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Evolution of knife-punch resectoscope
EVOLIJTION EARL
F. N.;\TION,
Pasadena,
OF KNIFE-PUNCH
RESECTOSCOPE
IZI, II.
Califi)rnia
Direct cystoscopy without a lens system remains a mystery to most urologists. Punch prostatectomy and other forms of direct endoscopic surgery are considered archaic by many and mechanically impossible by others, especially those who have only briefly looked through such instruments or “tried it once. ” The latter view was epitomized by a classified advertisement which appeared in the Journal ofthe A~wricc~n Medical Association. Paraphrased, this read “Thompson Punch: for sale cheap; used once.” These opinions are not well founded. Man) urologists who were trained at Mayo Clinic or, like the author, associated with Mayo Clinic trainees continue to use these instruments successfully and appreciate their unique advantages. The evolution of the knife-punch resectoscope is an interesting story and is interwoven with the bloody history of the perfection of prostatic surgery. Those early practitioners and innovators who pioneered endoscopic surgery must have been imbued with the same spirit, courage, and perhaps motivation that led the first man to try an oyster. Progress was slow, and there were many hurdles and discouragements. Persistent efforts by a relatively small number of clever, hardy urologists rather than major breakthroughs brought endoscopic urologic sllrgery to its present position. The first was a young British army surgeon 1,) the name of George James Guthrie who tried to solve the dilemma of vesical neck obstruction due to a “bar” as he termed it. In the 1830s he devised a small knife which could be projected beyond the end or from the side of a metal catheter to incise the obstruction (Fig. 1B). Guthrie described his instrument sketchily, did not depict it, and re-
ported having used it only twice. He credited William Blizard, as early as 1806, and later Mr. Stafford, with attempting the same operation with cruder instruments and methods. Lancets and other instruments to force a way through urethral obstructions had long been used, probably almost as long as man had chosen to endure the agony of blind urethral instrumentation with crude instruments rather than die ofpainful urinary retention. Ambroi’se Par4 in the sixteenth century had tried with some success to perfect an instrument which improved on earlier devices designed to scrape free or excise “carnosities” of the urethra (Fig. IA). The story of these ancient forays is told by Gutierrez in the Histmy of Urology, published under the auspices of the American Urological Association in 1933.’ Dr. Guthrie’s early instruments and ideas were disparaged with Gallic disdain by the prominent young French urologist, Xlercier.” The latter, in 1836 and succeeding years, described instruments of his own design for incising and excising “valves” of the vesical neck, as he called the two varieties of obstructions which he observed, one as prostatic and the other as muscular (Fig. 1C). He was even more vitriolic in his denunciation Civiale, who described of an older countryman, an instrument for incising the vesical neck in a book which appeared three months after %lertier’s book (Fig. 1D). This one-sided feud kept the French medical literature gurgling for several years. Randall and Gutierrez have both written appreciative accounts of this tea-cup-telnl,est over urologic matters. Leroy d’Etiolles and other French surgeons also entered the fray for a time with instruments and techniques of their own. Despite Ylercier’s enthusiasm for the procedure and his assllrmce that although he had been “troiiblecl I)!, hemorrhage” he had always been able to overcome this
FIGURE 1. Early instruments for incising vesical neck “bars,” without vision or provision for control of hemorrhage. (A) Pare’s instrument fw removal of “car(B) nosities” of the urethra (1575). Guthrie’s “bar” incisor with provision for projection of lancet from either the side or end of metal catheter (1830). (C) Mercier’s excisors and incisors for removal of bladder neck “valves” (I 839 1850). (D) Civiale’s “kiotome,” closed and open, used to incise the obstructing “engorged” prostate.
annoyance in his 300 cases, vesical neck incision and excision by the then current techniques failed to gain favor. Even Civiale wrote: I’ll add that the use of the cutting instrument for fungous tumors and prostatic engorgements has not yet emerged from the state of speculation, and that, although some modern surgeons have been bragging about it, a prudent practitioner will always hesitate to have recourse to it. For the ensuing thirty years most surgeons followed Civiale’s advice. In 1873 the British surgeon, A. C. Hutchinson could write that all methods of overcoming prostatic hypertrophy and presumably other obstructions of the vesical outlet were ineffectual. His woeful conclusion was that a permanent catheter was the only recourse, even though, as he said, this was sure to cause cystitis. A new concept was then applied to the problem which represents the beginning of the modern era in endoscopic urologic surgery. In 1874, an Italian, E. Bottini,5 used the one-hundred-year-old discovery of a countryman, Luigi Galvani, to produce his galvanocautery (Fig. 2A). This was essentially a classic lithotrite, the blades of which were insulated from one another and powered with
418
galvanic current to produce heat. It was possible to “cook” portions of the prostate, and anything else that got in the way, and remove these without excessive bleeding. A physician who submitted to such an operative procedure wrote: The pain is so easily borne that I would advise everyone against the use of chloroform. I can place on record that I have suffered more with burning of the prostate by silver nitrate than during the galvanic division. This procedure had a considerable vogue during the last quarter of the nineteenth century. The problems of precise application, responsible for many of the complications, discouraged most surgeons from using it. In 1897 Freudenberg’ attempted to solve some of these problems by better insulation and current application and, later, by the addition of vision with the irrigating cystoscope, then coming into use. Chetwood’s modification of Freudenberg’s Bottini galvanocautery was most widely used and written about in England and America during the first fifteen years of the twentieth century (Fig. 2B). It was still essentially an incisor rather than an excisor, however. During this period the anatomy of prostatic hypertrophy was being studied and clarified. The name of Albarran is perhaps preeminent in this
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/ APRIL 1976 / VOLUME
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FIGURE 2. Gnlvanocauteries for relief of prostatic obstruction. (A) Freudenberg’s modijcation (1897) of Bottini’s original instrument (1874). (B) Chetwood’s modification of gulvunocautery, reported in 1905 to have been used through a small perineul incision in 32 cases. re(C) Wishard’s modi.cation, ported on in 1902, was also used through perineum. lmproved on later by Goldschmidt.
c FIGURE 3. Young’s original punch (1909) with provision for viewing with small magnifying window and light that could be shined through. Cutting was blind and no way to control bleeding. (A) Shiath; (B) knife; (C) obturator.
area. Perineal and suprapubic prostatic surgery were being perfected to cope with most of these cases. There remained the median bars and lesser obstructions for which these open procedures were too ominous. Into this fertile field stepped the innovative Hugh Hampton Young, American urologist, whom Gutierrez calls, “the pioneer of modern transurethral technique.” In 1902 Young7 had published his extensive experience with Freudenberg’s modification of Bottini’s gal-
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vanocautery. He described his own considerable modifications and improvements of the instrument. However, time took its toll. In 1913 Young again went before the American Medical Association to describe the shortcomings of the Bottini operation and some of his misfortunes with the This marked the birth of the procedure.’ present-day cold knife-punch operation (Fig. 3). Young excised variable amounts of obstructing tissue under “adequate” vision and controlled the
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resulting bleeding with a 29 F two-way gum rubber catheter and piston syringe. The first operation was performed on February 1, 1909, in the office under local cocaine anesthesia “almost without pain, with little subsequent hemorrhage and splendid functional result.” A piece of tissue 7 mm. in diameter and 1.3 cm. long was excised. He reported in 1913, 100 cases with no deaths. Most of them were performed under local urethral anesthesia, using 4 per cent Novocain. This simple instrument received wide acceptance and was used through the open bladder as well as transurethrally. Patients in whom this operation was applicable were limited in number. Vision was poor because there was no provision for distention of the urethra and bladder or for constant flushing of blood from the area, thus few cuts could be made and these mostly by feel. In 1911 Young attempted to reduce the complications and limitations imposed by hemorrhage by incorporating a feature of earlier elec-
trocauteries into his punch (Fig. 4). Provision for heating the end of the tubular knife by electricity was made, and the outer sheath was water-cooled. This instrument was executed by Lowenstein in Berlin. It never achieved much popularity. Young’s punch was also modified by others. J. T.Geraghty in 1922’ used a concave, solid knife. Henry A. R. Kreutzmann in 1925lO suggested a knife with a serrated cutting edge. Also in 1925 Howard L. Tolson11~‘2 used diathermy to heat a solid nickel-silver electrode the size of the fenestra in Young’s punch to control bleeding by “cooking” the entire cut surface. Later, he added irrigation and a telescope to Young’s punch. Young summarized the development of his punch and the use of it in his “Practice of Urology.“13 William F. Braasch14 went one step nearer to solving the problem of vision. He adapted his direct irrigating cystoscope for excision of tissue, devising a tube with a fenestra for engaging tissue (Fig. 5). This was passed through the Braasch cystoscope and a tubular knife excised the tissue.
FIGURE 4. Young's modijed punch, manufactured by Lowenstein, of Berlin (1911), cutting tube, water cooling, and ratchet mechanism (notations made by Dr. Young).
incorporating
cautery
FIGURE 5. Braasch’s adaptation of his direct cystoscope for excising tissue with blind cut and no provision for control of bleeding. (A) Cystoscope; (B) inner sheath with fenestra fn- engaging tissue to be removed; and (C) tubular knife inserted through inner sheath for punching out tissue.
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FIGURE 6. Caulk’s modijcation of Young punch (1920): curved needle and syringe used to infiltrate prostate with local anesthesia; bottom component was knife equipped with iridio-platinum, heated, cutting edge.
guide for FIGURE 7. Walker punch (1925), made in London, utilized hake&e forf/rst time; incorporatedfiliform ease of introduction. Procedure jiijrst time became visual one, with telescope, light, and provi.sionfor.flu,shing cut .surf&e and bladder. (1) Bake&e sheath, (2)$1 if arm bougie guide, (3) ohturatcr, (4) tubular knifefor punching out coagulated tissue, (5) olmrator for remocin, ~7tissue from knife punch, (6) light current source, and (7) diathermy current.
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Three tubes were utilized. The two inner tubes reduced the caliber and the size of bites of tissue, which was a handicap. Irrigation removed the blood, so the tissue to be removed could be visualized and cut more accurately than with previous instruments. Inability to control hemorrhage continued to limit the use of the instrument to excision of median bars. Braasch reported in 1918 that he had been using his instrument “for several years.” The exact date of first use is not known. Beer’s15 introduction in 1910 of high frequency current for destruction of bladder tumors was applied to making incisions of the prostate and bladder neck contractures. The use for control of bleeding after incision or excision of bars and contractures seems obvious but was a long time in coming. Young credits A. R. Stevens, in 1913, with being the first to use high frequency current to destroy prostatic bars through a cystoscope.s,‘3 The next big advance broadening the scope and acceptability of transurethral resection of the prostate, and of the punch, was made by John R. Caulk.16 In 1920 he presented his first modification of Young’s punch to the American Association of Genito-Urinary Surgeons (Fig. 6). He put a
one-quarter inch “iridio-platinum cutting edge” on the knife. This was heated with 150 amp. current to burn through bars and contractures. It was used primarily as an office procedure. One patient was reported to have had 14 pieces of tissue removed in three sittings. modified the Kenneth Walker, l7 in England, cautery punch in several important ways in 1925 (Fig. 7). He was also the first to use a bakelite sheath. He originally heated the terminal metal edge of the fenestra with diathermy current to coagulate the tissue to be excised. This later was replaced with a coagulating needle. Light, telescope, and irrigation were used. It was during this same period, between 1926 and 1932, that Maximilian Stern,16T. M. Davis,lg the elecand Joseph McCarthy ‘O developed trotome and a machine to provide adequate cutting and coagulation currents that made the loop resectoscope a success. In 1933 Caulk’l modified his cautery punch by incorporating a foroblique telescope, a stop-cock for irrigation, and a fulgurating attachment (Fig. 8). D. K. Rose in 192521 had already modified Caulks punch to accept a telescope. Caulk and
Caulk’s modijcation of his earlier punch, incorporating telescope, light, and irrigation (1933): (A) FIGURE 8. punch sheath, (B) obturator, (C) telescope, fulgurating and irrigating element, (0) knife with iridio-platinum tip, (E) forcep for removing tissue from knife punch, (F) swab, (G) suction, and (H) catheter.
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FIGURE
9.
Braasch’s
median
bar excisor as modilfied by Bumpus
(1926):
sheath,
knife-punch,
and obturator.
FIGURE 10. Bumpus-Tyvand modifications of earlier blind punch. Early knife; multiple needle electrode for coagulating tissue before excision; punch with obturator closing fenestra; early electrode carrier; later knife, with adaptor into which knife was screwed, with viewing window in place; later electrode carrier with deflector tip and window with escape f& air bubble.
others presented their results with the cautery punch to urologists to stimulate interest in endoscopic surgery for prostatic and vesical neck obstructions. Another center of development of the punch during this period was the Mayo Clinic. While
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Caulk was developing and popularizing the “hot punch,” Herman Carey Bumpus, at the Mayo Clinic, was expanding the usefulness of the “cold became known as the punch. ” His instrument Braasch-Bumpus punch (Fig. 9). He cut a fenestrum in the Braasch cystoscope sheath rather than
323
FIGURE
11.
Day prostatic
punch;
cutting was toward operator
use a second tube for this purpose. By using the Bugbee electrode through his instrument Bumpus was better able to control bleeding, a truly revolutionary innovation. He found that these patients suffered fewer febrile reactions and less epididymitis than patients operated on with the Caulk instrument. In 1926 Bumpusz3 reported his early results; 4 of 22 patients expressed “full satisfaction” with the result of the knife-punch operation. The caliber of the Braasch punch had been increased to enable the surgeon to remove pieces of tissue comparable in size to those removed with the cautery-punch. By 1932 Bumpusz4 could report that 48 of 66 patients operated on with the knife-punch five years previously, and who responded, were satisfied. In 1932 Tyvand and Bumpusz5 and later Tyvand26 alone reported several improvements in the Braasch-Bumpus punch (Fig. 10). An air valve was incorporated in the window to permit bubbles that obscured vision to escape. Improvements in the knife and the Bugbee electrode carrier were made, and a multiple needle electrode was introduced. This could be inserted into the bite of tissue to be removed before excision to reduce bleeding. These improvements and increasing experience allowed Gershom Thompson, of the Mayo Clinic, to report that during 1932 and 1933, 721 prostate operations were done and only 46 of
12-1
fwfirst
time.
these were open procedures.27 Most of the open prostatectomies had been done early in 1932. The mortality rate was only 0.7 per cent. In ahnost 10 per cent of the transurethral procedures more than 25 Gm. of tissue had been removed. In one case 116 Gm. oftissue were removed. The mound of tissue was pictured beside a baseball and matched it in size. There was no longer any question about the success of the procedure. Thompson stated that for several years all physicians coming to the Mayo Clinic for prostatic obstruction had requested transurethral surgery. In 1931 Robert V. Day28 presented a single unit punch of his design which incorporated a lens system (Fig. 11). Vision was poor and cutting and control of hemorrhage were not accurate, thus the instrument achieved no widespread use, even at the Los Angeles County General Hospital where it was first tried. A principle not previously employed in a punch was a knife which cut toward the operator. Day, as early as 1913, had developed a needle with which to electrocoagulate tissue to be excised with the Young punch, so he had long been concerned with the problems related to endoscopic prostatic surgery. In 1935 Thompson2’ published the development of his modification of the Braasch-Bumpus and Day punches (Fig. 12). This dispensed with the multiple needle electrode and incorporated a channel in the sheath for the Bugbee electrode,
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Thompson modification punch; (A) obturator; (B) knife-punch and Bugbee system incorporated in one unit. Direct viewing without telescope.
FIGURE12. irrigation
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electrode
carrier
and
FIGURE 14. Modijed Braasch-Bumpus punch presently in use. Electrode carrier, with window with three diopters of magni&ation; obturator, knife, with modijied adaptor and magnifying window; resectoscope sheath made from 28 F Boehm cystoscope.
making one unit of the instrument. Thompson3’ had preceded this with the development of a modification of the Braasch-Bumpus punch to permit irrigation through the knife. In 1962 Hjalmar Carlson made in his hospital machine shop a spring-activated punch. Foley also produced a powered punch. A punch with a rotating blade likewise was developed. None of these instruments was widely used or achieved much popularity. Through the years other urologists made punch modifications and innovations, notably McCarthy and Wedgewood (Fig. 13).31 Each incorporated minor new principles but these achieved no popularity. In 1972 Joseph H. Kaplan32 modified Thompson’s punch incorporating new principles which included fiberoptic lighting and the ability to see the bite of tissue being removed while cutting it with the knife punch. The author and his associates continue to use a modified Braasch-Bumpus punch with three separate elements (Fig 14). The advantages are
426
shorter length and greater inner diameter in a 28 F instrument, hence better vision and more rapid tissue removal. The latter compensates for the time lost in inserting the electrode carrier, which is done while emptying the full bladder, for control of bleeding. Three diopters of magnification are built into the punch window, affording excellent vision. Rapid flow of irrigation fluid removes blood, regardless of rate of bleeding, so vision is never distorted or clouded. In addition, since a lens system is not employed, the appearance of tissue is natural. The knife punch gives accurate dissection of tissue with less danger of perforation of the prostatic capsule since this is not readily forced into the fenestra. Point fulguration of bleeding vessels results in less necrosis, slough, and fibrosis. The true secret of success of the procedure, however, as with all endoscopic prostatic surgery, is rapid, accurate, and complete removal of adenomatous hyperplasia of the prostate, with good control of bleeding without excessive electrocoagulation of tissue.
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For those urologists who have mastered the knife-punch there is no system to compare with it. Those of us who first learned to use the SternMcCarthy resectoscope have never been tempted to return to it except in exceptional circumstances. Not only can prostatic obstructions be more expeditiously removed with the punch but no other instrument can compare with it for the removal of large vesical neoplasms and calculi. Our modification of the Braasch-Bumpus punch is superior for the latter purpose. Urologists and their patients today owe as great a debt to the pioneers in prostatic surgery and to the innovators among them as to any in the field of surgery. One would like to believe that endoscopic prostatic surgery and instruments have reached their apogee, but experience has taught the foolishness of such arrogance. Transurethral prostatic surgery is a very personal choice for the surgeon. It remains the loneliest surgical procedure which urologists perform. The prostatic resectionist soon learns humility and should never cease to learn by experience. Happy is the day that he can approach each new procedure with respectful confidence and assurance. Mastery of his instrument, adequate dexterity, and a proper temperament make this possible for the fortunate resectionist. While practicing and teaching what he has learned, the resectionist should be mindful of those who have made it possible. And if the day comes when he must relinquish his own prostate he truly will be indebted to those doughty forebears. 112 North Madison Avenue Pasadena, California 91101 References 1. GUTHRIE, G. J. : Anatomy and Diseases of the Neck of the Bladder and of the Urethra, London, Burgess and Hill, 1834. 2. GUTJERREZ, R. : Transurethral treatment of bladder neck obstructions: endoscopic prostatic resection, in History of Urology, vol. 2, Baltimore, Williams and Wilkins Co., 1933, p. 137. :3. MERCIER, A. : Recherches anatomiques sur la prostate des vieillards, Bull. Sociktit Anat. (1836). 1. HUTCHINSON, A. C. : London Med. Repository 22: 128 (1873), quoted by Gutierrez.’ 5. BOTTINI, E.: Radicale Behandlung der auf hypertrophic der Prostata beruhenden Ischurie, Arch. Klin. Chir. 21: 1 (1877). 6. FREUDENBERG, A. : Eine modificirter bottinischer Incisor, Zentbl. Chir. 24: 788 (1897).
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/ APRIL 1976 / VOLUME VII. NUMBER 4
7. YOUNG, H. H.: A new combined electro-cautery incisor for the Bottini operation for prostatic obstruction, J.A.M.A. 38: 86 (1902). 8. IDEM: A new procedure (punch operation) for small prostatic bars and contracture of the prostatic orifice, ibid. 60: 253 (1913). per urethram, a 9. GERACHTY, J. T.: Sphincterotomy simple and safe procedure for the cure of contracture of the vesical orifice, J. Ural. 7: 367 (1922). 10. KREUTZMANN, H. A. R.: An improved knife for Young’s prostatic punch, ibid. 14: 311 (1925). 11. TOLSON, H. L.: An electrode for use with Young’s punch. Diathermy as a supplement to the prostatic punch operation, ibid. 14: 63 (1925). resection with modifications of 12. IDEM: Prostatic Young’s punch, ibid. 43: 116 (1940). 13. YOUNG, H. H.: Practice of Urology, Philadelphia, W. B. Saunders Co., 1926, vol. 20, pp. 481-512. Median bar excisor, J..4.M..4. 70: 14. BRAASCH, W. F.: 758 (1918). 15. BEER, E. : Removal of neoplasms of the urinary bladder, ibid. 54: 1768 (1910). 16. CAULK, J. R.: Infiltration anesthesia of the internal vesical orifice for the removal of minor obstruction: presentation of a cautery punch, J. Ural. 4: 399 (1920). 17. WALKER, K. M.: Periurethral operations for prostatic obstruction, Br. Med. J. 1: 201 (1925). at the vesical 18. STERN, M.: Resection of obstruction orifice; new instruments (resectotherm; resectoscope) and a new method, J.A.M.A. 87: 1726 (1926). 19. DAVIS, T. M.: Prostatic operation: prospects of the patient with prostatic disease in prostatectomy vs. resection, J.A.M.A. 97: 1674 (1931). 20. MCCARTHY, J. F.: A new apparatus for endoscopic plastic surgery of the prostate, diathermia, and excision of vesical growths, J. Urol. 26: 695 (193131). of a new cautery prmch, 21. CAULK, J. R.: Presentation ibid. 30: 737 (1933). 22. ROSE,D. K.: A visual prostatic punch, Surg. Gynecol. Obstet. 41: 109 (1925). J. 23. BUMPUS, H. C.: Results of punch prostatectomy, Urol. 16: 59 (1926). treatment 24. IDEM: Results five years after transurethral of benign prostatic hypertropy, ibid. 28: 561 (1932). A simple 25. TYVAND, R. E., and BUMPUS, H. C.: technique for prostatic resection, ibid. 27: 503 (1932). Improved model of the Braasch26. TYVAND, R. E.: Bumpus punch instrument, ibid. 35: 109 (1936). prostatic surgery, 27. THOMPSON, G. J.: Transurethral Mayo Clin. Proc. 26: 349 (1934). 28. DAY, R. V. : Management of contracture of the bladder neck. A new cysto-urethroscopic punch, Ural. Cutan. Rev. 35: 25 (1931). 29. THOMPSON, G. J,: A new direct vision resectoscope, ibid. 39: 545 (1935). attachment, Mayo Clin. Proc. 30. IDEM: A resectoscope 11: 335 (1936). Modification of the McCarthy 31. WEDGEWOOD, P. E.: visible prostatic punch for transurethral prostatic resections, J. Urol. 32: 287 (1934). ibid. 32. KAPLAN, J. H. : A new cold punch resectoscope, 107: 1054 (1972).
427
F. N.;\TION,
Pasadena,
OF KNIFE-PUNCH
RESECTOSCOPE
IZI, II.
Califi)rnia
Direct cystoscopy without a lens system remains a mystery to most urologists. Punch prostatectomy and other forms of direct endoscopic surgery are considered archaic by many and mechanically impossible by others, especially those who have only briefly looked through such instruments or “tried it once. ” The latter view was epitomized by a classified advertisement which appeared in the Journal ofthe A~wricc~n Medical Association. Paraphrased, this read “Thompson Punch: for sale cheap; used once.” These opinions are not well founded. Man) urologists who were trained at Mayo Clinic or, like the author, associated with Mayo Clinic trainees continue to use these instruments successfully and appreciate their unique advantages. The evolution of the knife-punch resectoscope is an interesting story and is interwoven with the bloody history of the perfection of prostatic surgery. Those early practitioners and innovators who pioneered endoscopic surgery must have been imbued with the same spirit, courage, and perhaps motivation that led the first man to try an oyster. Progress was slow, and there were many hurdles and discouragements. Persistent efforts by a relatively small number of clever, hardy urologists rather than major breakthroughs brought endoscopic urologic sllrgery to its present position. The first was a young British army surgeon 1,) the name of George James Guthrie who tried to solve the dilemma of vesical neck obstruction due to a “bar” as he termed it. In the 1830s he devised a small knife which could be projected beyond the end or from the side of a metal catheter to incise the obstruction (Fig. 1B). Guthrie described his instrument sketchily, did not depict it, and re-
ported having used it only twice. He credited William Blizard, as early as 1806, and later Mr. Stafford, with attempting the same operation with cruder instruments and methods. Lancets and other instruments to force a way through urethral obstructions had long been used, probably almost as long as man had chosen to endure the agony of blind urethral instrumentation with crude instruments rather than die ofpainful urinary retention. Ambroi’se Par4 in the sixteenth century had tried with some success to perfect an instrument which improved on earlier devices designed to scrape free or excise “carnosities” of the urethra (Fig. IA). The story of these ancient forays is told by Gutierrez in the Histmy of Urology, published under the auspices of the American Urological Association in 1933.’ Dr. Guthrie’s early instruments and ideas were disparaged with Gallic disdain by the prominent young French urologist, Xlercier.” The latter, in 1836 and succeeding years, described instruments of his own design for incising and excising “valves” of the vesical neck, as he called the two varieties of obstructions which he observed, one as prostatic and the other as muscular (Fig. 1C). He was even more vitriolic in his denunciation Civiale, who described of an older countryman, an instrument for incising the vesical neck in a book which appeared three months after %lertier’s book (Fig. 1D). This one-sided feud kept the French medical literature gurgling for several years. Randall and Gutierrez have both written appreciative accounts of this tea-cup-telnl,est over urologic matters. Leroy d’Etiolles and other French surgeons also entered the fray for a time with instruments and techniques of their own. Despite Ylercier’s enthusiasm for the procedure and his assllrmce that although he had been “troiiblecl I)!, hemorrhage” he had always been able to overcome this
FIGURE 1. Early instruments for incising vesical neck “bars,” without vision or provision for control of hemorrhage. (A) Pare’s instrument fw removal of “car(B) nosities” of the urethra (1575). Guthrie’s “bar” incisor with provision for projection of lancet from either the side or end of metal catheter (1830). (C) Mercier’s excisors and incisors for removal of bladder neck “valves” (I 839 1850). (D) Civiale’s “kiotome,” closed and open, used to incise the obstructing “engorged” prostate.
annoyance in his 300 cases, vesical neck incision and excision by the then current techniques failed to gain favor. Even Civiale wrote: I’ll add that the use of the cutting instrument for fungous tumors and prostatic engorgements has not yet emerged from the state of speculation, and that, although some modern surgeons have been bragging about it, a prudent practitioner will always hesitate to have recourse to it. For the ensuing thirty years most surgeons followed Civiale’s advice. In 1873 the British surgeon, A. C. Hutchinson could write that all methods of overcoming prostatic hypertrophy and presumably other obstructions of the vesical outlet were ineffectual. His woeful conclusion was that a permanent catheter was the only recourse, even though, as he said, this was sure to cause cystitis. A new concept was then applied to the problem which represents the beginning of the modern era in endoscopic urologic surgery. In 1874, an Italian, E. Bottini,5 used the one-hundred-year-old discovery of a countryman, Luigi Galvani, to produce his galvanocautery (Fig. 2A). This was essentially a classic lithotrite, the blades of which were insulated from one another and powered with
418
galvanic current to produce heat. It was possible to “cook” portions of the prostate, and anything else that got in the way, and remove these without excessive bleeding. A physician who submitted to such an operative procedure wrote: The pain is so easily borne that I would advise everyone against the use of chloroform. I can place on record that I have suffered more with burning of the prostate by silver nitrate than during the galvanic division. This procedure had a considerable vogue during the last quarter of the nineteenth century. The problems of precise application, responsible for many of the complications, discouraged most surgeons from using it. In 1897 Freudenberg’ attempted to solve some of these problems by better insulation and current application and, later, by the addition of vision with the irrigating cystoscope, then coming into use. Chetwood’s modification of Freudenberg’s Bottini galvanocautery was most widely used and written about in England and America during the first fifteen years of the twentieth century (Fig. 2B). It was still essentially an incisor rather than an excisor, however. During this period the anatomy of prostatic hypertrophy was being studied and clarified. The name of Albarran is perhaps preeminent in this
UROLOGY
/ APRIL 1976 / VOLUME
VII, NUMBER 4
FIGURE 2. Gnlvanocauteries for relief of prostatic obstruction. (A) Freudenberg’s modijcation (1897) of Bottini’s original instrument (1874). (B) Chetwood’s modification of gulvunocautery, reported in 1905 to have been used through a small perineul incision in 32 cases. re(C) Wishard’s modi.cation, ported on in 1902, was also used through perineum. lmproved on later by Goldschmidt.
c FIGURE 3. Young’s original punch (1909) with provision for viewing with small magnifying window and light that could be shined through. Cutting was blind and no way to control bleeding. (A) Shiath; (B) knife; (C) obturator.
area. Perineal and suprapubic prostatic surgery were being perfected to cope with most of these cases. There remained the median bars and lesser obstructions for which these open procedures were too ominous. Into this fertile field stepped the innovative Hugh Hampton Young, American urologist, whom Gutierrez calls, “the pioneer of modern transurethral technique.” In 1902 Young7 had published his extensive experience with Freudenberg’s modification of Bottini’s gal-
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vanocautery. He described his own considerable modifications and improvements of the instrument. However, time took its toll. In 1913 Young again went before the American Medical Association to describe the shortcomings of the Bottini operation and some of his misfortunes with the This marked the birth of the procedure.’ present-day cold knife-punch operation (Fig. 3). Young excised variable amounts of obstructing tissue under “adequate” vision and controlled the
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resulting bleeding with a 29 F two-way gum rubber catheter and piston syringe. The first operation was performed on February 1, 1909, in the office under local cocaine anesthesia “almost without pain, with little subsequent hemorrhage and splendid functional result.” A piece of tissue 7 mm. in diameter and 1.3 cm. long was excised. He reported in 1913, 100 cases with no deaths. Most of them were performed under local urethral anesthesia, using 4 per cent Novocain. This simple instrument received wide acceptance and was used through the open bladder as well as transurethrally. Patients in whom this operation was applicable were limited in number. Vision was poor because there was no provision for distention of the urethra and bladder or for constant flushing of blood from the area, thus few cuts could be made and these mostly by feel. In 1911 Young attempted to reduce the complications and limitations imposed by hemorrhage by incorporating a feature of earlier elec-
trocauteries into his punch (Fig. 4). Provision for heating the end of the tubular knife by electricity was made, and the outer sheath was water-cooled. This instrument was executed by Lowenstein in Berlin. It never achieved much popularity. Young’s punch was also modified by others. J. T.Geraghty in 1922’ used a concave, solid knife. Henry A. R. Kreutzmann in 1925lO suggested a knife with a serrated cutting edge. Also in 1925 Howard L. Tolson11~‘2 used diathermy to heat a solid nickel-silver electrode the size of the fenestra in Young’s punch to control bleeding by “cooking” the entire cut surface. Later, he added irrigation and a telescope to Young’s punch. Young summarized the development of his punch and the use of it in his “Practice of Urology.“13 William F. Braasch14 went one step nearer to solving the problem of vision. He adapted his direct irrigating cystoscope for excision of tissue, devising a tube with a fenestra for engaging tissue (Fig. 5). This was passed through the Braasch cystoscope and a tubular knife excised the tissue.
FIGURE 4. Young's modijed punch, manufactured by Lowenstein, of Berlin (1911), cutting tube, water cooling, and ratchet mechanism (notations made by Dr. Young).
incorporating
cautery
FIGURE 5. Braasch’s adaptation of his direct cystoscope for excising tissue with blind cut and no provision for control of bleeding. (A) Cystoscope; (B) inner sheath with fenestra fn- engaging tissue to be removed; and (C) tubular knife inserted through inner sheath for punching out tissue.
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FIGURE 6. Caulk’s modijcation of Young punch (1920): curved needle and syringe used to infiltrate prostate with local anesthesia; bottom component was knife equipped with iridio-platinum, heated, cutting edge.
guide for FIGURE 7. Walker punch (1925), made in London, utilized hake&e forf/rst time; incorporatedfiliform ease of introduction. Procedure jiijrst time became visual one, with telescope, light, and provi.sionfor.flu,shing cut .surf&e and bladder. (1) Bake&e sheath, (2)$1 if arm bougie guide, (3) ohturatcr, (4) tubular knifefor punching out coagulated tissue, (5) olmrator for remocin, ~7tissue from knife punch, (6) light current source, and (7) diathermy current.
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Three tubes were utilized. The two inner tubes reduced the caliber and the size of bites of tissue, which was a handicap. Irrigation removed the blood, so the tissue to be removed could be visualized and cut more accurately than with previous instruments. Inability to control hemorrhage continued to limit the use of the instrument to excision of median bars. Braasch reported in 1918 that he had been using his instrument “for several years.” The exact date of first use is not known. Beer’s15 introduction in 1910 of high frequency current for destruction of bladder tumors was applied to making incisions of the prostate and bladder neck contractures. The use for control of bleeding after incision or excision of bars and contractures seems obvious but was a long time in coming. Young credits A. R. Stevens, in 1913, with being the first to use high frequency current to destroy prostatic bars through a cystoscope.s,‘3 The next big advance broadening the scope and acceptability of transurethral resection of the prostate, and of the punch, was made by John R. Caulk.16 In 1920 he presented his first modification of Young’s punch to the American Association of Genito-Urinary Surgeons (Fig. 6). He put a
one-quarter inch “iridio-platinum cutting edge” on the knife. This was heated with 150 amp. current to burn through bars and contractures. It was used primarily as an office procedure. One patient was reported to have had 14 pieces of tissue removed in three sittings. modified the Kenneth Walker, l7 in England, cautery punch in several important ways in 1925 (Fig. 7). He was also the first to use a bakelite sheath. He originally heated the terminal metal edge of the fenestra with diathermy current to coagulate the tissue to be excised. This later was replaced with a coagulating needle. Light, telescope, and irrigation were used. It was during this same period, between 1926 and 1932, that Maximilian Stern,16T. M. Davis,lg the elecand Joseph McCarthy ‘O developed trotome and a machine to provide adequate cutting and coagulation currents that made the loop resectoscope a success. In 1933 Caulk’l modified his cautery punch by incorporating a foroblique telescope, a stop-cock for irrigation, and a fulgurating attachment (Fig. 8). D. K. Rose in 192521 had already modified Caulks punch to accept a telescope. Caulk and
Caulk’s modijcation of his earlier punch, incorporating telescope, light, and irrigation (1933): (A) FIGURE 8. punch sheath, (B) obturator, (C) telescope, fulgurating and irrigating element, (0) knife with iridio-platinum tip, (E) forcep for removing tissue from knife punch, (F) swab, (G) suction, and (H) catheter.
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FIGURE
9.
Braasch’s
median
bar excisor as modilfied by Bumpus
(1926):
sheath,
knife-punch,
and obturator.
FIGURE 10. Bumpus-Tyvand modifications of earlier blind punch. Early knife; multiple needle electrode for coagulating tissue before excision; punch with obturator closing fenestra; early electrode carrier; later knife, with adaptor into which knife was screwed, with viewing window in place; later electrode carrier with deflector tip and window with escape f& air bubble.
others presented their results with the cautery punch to urologists to stimulate interest in endoscopic surgery for prostatic and vesical neck obstructions. Another center of development of the punch during this period was the Mayo Clinic. While
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Caulk was developing and popularizing the “hot punch,” Herman Carey Bumpus, at the Mayo Clinic, was expanding the usefulness of the “cold became known as the punch. ” His instrument Braasch-Bumpus punch (Fig. 9). He cut a fenestrum in the Braasch cystoscope sheath rather than
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FIGURE
11.
Day prostatic
punch;
cutting was toward operator
use a second tube for this purpose. By using the Bugbee electrode through his instrument Bumpus was better able to control bleeding, a truly revolutionary innovation. He found that these patients suffered fewer febrile reactions and less epididymitis than patients operated on with the Caulk instrument. In 1926 Bumpusz3 reported his early results; 4 of 22 patients expressed “full satisfaction” with the result of the knife-punch operation. The caliber of the Braasch punch had been increased to enable the surgeon to remove pieces of tissue comparable in size to those removed with the cautery-punch. By 1932 Bumpusz4 could report that 48 of 66 patients operated on with the knife-punch five years previously, and who responded, were satisfied. In 1932 Tyvand and Bumpusz5 and later Tyvand26 alone reported several improvements in the Braasch-Bumpus punch (Fig. 10). An air valve was incorporated in the window to permit bubbles that obscured vision to escape. Improvements in the knife and the Bugbee electrode carrier were made, and a multiple needle electrode was introduced. This could be inserted into the bite of tissue to be removed before excision to reduce bleeding. These improvements and increasing experience allowed Gershom Thompson, of the Mayo Clinic, to report that during 1932 and 1933, 721 prostate operations were done and only 46 of
12-1
fwfirst
time.
these were open procedures.27 Most of the open prostatectomies had been done early in 1932. The mortality rate was only 0.7 per cent. In ahnost 10 per cent of the transurethral procedures more than 25 Gm. of tissue had been removed. In one case 116 Gm. oftissue were removed. The mound of tissue was pictured beside a baseball and matched it in size. There was no longer any question about the success of the procedure. Thompson stated that for several years all physicians coming to the Mayo Clinic for prostatic obstruction had requested transurethral surgery. In 1931 Robert V. Day28 presented a single unit punch of his design which incorporated a lens system (Fig. 11). Vision was poor and cutting and control of hemorrhage were not accurate, thus the instrument achieved no widespread use, even at the Los Angeles County General Hospital where it was first tried. A principle not previously employed in a punch was a knife which cut toward the operator. Day, as early as 1913, had developed a needle with which to electrocoagulate tissue to be excised with the Young punch, so he had long been concerned with the problems related to endoscopic prostatic surgery. In 1935 Thompson2’ published the development of his modification of the Braasch-Bumpus and Day punches (Fig. 12). This dispensed with the multiple needle electrode and incorporated a channel in the sheath for the Bugbee electrode,
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Thompson modification punch; (A) obturator; (B) knife-punch and Bugbee system incorporated in one unit. Direct viewing without telescope.
FIGURE12. irrigation
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electrode
carrier
and
FIGURE 14. Modijed Braasch-Bumpus punch presently in use. Electrode carrier, with window with three diopters of magni&ation; obturator, knife, with modijied adaptor and magnifying window; resectoscope sheath made from 28 F Boehm cystoscope.
making one unit of the instrument. Thompson3’ had preceded this with the development of a modification of the Braasch-Bumpus punch to permit irrigation through the knife. In 1962 Hjalmar Carlson made in his hospital machine shop a spring-activated punch. Foley also produced a powered punch. A punch with a rotating blade likewise was developed. None of these instruments was widely used or achieved much popularity. Through the years other urologists made punch modifications and innovations, notably McCarthy and Wedgewood (Fig. 13).31 Each incorporated minor new principles but these achieved no popularity. In 1972 Joseph H. Kaplan32 modified Thompson’s punch incorporating new principles which included fiberoptic lighting and the ability to see the bite of tissue being removed while cutting it with the knife punch. The author and his associates continue to use a modified Braasch-Bumpus punch with three separate elements (Fig 14). The advantages are
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shorter length and greater inner diameter in a 28 F instrument, hence better vision and more rapid tissue removal. The latter compensates for the time lost in inserting the electrode carrier, which is done while emptying the full bladder, for control of bleeding. Three diopters of magnification are built into the punch window, affording excellent vision. Rapid flow of irrigation fluid removes blood, regardless of rate of bleeding, so vision is never distorted or clouded. In addition, since a lens system is not employed, the appearance of tissue is natural. The knife punch gives accurate dissection of tissue with less danger of perforation of the prostatic capsule since this is not readily forced into the fenestra. Point fulguration of bleeding vessels results in less necrosis, slough, and fibrosis. The true secret of success of the procedure, however, as with all endoscopic prostatic surgery, is rapid, accurate, and complete removal of adenomatous hyperplasia of the prostate, with good control of bleeding without excessive electrocoagulation of tissue.
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For those urologists who have mastered the knife-punch there is no system to compare with it. Those of us who first learned to use the SternMcCarthy resectoscope have never been tempted to return to it except in exceptional circumstances. Not only can prostatic obstructions be more expeditiously removed with the punch but no other instrument can compare with it for the removal of large vesical neoplasms and calculi. Our modification of the Braasch-Bumpus punch is superior for the latter purpose. Urologists and their patients today owe as great a debt to the pioneers in prostatic surgery and to the innovators among them as to any in the field of surgery. One would like to believe that endoscopic prostatic surgery and instruments have reached their apogee, but experience has taught the foolishness of such arrogance. Transurethral prostatic surgery is a very personal choice for the surgeon. It remains the loneliest surgical procedure which urologists perform. The prostatic resectionist soon learns humility and should never cease to learn by experience. Happy is the day that he can approach each new procedure with respectful confidence and assurance. Mastery of his instrument, adequate dexterity, and a proper temperament make this possible for the fortunate resectionist. While practicing and teaching what he has learned, the resectionist should be mindful of those who have made it possible. And if the day comes when he must relinquish his own prostate he truly will be indebted to those doughty forebears. 112 North Madison Avenue Pasadena, California 91101 References 1. GUTHRIE, G. J. : Anatomy and Diseases of the Neck of the Bladder and of the Urethra, London, Burgess and Hill, 1834. 2. GUTJERREZ, R. : Transurethral treatment of bladder neck obstructions: endoscopic prostatic resection, in History of Urology, vol. 2, Baltimore, Williams and Wilkins Co., 1933, p. 137. :3. MERCIER, A. : Recherches anatomiques sur la prostate des vieillards, Bull. Sociktit Anat. (1836). 1. HUTCHINSON, A. C. : London Med. Repository 22: 128 (1873), quoted by Gutierrez.’ 5. BOTTINI, E.: Radicale Behandlung der auf hypertrophic der Prostata beruhenden Ischurie, Arch. Klin. Chir. 21: 1 (1877). 6. FREUDENBERG, A. : Eine modificirter bottinischer Incisor, Zentbl. Chir. 24: 788 (1897).
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7. YOUNG, H. H.: A new combined electro-cautery incisor for the Bottini operation for prostatic obstruction, J.A.M.A. 38: 86 (1902). 8. IDEM: A new procedure (punch operation) for small prostatic bars and contracture of the prostatic orifice, ibid. 60: 253 (1913). per urethram, a 9. GERACHTY, J. T.: Sphincterotomy simple and safe procedure for the cure of contracture of the vesical orifice, J. Ural. 7: 367 (1922). 10. KREUTZMANN, H. A. R.: An improved knife for Young’s prostatic punch, ibid. 14: 311 (1925). 11. TOLSON, H. L.: An electrode for use with Young’s punch. Diathermy as a supplement to the prostatic punch operation, ibid. 14: 63 (1925). resection with modifications of 12. IDEM: Prostatic Young’s punch, ibid. 43: 116 (1940). 13. YOUNG, H. H.: Practice of Urology, Philadelphia, W. B. Saunders Co., 1926, vol. 20, pp. 481-512. Median bar excisor, J..4.M..4. 70: 14. BRAASCH, W. F.: 758 (1918). 15. BEER, E. : Removal of neoplasms of the urinary bladder, ibid. 54: 1768 (1910). 16. CAULK, J. R.: Infiltration anesthesia of the internal vesical orifice for the removal of minor obstruction: presentation of a cautery punch, J. Ural. 4: 399 (1920). 17. WALKER, K. M.: Periurethral operations for prostatic obstruction, Br. Med. J. 1: 201 (1925). at the vesical 18. STERN, M.: Resection of obstruction orifice; new instruments (resectotherm; resectoscope) and a new method, J.A.M.A. 87: 1726 (1926). 19. DAVIS, T. M.: Prostatic operation: prospects of the patient with prostatic disease in prostatectomy vs. resection, J.A.M.A. 97: 1674 (1931). 20. MCCARTHY, J. F.: A new apparatus for endoscopic plastic surgery of the prostate, diathermia, and excision of vesical growths, J. Urol. 26: 695 (193131). of a new cautery prmch, 21. CAULK, J. R.: Presentation ibid. 30: 737 (1933). 22. ROSE,D. K.: A visual prostatic punch, Surg. Gynecol. Obstet. 41: 109 (1925). J. 23. BUMPUS, H. C.: Results of punch prostatectomy, Urol. 16: 59 (1926). treatment 24. IDEM: Results five years after transurethral of benign prostatic hypertropy, ibid. 28: 561 (1932). A simple 25. TYVAND, R. E., and BUMPUS, H. C.: technique for prostatic resection, ibid. 27: 503 (1932). Improved model of the Braasch26. TYVAND, R. E.: Bumpus punch instrument, ibid. 35: 109 (1936). prostatic surgery, 27. THOMPSON, G. J.: Transurethral Mayo Clin. Proc. 26: 349 (1934). 28. DAY, R. V. : Management of contracture of the bladder neck. A new cysto-urethroscopic punch, Ural. Cutan. Rev. 35: 25 (1931). 29. THOMPSON, G. J,: A new direct vision resectoscope, ibid. 39: 545 (1935). attachment, Mayo Clin. Proc. 30. IDEM: A resectoscope 11: 335 (1936). Modification of the McCarthy 31. WEDGEWOOD, P. E.: visible prostatic punch for transurethral prostatic resections, J. Urol. 32: 287 (1934). ibid. 32. KAPLAN, J. H. : A new cold punch resectoscope, 107: 1054 (1972).
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