive bladder residual. The prostate was small. An operation was done on January 16, 1946. The bladder wall was 2½ cm. thick, scarred and noncontractile. The vesical neck was contracted. The bladder was extraperitonealized, mobilized, and two-thirds of it excised. On January 29, 1946 the bladder neck was resected transurethrally. He voided with good control. The residual urine was 60 cc. Case 4- John S., aged 78, was admitted to the New England Baptist Hospital on February 9, 1947. He had prostatism for 2 years and urinary retention
EXCESSIVE BLADDER HYPERTROPHY
597
2 weeks before admission to the hospital. The prostate was small. The urine sediment contained 10-15 white blood cells per high power field. A cystogram showed a bladder stone. At operation on February 24, 1947 the bladder wall was found to be thick and leathery. The bladder was mobilized and a large portion of the dome was excised. The contracted vesical neck was punched out with a Young's punch instrument. The pathological diagnosis was fibrosis of the bladder. When checked on April 9, 1947 he voided with a good stream. The residual urine was 45 cc (fig. 2). Case 5. William O'N., aged 33, was admitted to the New England Baptist Hospital on September 25, 1945. He had frequency and nocturia for many years, becoming more marked in recent months. His stream lacked force and he had to strain to void. The bladder was large; the prostate small and firm. The urine was uninfected. At operation on October 11, 1945 the bladder wall was found to be 2 cm. thick. The bladder was mobilized, extraperitonealized and two-thirds of the mobile portion excised. The contracted vesical neck was resected. On July 12, 1946, he voided well with a "small residual." Case 6. Frank F., aged 90, was admitted to the New England Baptist Hospital on March 18, 1947. Many years ago he underwent suprapubic prostatectomy elsewhere, following which he was unable to void. Within recent years he had had one or two transurethral resections as well, but was still unable to void. He was admitted with an indwelling catheter. The bladder was large and atonic and collapsed into thick folds like "wet leather" when emptied. The bladder residual was 1500 cc. Because of the patient's advanced age and poor general health he was advised to continue with the indwelling catheter drainage. Case 7. Hyman U., aged 80, was admitted to Beth Israel Hospital in August 1945. He had a 10-year history of prostatism with increasing frequency and decreasing size of his stream. For a few months before admission, he noticed considerable dribbling. The bladder was palpable at the umbilicus. The urine was uninfected. The prostate was moderately enlarged. At cystotomy, the bladder wall was found to be very thick. His incision healed well after suprapubic prostatectomy. He voided small amounts of urine, but the residual urine was 500 cc. The indwelling catheter was replaced and he was given 100 mg. of testosterone propionate weekly. After 2 weeks' treatment he voided easily, had a good stream, and the residual urine was reduced to 150 cc. Case 8. Joseph H., aged 92, was admitted to the Boston City Hospital in acute retention. He had had prostatism for 30 years. He had a large prostate (200 gm.) and a large bladder. The bladder at cystotomy was 2.5 cm. thick. The bladder wall was fibrous and its cut edge was streaked with whitish fibers. The bladder was markedly trabeculated and sacculated and contained a large, smooth, hard stone. The urine was infected. Postoperatively the patient voided small amounts and retained considerable residual. The fistula reopened on two occasions. After 3 months' catheter drainage, however, the fistula healed securely, the patient voided fairly well. The amount of the residual was not recorded.
598
E. G. CRABTREE AND S. RICHARD MUELLNER CONCLUSIONS
A detrusor, which in rare instances of prostat.ism becomes markedly scarred, and thus loses a great deal of its contractile and expulsive power, is responsible for large bladder residuals and inability to void, despite adequate prostatectomy. Satisfactory micturition can be achieved in such patients by an operation wherein about two-thirds of the scarred bladder is excised. Following such an excision the remainder of the bladder tends to regenerate to normal size, and will empty fairly satisfactorily.
520 Beacon St., Boston,
Jl,f ass.