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A New Endourethral Resectoscope
TH E J Ot:HNAL OF U ROLOGY
\' ol. 74 , No. 4, Octohe r 1055 1~ ri nl cd i n U. f-J .11..
A l\EW EJ\DOlHETl-lH AL H Ef-;ECTOSCOPE JOSEPH FRA:--:C l S l\lcCA HTHY
:1:--:JJ
J . ~ YDi\ 1,: y R l TT l-:It
Frnm the i\/ cC'orthy l.' rological Clinic, :\" ew )' ork P c,/ycli11it .1/ rclirnl .'frhool and H os pi tal , X ew i ·ork , ,V . i ·.
ft .is no11· mo re t ha n 25 years sin ce McCarth y f-i rs t· i11trodu ct'd t he mod e rn in s truments for e11d ourethral a nd e11d o,·cs if'a l surge ry , 11 011· in c·o mm1,11 prn!'ti('(·. ?11any have con t ributed minor im pro,·eme1it s, gadgets l'I<-. ; hm,·<·,·(• r, th e ha s i(· prinr·ipl es h ave rema in ed th e same . Through l hc geniu s of M r. Frrcl r ri r·k .J. \\' a ll a l'e, pn':,; id e11t of .·\ meri!'a 11 Cys tosrope :VIa kers, 111<·., ,,·c- han• hee11 a hl P to att a in ,·isua l pc- rfPdio 11 . Tlwn· ha,·e bee n ohj ect i,·cs to a<'hiP,·e in tlw <·01Te(' tio11 of some of the m in or (i(, fp<·t s ex i;;h 11 g in Hw vi;;ua l a nn ame 11 t·a riurn a;; foll mm: Firs t , th e hli 11d spot ; sc•c·rnicl , to minimi ze exre;;sive mct nip1il a ti o11 of tlw sht'at h ; third , to ,· i;;1iali ze t he e11tir<· u11di stort-ed lum en of th e urethra ; fourth , to hri11g t hC' pC'1H.lul ow, urC'thrn 111Hkr tot a l Sl' ruh11 y for sh1cl y or surger.v. Figures I, :Z , a nd :3 dc-pi!'t m1r 11e11· i11 stn1 nw11 t a 11d it s use. Th e fe nes t ra of t he sta 11 da rd resedos<·o pe shea t h has a t e11de1H·y to hold ha c·k m·e rha ngin g ti ssue pa rti('ul a rl y \Y hC'11 the shea th is mt a t ed . Wi t h th e pros tat" ir t iss 11 e in <'Oil t·ad with th e top of t he frn es tra , t lw l iss11 c- te nd s to fo ll o,1· l he slwa t Ii ,Yhc-11 mt ated a nd O
Lamp \
--
.;
Loop
?"
-:ih.ec1lh. w,\he!lJa\ i:1ihlan.5l elo a,1,; /
C Oblucaloc
D ,
~~' ,.vr
/
ln5trnmenla55ernbled
Tele':Scope, wo, k,,v,
elerrwt1.t, looR and' lom.p rotatable
v. ,Uw, >oh.ealh. 1,' , n. I . i\kC':1rll1 _,·- lli1l <'r c·ndo1 1rf'lhrn l r0s 0cl os!'ope " ·i1l11·omponf'1il pn r1s
\ e1: umonLa:num
llcrnoval o1 hvpexlxo-
obed l::icAue
Fr c; . 2 . Sagi 11 a l se c,( ion s ho\\·s remo va l of o\,s 1rn et i ng li _q lC' r1 rnphiPd pros 1a 1i!' 1iss 11C' . 1-i heab lr is he ld i11 fi ,ed pos iti o n , s lighil _,. l'orn·an l or vcrnmo nLwurn , a llll work in g c•lern e nl
is rotat a ble wi l hi u s heal h as tiss ue is removed .
560
N KIi" K, llO l " Hl!:'1' 111{ .\
Bladder
N~\on i n:serl over loop
l
I,
,j (; I
1n:s 1•: f "!'()i-i( '(J I' 1-:
1
/
B\addev
_
Loop
Bb.ddec
/ -( fucthec ex.curs ion. ot loop
5h.ealh. Groov e made b\J 1:-emova\ ot
h.\Jpedrnpl1ied
tl'55Ue
l-' 1G. 3 . I , Loop in hlndd e r beyond h_,·pertrophiNI mass. ;\" _ d on insrrt rovc riug ar ms of loo p ca n be seen on eac h id e . .? , Beginning exc urs ion of loo p . 3, F11rt lwr excurs io n of loop . 4, l•:xc urs io11 of loop co mpl eted " ·it h groovP following re mo val of ti s:; uc .
o bj ect m ay ham bee 11 aC'C'o mpli s lw d . Durin g t he rc•sed io11 , t he hl a d dN is f1tl l.,· di s t end ed a nd 11·ith th e outle t ope11 (J\"e r-di s t e11tirn1 is unlike ly. O nl y afte r Lhe f-ie ld beL"o m es L" io ud y is it neeessa ry to e mpt y t he bl add e r . \Vlw 11 s uffit' ie n t ti sstt l' has bee 11 rem oved , on e C'a 11 e mpty th e bl a dd e r 11·it hout re i11trodu et io11 of t lw ;; heath in t o th e bla dd e r. S in ee the sheath is he ld i11 a fi xed pos it io n a 11d t he op eratin g unit is rot ated within th e s heath t he re is 11 0 cli ,;to rt io n of t he urethra no r a n · a 11 y ta b,; or po rt io ns of t he prosta te left i11 s itu . Wi t h th e hla clcl e r dis te nd ed , a p1111<"1a t e e lectrod e m ay be used for a rrestatio n of a rt e ri ola r bl eedin g. T he ,·e no w; ooze is readil y con t roll ed by catheter eompressio 11 . HeeP11tly 11·l' have e 1H·ou11te red severa l cases of ure th ra l neo pl as m i11 vo h ·in g t he p e11d11lous 11re thra. Many of t·hese 1re re ove rl ooked b:v ou r::;e lH·s a nd o ur eo ll eagu e,;, pe rha ps expl a i11i11 g the hcm a turia as bein g du e Lo ,·ari eosity of t he prostati e ure th ra, 11·he rcas th e t rn e cause ,ra s a t um o r of t he pendul ous urethra . Tlwse a rc readil y t reat ed 11·ith thi s in s t rum e nt . Th e e n t ire ure th ra is seen wit hout· rota ting th e s heath . I Lr re th e rc m orn l of ti ssu!· fo r pat ho logic·a l ,; Lud y i,-; bet-te r a ('e ompli shed ,,·i t h th e eo ld b iopsy for,· eps fo ll o11·ed by eleetro,;urg ic·a l C'Oagul at io n . , v it h t hese ins trum e n ts 11·c ho pe to aC'eo m p li s h t he fi 11[l l s tep in e nd o uret hral surge ry, brin g in g to li g h t a nd 11nd <' r C'a ref1tl SC' l'lthn y tlw e n t ire bla dd e r a nd u ret hrn .
562
JO SE P J-f F. M CC:\HTI-TY A"1 1l J. S YD N" lcY
li lTTJ-.; B
Tha t traum a is an impo rta11t fador i11 procl11<"ing ::; tric·tt1re::; of th e ureth ra fol low ing c11dourethral surge ry i,; a<·<·Ppted. ThP rdorc, by rPduc·ing t he 1wecl for rna11ipt1l a t io11 tra11ma is rn inirni ,,cd . Th e frcqu e11tly inc·ompl cte resec ti o11 clue· to th e sheath pulling a nd di sto rting th e m et li ra, hicli11 g ti ssue th a t should he n·SC('ted , is elimin ated. Visua li zat ion of a rte ri a l bleeding is readil y attai 11 ecl a nd punc-t a tP lwmostas is <"an be practiced. Sli~ I M.\H Y
H e rc t hen is a di stin ct clr,pa rtun· from our prese nt a pparat 11 s. There i::; tota l ('in·umfc re11 t ia l vision , 1Yith a cl egreP of c·l a rit y 11ot lw ret-ofore ad1 iP1Td . Th e a u t hors rega rd lhi s 11 e11· apparat w; 1101 as a rcpl a <"e111 c11t of prc::;e nt praC' t ic·e i11 the fi eld of prostat-i<" rPsPd io11 , h11 t rat he r as s11 pp lcrne11 t a l th e reto . Bcc·ause of , at t he moment , lirni tat io11 s in th e s i,,e of the loop , it s <"hid. app li <"a tio11 11·ill be in t he ma nagement of moderate ly e11larged prosta t.e;-;, ,·csic·a l 11 eC'k c·o 11 tracture8, end ouret hra l ob8l' 1·vation a11d treatme nt. Th e g rPat adn11H·c in thi s instrument, bes id es en hanced \·isuali za tio11 , is i11 t he decrcace of ma nipul at ion of t·he sheath in and out a nd rotary. Thi s sho1ilcl olw iate in l'0 11 sidPrahl e meas m c th e di cagreeab le experi enee of ureth ral ::; t ri dure as a po::; topc rati,·p ('()mpli('atio11 .
755 Park Ave., N Pw Yu rk 21, N. l' .
\' ol. 74 , No. 4, Octohe r 1055 1~ ri nl cd i n U. f-J .11..
A l\EW EJ\DOlHETl-lH AL H Ef-;ECTOSCOPE JOSEPH FRA:--:C l S l\lcCA HTHY
:1:--:JJ
J . ~ YDi\ 1,: y R l TT l-:It
Frnm the i\/ cC'orthy l.' rological Clinic, :\" ew )' ork P c,/ycli11it .1/ rclirnl .'frhool and H os pi tal , X ew i ·ork , ,V . i ·.
ft .is no11· mo re t ha n 25 years sin ce McCarth y f-i rs t· i11trodu ct'd t he mod e rn in s truments for e11d ourethral a nd e11d o,·cs if'a l surge ry , 11 011· in c·o mm1,11 prn!'ti('(·. ?11any have con t ributed minor im pro,·eme1it s, gadgets l'I<-. ; hm,·<·,·(• r, th e ha s i(· prinr·ipl es h ave rema in ed th e same . Through l hc geniu s of M r. Frrcl r ri r·k .J. \\' a ll a l'e, pn':,; id e11t of .·\ meri!'a 11 Cys tosrope :VIa kers, 111<·., ,,·c- han• hee11 a hl P to att a in ,·isua l pc- rfPdio 11 . Tlwn· ha,·e bee n ohj ect i,·cs to a<'hiP,·e in tlw <·01Te(' tio11 of some of the m in or (i(, fp<·t s ex i;;h 11 g in Hw vi;;ua l a nn ame 11 t·a riurn a;; foll mm: Firs t , th e hli 11d spot ; sc•c·rnicl , to minimi ze exre;;sive mct nip1il a ti o11 of tlw sht'at h ; third , to ,· i;;1iali ze t he e11tir<· u11di stort-ed lum en of th e urethra ; fourth , to hri11g t hC' pC'1H.lul ow, urC'thrn 111Hkr tot a l Sl' ruh11 y for sh1cl y or surger.v. Figures I, :Z , a nd :3 dc-pi!'t m1r 11e11· i11 stn1 nw11 t a 11d it s use. Th e fe nes t ra of t he sta 11 da rd resedos<·o pe shea t h has a t e11de1H·y to hold ha c·k m·e rha ngin g ti ssue pa rti('ul a rl y \Y hC'11 the shea th is mt a t ed . Wi t h th e pros tat" ir t iss 11 e in <'Oil t·ad with th e top of t he frn es tra , t lw l iss11 c- te nd s to fo ll o,1· l he slwa t Ii ,Yhc-11 mt ated a nd O
Lamp \
--
.;
Loop
?"
-:ih.ec1lh. w,\he!lJa\ i:1ihlan.5l elo a,1,; /
C Oblucaloc
D ,
~~' ,.vr
/
ln5trnmenla55ernbled
Tele':Scope, wo, k,,v,
elerrwt1.t, looR and' lom.p rotatable
v. ,Uw, >oh.ealh. 1,' , n. I . i\kC':1rll1 _,·- lli1l <'r c·ndo1 1rf'lhrn l r0s 0cl os!'ope " ·i1l11·omponf'1il pn r1s
\ e1: umonLa:num
llcrnoval o1 hvpexlxo-
obed l::icAue
Fr c; . 2 . Sagi 11 a l se c,( ion s ho\\·s remo va l of o\,s 1rn et i ng li _q lC' r1 rnphiPd pros 1a 1i!' 1iss 11C' . 1-i heab lr is he ld i11 fi ,ed pos iti o n , s lighil _,. l'orn·an l or vcrnmo nLwurn , a llll work in g c•lern e nl
is rotat a ble wi l hi u s heal h as tiss ue is removed .
560
N KIi" K, llO l " Hl!:'1' 111{ .\
Bladder
N~\on i n:serl over loop
l
I,
,j (; I
1n:s 1•: f "!'()i-i( '(J I' 1-:
1
/
B\addev
_
Loop
Bb.ddec
/ -( fucthec ex.curs ion. ot loop
5h.ealh. Groov e made b\J 1:-emova\ ot
h.\Jpedrnpl1ied
tl'55Ue
l-' 1G. 3 . I , Loop in hlndd e r beyond h_,·pertrophiNI mass. ;\" _ d on insrrt rovc riug ar ms of loo p ca n be seen on eac h id e . .? , Beginning exc urs ion of loo p . 3, F11rt lwr excurs io n of loop . 4, l•:xc urs io11 of loop co mpl eted " ·it h groovP following re mo val of ti s:; uc .
o bj ect m ay ham bee 11 aC'C'o mpli s lw d . Durin g t he rc•sed io11 , t he hl a d dN is f1tl l.,· di s t end ed a nd 11·ith th e outle t ope11 (J\"e r-di s t e11tirn1 is unlike ly. O nl y afte r Lhe f-ie ld beL"o m es L" io ud y is it neeessa ry to e mpt y t he bl add e r . \Vlw 11 s uffit' ie n t ti sstt l' has bee 11 rem oved , on e C'a 11 e mpty th e bl a dd e r 11·it hout re i11trodu et io11 of t lw ;; heath in t o th e bla dd e r. S in ee the sheath is he ld i11 a fi xed pos it io n a 11d t he op eratin g unit is rot ated within th e s heath t he re is 11 0 cli ,;to rt io n of t he urethra no r a n · a 11 y ta b,; or po rt io ns of t he prosta te left i11 s itu . Wi t h th e hla clcl e r dis te nd ed , a p1111<"1a t e e lectrod e m ay be used for a rrestatio n of a rt e ri ola r bl eedin g. T he ,·e no w; ooze is readil y con t roll ed by catheter eompressio 11 . HeeP11tly 11·l' have e 1H·ou11te red severa l cases of ure th ra l neo pl as m i11 vo h ·in g t he p e11d11lous 11re thra. Many of t·hese 1re re ove rl ooked b:v ou r::;e lH·s a nd o ur eo ll eagu e,;, pe rha ps expl a i11i11 g the hcm a turia as bein g du e Lo ,·ari eosity of t he prostati e ure th ra, 11·he rcas th e t rn e cause ,ra s a t um o r of t he pendul ous urethra . Tlwse a rc readil y t reat ed 11·ith thi s in s t rum e nt . Th e e n t ire ure th ra is seen wit hout· rota ting th e s heath . I Lr re th e rc m orn l of ti ssu!· fo r pat ho logic·a l ,; Lud y i,-; bet-te r a ('e ompli shed ,,·i t h th e eo ld b iopsy for,· eps fo ll o11·ed by eleetro,;urg ic·a l C'Oagul at io n . , v it h t hese ins trum e n ts 11·c ho pe to aC'eo m p li s h t he fi 11[l l s tep in e nd o uret hral surge ry, brin g in g to li g h t a nd 11nd <' r C'a ref1tl SC' l'lthn y tlw e n t ire bla dd e r a nd u ret hrn .
562
JO SE P J-f F. M CC:\HTI-TY A"1 1l J. S YD N" lcY
li lTTJ-.; B
Tha t traum a is an impo rta11t fador i11 procl11<"ing ::; tric·tt1re::; of th e ureth ra fol low ing c11dourethral surge ry i,; a<·<·Ppted. ThP rdorc, by rPduc·ing t he 1wecl for rna11ipt1l a t io11 tra11ma is rn inirni ,,cd . Th e frcqu e11tly inc·ompl cte resec ti o11 clue· to th e sheath pulling a nd di sto rting th e m et li ra, hicli11 g ti ssue th a t should he n·SC('ted , is elimin ated. Visua li zat ion of a rte ri a l bleeding is readil y attai 11 ecl a nd punc-t a tP lwmostas is <"an be practiced. Sli~ I M.\H Y
H e rc t hen is a di stin ct clr,pa rtun· from our prese nt a pparat 11 s. There i::; tota l ('in·umfc re11 t ia l vision , 1Yith a cl egreP of c·l a rit y 11ot lw ret-ofore ad1 iP1Td . Th e a u t hors rega rd lhi s 11 e11· apparat w; 1101 as a rcpl a <"e111 c11t of prc::;e nt praC' t ic·e i11 the fi eld of prostat-i<" rPsPd io11 , h11 t rat he r as s11 pp lcrne11 t a l th e reto . Bcc·ause of , at t he moment , lirni tat io11 s in th e s i,,e of the loop , it s <"hid. app li <"a tio11 11·ill be in t he ma nagement of moderate ly e11larged prosta t.e;-;, ,·csic·a l 11 eC'k c·o 11 tracture8, end ouret hra l ob8l' 1·vation a11d treatme nt. Th e g rPat adn11H·c in thi s instrument, bes id es en hanced \·isuali za tio11 , is i11 t he decrcace of ma nipul at ion of t·he sheath in and out a nd rotary. Thi s sho1ilcl olw iate in l'0 11 sidPrahl e meas m c th e di cagreeab le experi enee of ureth ral ::; t ri dure as a po::; topc rati,·p ('()mpli('atio11 .
755 Park Ave., N Pw Yu rk 21, N. l' .