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Management of Benign Prostatic Hypertrophy
Management of Benign Prostatic Hypertrophy EARL HALTIWANGER, M.D.*
Benign prostatic hypertrophy frequently is present in the aging male. However, in many instances no treatment is indicated for this condition. By referring to five specific indications for surgical intervention, unnecessary treatment may be avoided. The term benign prostatic hypertrophy is used here because of its common clinical acceptance. Although there is disagreement concerning the exact etiology, development and terminology of this condition, this is of no significance to the practicing physician. Benign prostatic hypertrophy consists of periurethral masses composed of glands and fibromuscular tissue. This tissue is frequently referred to as the prostatic adenoma and it compresses the true prostate to the periphery. This adenoma usually occurs as two lateral lobes, a median lobe, or a combination of all three lobes. Rarely an anterior lobe is present.
INDICATIONS FOR THERAPY
The five indications for therapy are residual urine, symptoms, bladder changes, other states adversely affected by increased intra-abdominal pressure and uncontrollable hemorrhage. The size of the prostatic adenoma plays no part in the decision as to whether or not treatment is indicated. Some adenomas can reach a large size without causing trouble while others which are quite small can cause complete urinary retention.
Residual Urine Residual urine of 75 cc. or more perhaps is the strongest indication for the need of intervention. This represents early decompensation of the bladder and alerts the physician to the possibility of progressive difficulty. Urinary tract obstruction with residual urine provides a fertile field for
* Chief, Urology Section, Atlanta Veterans Administration Hospital; Associate in Surgery (Urology), Emory University School of Medicine
1441
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EARL HALTIWANGER
urinary tract infection. Once established it is most difficult, if not impossible, to eradicate infection in the presence of urinary stasis. The figure of 75 cc. is not a rigid one and may be modified somewhat by other factors. If a patient has a persistent urinary tract infection with attacks of cystitis operation is considered when a smaller amount of residual urine is present. On the other hand, a residual urine of 100 cc. is occasionally permitted if there is no infection and the patient otherwise is doing well. Residual urine may be evaluated by several methods. 1. The catheter is the most accurate means of determining the amount of residual urine. Complete urinary retention, with or without overflow, is interpreted as a residual urine. When complete retention is not present it is necessary to catheterize the patient immediately after voiding. The discovery of 125 cc. of urine in the bladder of a patient who cannot void is not an indication of residual urine. If a catheter cannot be passed, or if it is not desirable to do so, residual urine may be ruled out by other means. However, if any of these other methods fail to rule out a residual urine a catheter should be used if at all possible. 2. The air test is simple and is done easily in the office. A patient is taken at a time when he feels that he will be able to void. The patient lies on the examining table and the glans penis is cleansed. The tip of a bulb syringe is wedged into the urethral meatus and approximatel y 40 cc. of air is injected into the bladder. One can determine the moment the urinary sphincter relaxes and allows the air to enter the bladder, for there will be a diminution of pressure in the rubber bulb of the syringe at this time. The patient then stands to void. As the urine is expelled the air remains in the most superior portion of the bladder. It does not escape until after the urine has been eliminated. The sound of air passing per urethra will not be mistaken and will rule out residual urine. 3. Post-voiding x-ray films may be used to evaluate residual urine. A radiopaque aqueous solution is introduced through the penis with a bulb syringe and the patient asked to void. An x-ray film of the bladder then is taken. A post-voiding film may be taken in conjunction with an intravenous pyelogram provided that the patient is able to void and there is sufficient contrast material in the bladder for adequate visualization. X-ray determination of residual urine lacks popularity because of the comparative costs involved. 4. The phenolsulfonphthalein test is occasionally used for determining the presence of a residual urine. The phenolsulfonp hthalein test gives one an indication of overall renal function. When used properly it also gives information concerning stasis in the urinary tract. After adequate hydration a patient is given an intravenous injection of 1 cc. of phenolsulfonp hthalein measured in a l-cc. tuberculin syringe. The urine is collected every 30 minutes for two hours, care being taken that each entire specimen is saved. For a satisfactory test 100 cc. or more must be collected each 30 minutes. The highest concentration of dye should be present in the first 30 minute
MANAGEMENT OF BENIGN PROSTATIC HYPERTROPHY
1443
specimen. If a higher concentration is present in a later specimen this is known as a delayed peak and indicates residual urine. As a rule of thumb, the 30-minute specimen will contain at least one-half of the total two-hour excretion unless residual urine is present. Symptoms
Nocturia of three or more times from benign prostatic hypertrophy is an indication for treatment. Lower urinary tract obstruction causes a number of signs and symptoms. Although these do not progress in any consistent order, the first sign usually noted is diminution in the size and force of the urinary stream. Hesitancy in initiation of urinary stream and straining to void are frequently the first hints that therapy may be required. Occasionally double voiding is seen. This arises when the bladder muscles become fatigued before the bladder is empty. After a rest of a few minutes enough strength is regained to force out an additional amount of urine. Often a sensation of incomplete emptying of the bladder is noted. Increased resistance to urinary outflow requires a higher intravesical pressure to initiate voiding and hypertrophy of the detrusor muscle occurs. This, in turn, causes increased irritability of the muscle so that a smaller amount of urine in the bladder gives rise to the desire to void. Urinary frequency and ofttimes urinary urgency is the result. Frequency in benign prostatic hypertrophy also is seen when a residual urine is present, and, thus, the functional capacity of the bladder is reduced. Frequency is caused by other factors which must be taken into consideration. An acute urinary tract infection is usually recognized and must be corrected before evaluation of this symptom can be made. Occasionally frequency is caused by a bladder tumor or foreign body. Some patients experience urinary frequency and urgency because of nervous tension. Because of this, the amount of nocturia is of great importance. Patients with nervous tension usually will not be awakened by the desire to void once they have gone to sleep. Patients with frequency because of urinary tract obstruction will be awakened by the desire to void. Nocturia of three or more times is sufficient to warrant surgical intervention. The nocturia of benign prostatic hypertrophy is not characterized by the voiding of large quantities of urine. However, polyuria from uncontrolled diabetes mellitus or from diabetes insipidus will cause nocturia in a patient with a normal voiding mechanism. Similarly, nocturia may be seen in a patient in congestive heart failure when fluid is pooled in the body during periods of activity only to be eliminated by a nocturnal diuresis. This can be overlooked in instances of early failure. An accurate method of obtaining facts concerning nocturia is the recording of individual voidings. To do this a record is maintained of the time and volume of each voiding. By examination of this record the patient with nocturia but with large urinary output is discovered.
1444
EAR,L HALTIWANGER
Bladder Changes
The presence of bladder diverticula formation or impending formation from prostatic obstruction is an indication for operation. As the detrusor muscle does more work to overcome the increased resistance of the prostatic urethra, muscular hypertrophy results. This is seen through the cystoscope as trabeculation. As voiding bladder pressure increases, further small protrusions of the mucosa are seen between the hypertrophied muscle fibers and are known as cellules. The final stage of change is diverticula formation in which the cellules enlarge and extend beyond the bladder wall. These diverticula have no effective muscle in their walls and thus harbor residual urine. Intervention should be made before these changes have progressed to diverticula formation. The appearance of the prostatic urethra through the endoscope is not in itself an indication for surgery. It is not rare to find a gland that appears to be obstructing the urethra by endoscopy but does not lead to the presence of criteria for therapy. One must determine from history and examination whether bladder changes may be the result of a urethral stricture which has been relieved. Prostatic surgery is not indicated in such a case. Hernia or Hemorrhoids
Prostatic obstruction should be treated when increased intra-abdominal pressure is required for voiding which adversely affects other diseases or body conditions that are present. The two most common examples of these are hernia and hemorrhoids. Prior to herniorrhaphy it should be determined whether or not it is necessary for the patient to strain to void. If this is required lower urinary tract obstruction should be corrected, for any increase in intra-abdominal pressure will make the herniorrhaphy less likely to succeed: The same principle applies to the patient for hemorrhoidectomy. Hemorrhage
On rare occasions it is necessary to enucleate a prostatic adenoma to control bleeding. This is seen almost entirely in the very large adenoma in which all efforts fail to stop massive hemorrhage. The bleeding is often precipitated by urethral instrumentation or an infarction in the prostate. By removal of the adenoma the physician is able to leave the patient with a relatively smooth and viable lining of the prostatic fossa. Under these circumstances bleeding is more readily controlled. Diseases Other Than Benign Prostatic Hypertrophy That Can Give Similar Findings
Even when one of the five indications for treatment does exist the physician still must consider if this could be produced by a disease or condition other than benign prostatic hypertrophy.
MANAGEMENT OF BENIGN PROSTATIC HYPERTROPHY
1445
A urethral stricture can cause obstruction leading to bladder changes, residual urine, frequency, nocturia and urgency. Following relief of the stricture, bladder changes often linger. Often benign prostatic hypertrophy coexists with a stricture. In this instance the stricture must be treated and then the patient re-evaluated for benign prostatic hypertrophy. Neurogenic bladder with residual urine may be present without obvious neurological signs, as is sometimes seen in pernicious anemia or diabetes mellitus. Carcinoma of the prostate can cause urethral obstruction or it may be present in a gland in which the benign prostatic hypertrophy is causing the obstruction. Carcinoma of the prostate should be treated for at least two weeks before an operation is considered on the prostate for obstruction. Under hormone therapy the carcinoma will frequently shrink enough to relieve the obstruction. Even when shrinkage is not this complete the surgeon is left with a smaller gland for surgery. Bladder irritation with frequency, urgency and nocturia is also present with acute infections, bladder tumors or foreign bodies in the bladder. A patient with borderline urinary compensation can be pushed into retention by administration of drugs such as atropine and Pro-Banthine in the treatment of ulcer disease. Effective voiding often can be restored by discontinuing the drugs. Retention can occur when a patient becomes debilitated by a serious illness or operation or whenever the bladder is allowed to become overdistended.
PREOPERATIVE EVALUATION AND PREPARATION
Surgery is the only definitive treatment for benign prostatic hypertrophy. After the need for therapy has been established it is determined whether or not this surgery may be done. A blood urea nitrogen determination is made to evaluate overall renal function. An elevated blood urea nitrogen may be secondary to lower urinary tract obstruction or to chronic, irreversible, renal parenchymal changes. The patient with residual urine and azotemia is treated with an indwelling catheter. The blood urea nitrogen is redetermined at weekly intervals until it returns to normal. Following the relief of chronic urinary retention the patient must be observed for excessive sodium diuresis. If the blood urea nitrogen stabilizes at an elevated value an operation still may be considered. However, a constant value above 40 mg. per 100 ml. of blood is a poor prognostic sign and surgery is contraindicated. An intravenous pyelogram reveals the status of the upper urinary tract. Following longstanding prostatic obstruction hydronephrosis and hydroureter are frequently seen and are treated with an indwelling catheter prior to operation. Most instances of hydronephrosis secondary to benign pros-
1446
EARL lIALTIWANGER
tatic hypertrophy will disappear following two to three weeks of bladder drainage. Anemia when present with benign prostatic hypertrophy is frequently related to an elevated blood urea nitrogen or to infections in the urinary tract. Before surgery the hemoglobin level should be raised to 13 grams or more. This may be done by removing the cause of anemia or by transfusion. An indwelling catheter is indicated for an elevated blood urea nitrogen or hydronephrosis and in the presence of a large residual urine in an attempt to allow the bladder to regain its normal tone. An indwelling catheter is not needed always in instances of less than 200 cc. of uninfected residual urine provided that surgical intervention is planned in the near future. However, a catheter must be used if infection is present. Antimicrobial therapy is used with the preoperative retention catheter. General medical evaluation of the patient is made, as is usual in other surgical candidates, to evaluate the anesthetic risk. Cardiovascular disorders as well as hemorrhagic tendencies are particularly important.
CHOICE OF OPERATION
At this point in the evaluation the type of surgery to be performed is determined. The choice here is between a closed prostatectomy (transurethral resection) and an open prostatectomy. This is based primarily upon the size of the prostatic adenoma. This size is first determined by rectal palpation which is done with the bladder empty. A distended bladder can force the prostate downward in such a manner as to cause the size of the adenoma to be overestimated. A transurethral resection is performed if the surgeon thinks that he can remove the adenoma in one hour or less with a resectoscope. This amount of tissue will vary somewhat according to the skill of the resectionist but will usually be 50 grams or less. A transurethral resection should not be prolonged over one hour because of the possibility of excessive absorption of fluid from the prostatic fossa causing water intoxication and sodium diuresis. Prolonged cutting time during a transurethral resection also allows an extended time for bleeding to occur from the adenoma. Transurethral resection of the prostate is carried out in patients with coexistent, incurable carcinoma of the prostate regardless of the size of the prostate. A cystoscopy is done immediately preceding the transurethral resection to evaluate any bladder disease that may be present. A bilateral vas ligation lowers the incidence of postoperative epididymitis. If the prostate feels large on rectal examination the patient is further evaluated by endoscopy for open surgery. At the same time the bladder is examined. Unless the adenoma is found to be large by both rectal examination and endoscopy an open prostatectomy should not be done. Open prostatectomy is best done when there is a well developed cleavage plane between the adenoma and the true prostatic tissue. This plane is poorly
MANAGEMENT OF BENIGN PROSTATIC HYPERTROPHY
1447
developed in small prostates and is often destroyed in patients with prostatic carcinoma. These patients should be treated by transurethral resection. Coexisting bladder disease requiring surgry allows open prostatectomy to be considered in a patient with a smaller prostate than is usually removed by open operation. If open prostatectomy is chosen for the patient the surgeon must then decide upon his approach. The three most common procedures are suprapubic prostatectomy, retropubic prostatectomy and perineal prostatectomy. The choice between these is primarily a matter of individual preference. The suprapubic prostatectomy is the easiest performed and allows surgery to be performed upon the bladder. The retropubic prostatectomy requires more operating time but allows hemostasis under direct visualization. The length of hospitalization in retropubic prostatectomy is shorter than in the other two open operations. The perineal operation is the least frequently used because there are few operators with adequate experience in working in the perineum. The distressing complications of urethrorectal fistula and incontinence turn many away from this approach. Bilateral vasectomy is done with open prostatectomies to lower the incidence of postoperative epididymitis.
COMPLICATIONS OF SURGERY
Incontinence can follow any type of surgery but decreases as the skill of the operator increases. The incidence is highest following transurethral resection and perineal prostatectomy but may follow an attempted suprapubic enucleation of a small adenoma. Secondary hemorrhage is not rare in any of the operations but is more frequent following transurethral resection. This usually occurs between 7 and 14 days postoperatively and in most instances is easily managed with evacuation of bladder clots followed by an indwelling catheter for one to two days. Impotence is most common following perineal prostatectomy and is seen least with transurethral resection. However, retrograde ejaculation frequently is seen following transurethral resection and this should be explained to the patient prior to discharge. Urethral stricture is a hazard of transurethral resection, and perforation of the bladder with extravasation of urine is a complication solely of this procedure. Osteitis pubis occasionally is seen following retropubic prostatectomy but on rare occasions had been reported after a transurethral resection. Urethrorectal fistula is seen almost exclusively with perineal prostatectomy and may be quite difficult to correct. Pyuria will follow all prostatectomies and patients are placed on antimicrobial treatment for at least two weeks.
1448
EARL HALTIWANGER
If patients are chosen for operation on the basis of the five indications given above the surgeon may expect to have a high success rate following the properly chosen operation.
SUMMARY Benign prostatic hypertrophy is seen frequently but often does not require therapy. The five indications for treatment are residual urine, symptoms, bladder changes, conditions made worse by increased intraabdominal pressure, and uncontrollable hemorrhage. Surgery is the only definitive treatment but is not done when the patient is uremic or anemic. The size of the prostate determines whether a transurethral resection or an open prostatectomy is done. Complications of surgery are incontinence, secondary hemorrhage, impotence, urethral stricture, osteitis pubis and urethrorectal fistula.
REFERENCES 1. Campbell, M. F.: Urology, Volume III, 2nd Ed. Philadelphia & London, W. B.
Saunders Co., 1963. 2. Weyrauch, H. M.: Surgery of the Prostate. Philadelphia & London, W. B. Saunders Co., 1959. Section of Urology, Veterans Administration Hospital 4158 Peachtree Road, N.E. Atlanta, Georgia 30319
Benign prostatic hypertrophy frequently is present in the aging male. However, in many instances no treatment is indicated for this condition. By referring to five specific indications for surgical intervention, unnecessary treatment may be avoided. The term benign prostatic hypertrophy is used here because of its common clinical acceptance. Although there is disagreement concerning the exact etiology, development and terminology of this condition, this is of no significance to the practicing physician. Benign prostatic hypertrophy consists of periurethral masses composed of glands and fibromuscular tissue. This tissue is frequently referred to as the prostatic adenoma and it compresses the true prostate to the periphery. This adenoma usually occurs as two lateral lobes, a median lobe, or a combination of all three lobes. Rarely an anterior lobe is present.
INDICATIONS FOR THERAPY
The five indications for therapy are residual urine, symptoms, bladder changes, other states adversely affected by increased intra-abdominal pressure and uncontrollable hemorrhage. The size of the prostatic adenoma plays no part in the decision as to whether or not treatment is indicated. Some adenomas can reach a large size without causing trouble while others which are quite small can cause complete urinary retention.
Residual Urine Residual urine of 75 cc. or more perhaps is the strongest indication for the need of intervention. This represents early decompensation of the bladder and alerts the physician to the possibility of progressive difficulty. Urinary tract obstruction with residual urine provides a fertile field for
* Chief, Urology Section, Atlanta Veterans Administration Hospital; Associate in Surgery (Urology), Emory University School of Medicine
1441
1442
EARL HALTIWANGER
urinary tract infection. Once established it is most difficult, if not impossible, to eradicate infection in the presence of urinary stasis. The figure of 75 cc. is not a rigid one and may be modified somewhat by other factors. If a patient has a persistent urinary tract infection with attacks of cystitis operation is considered when a smaller amount of residual urine is present. On the other hand, a residual urine of 100 cc. is occasionally permitted if there is no infection and the patient otherwise is doing well. Residual urine may be evaluated by several methods. 1. The catheter is the most accurate means of determining the amount of residual urine. Complete urinary retention, with or without overflow, is interpreted as a residual urine. When complete retention is not present it is necessary to catheterize the patient immediately after voiding. The discovery of 125 cc. of urine in the bladder of a patient who cannot void is not an indication of residual urine. If a catheter cannot be passed, or if it is not desirable to do so, residual urine may be ruled out by other means. However, if any of these other methods fail to rule out a residual urine a catheter should be used if at all possible. 2. The air test is simple and is done easily in the office. A patient is taken at a time when he feels that he will be able to void. The patient lies on the examining table and the glans penis is cleansed. The tip of a bulb syringe is wedged into the urethral meatus and approximatel y 40 cc. of air is injected into the bladder. One can determine the moment the urinary sphincter relaxes and allows the air to enter the bladder, for there will be a diminution of pressure in the rubber bulb of the syringe at this time. The patient then stands to void. As the urine is expelled the air remains in the most superior portion of the bladder. It does not escape until after the urine has been eliminated. The sound of air passing per urethra will not be mistaken and will rule out residual urine. 3. Post-voiding x-ray films may be used to evaluate residual urine. A radiopaque aqueous solution is introduced through the penis with a bulb syringe and the patient asked to void. An x-ray film of the bladder then is taken. A post-voiding film may be taken in conjunction with an intravenous pyelogram provided that the patient is able to void and there is sufficient contrast material in the bladder for adequate visualization. X-ray determination of residual urine lacks popularity because of the comparative costs involved. 4. The phenolsulfonphthalein test is occasionally used for determining the presence of a residual urine. The phenolsulfonp hthalein test gives one an indication of overall renal function. When used properly it also gives information concerning stasis in the urinary tract. After adequate hydration a patient is given an intravenous injection of 1 cc. of phenolsulfonp hthalein measured in a l-cc. tuberculin syringe. The urine is collected every 30 minutes for two hours, care being taken that each entire specimen is saved. For a satisfactory test 100 cc. or more must be collected each 30 minutes. The highest concentration of dye should be present in the first 30 minute
MANAGEMENT OF BENIGN PROSTATIC HYPERTROPHY
1443
specimen. If a higher concentration is present in a later specimen this is known as a delayed peak and indicates residual urine. As a rule of thumb, the 30-minute specimen will contain at least one-half of the total two-hour excretion unless residual urine is present. Symptoms
Nocturia of three or more times from benign prostatic hypertrophy is an indication for treatment. Lower urinary tract obstruction causes a number of signs and symptoms. Although these do not progress in any consistent order, the first sign usually noted is diminution in the size and force of the urinary stream. Hesitancy in initiation of urinary stream and straining to void are frequently the first hints that therapy may be required. Occasionally double voiding is seen. This arises when the bladder muscles become fatigued before the bladder is empty. After a rest of a few minutes enough strength is regained to force out an additional amount of urine. Often a sensation of incomplete emptying of the bladder is noted. Increased resistance to urinary outflow requires a higher intravesical pressure to initiate voiding and hypertrophy of the detrusor muscle occurs. This, in turn, causes increased irritability of the muscle so that a smaller amount of urine in the bladder gives rise to the desire to void. Urinary frequency and ofttimes urinary urgency is the result. Frequency in benign prostatic hypertrophy also is seen when a residual urine is present, and, thus, the functional capacity of the bladder is reduced. Frequency is caused by other factors which must be taken into consideration. An acute urinary tract infection is usually recognized and must be corrected before evaluation of this symptom can be made. Occasionally frequency is caused by a bladder tumor or foreign body. Some patients experience urinary frequency and urgency because of nervous tension. Because of this, the amount of nocturia is of great importance. Patients with nervous tension usually will not be awakened by the desire to void once they have gone to sleep. Patients with frequency because of urinary tract obstruction will be awakened by the desire to void. Nocturia of three or more times is sufficient to warrant surgical intervention. The nocturia of benign prostatic hypertrophy is not characterized by the voiding of large quantities of urine. However, polyuria from uncontrolled diabetes mellitus or from diabetes insipidus will cause nocturia in a patient with a normal voiding mechanism. Similarly, nocturia may be seen in a patient in congestive heart failure when fluid is pooled in the body during periods of activity only to be eliminated by a nocturnal diuresis. This can be overlooked in instances of early failure. An accurate method of obtaining facts concerning nocturia is the recording of individual voidings. To do this a record is maintained of the time and volume of each voiding. By examination of this record the patient with nocturia but with large urinary output is discovered.
1444
EAR,L HALTIWANGER
Bladder Changes
The presence of bladder diverticula formation or impending formation from prostatic obstruction is an indication for operation. As the detrusor muscle does more work to overcome the increased resistance of the prostatic urethra, muscular hypertrophy results. This is seen through the cystoscope as trabeculation. As voiding bladder pressure increases, further small protrusions of the mucosa are seen between the hypertrophied muscle fibers and are known as cellules. The final stage of change is diverticula formation in which the cellules enlarge and extend beyond the bladder wall. These diverticula have no effective muscle in their walls and thus harbor residual urine. Intervention should be made before these changes have progressed to diverticula formation. The appearance of the prostatic urethra through the endoscope is not in itself an indication for surgery. It is not rare to find a gland that appears to be obstructing the urethra by endoscopy but does not lead to the presence of criteria for therapy. One must determine from history and examination whether bladder changes may be the result of a urethral stricture which has been relieved. Prostatic surgery is not indicated in such a case. Hernia or Hemorrhoids
Prostatic obstruction should be treated when increased intra-abdominal pressure is required for voiding which adversely affects other diseases or body conditions that are present. The two most common examples of these are hernia and hemorrhoids. Prior to herniorrhaphy it should be determined whether or not it is necessary for the patient to strain to void. If this is required lower urinary tract obstruction should be corrected, for any increase in intra-abdominal pressure will make the herniorrhaphy less likely to succeed: The same principle applies to the patient for hemorrhoidectomy. Hemorrhage
On rare occasions it is necessary to enucleate a prostatic adenoma to control bleeding. This is seen almost entirely in the very large adenoma in which all efforts fail to stop massive hemorrhage. The bleeding is often precipitated by urethral instrumentation or an infarction in the prostate. By removal of the adenoma the physician is able to leave the patient with a relatively smooth and viable lining of the prostatic fossa. Under these circumstances bleeding is more readily controlled. Diseases Other Than Benign Prostatic Hypertrophy That Can Give Similar Findings
Even when one of the five indications for treatment does exist the physician still must consider if this could be produced by a disease or condition other than benign prostatic hypertrophy.
MANAGEMENT OF BENIGN PROSTATIC HYPERTROPHY
1445
A urethral stricture can cause obstruction leading to bladder changes, residual urine, frequency, nocturia and urgency. Following relief of the stricture, bladder changes often linger. Often benign prostatic hypertrophy coexists with a stricture. In this instance the stricture must be treated and then the patient re-evaluated for benign prostatic hypertrophy. Neurogenic bladder with residual urine may be present without obvious neurological signs, as is sometimes seen in pernicious anemia or diabetes mellitus. Carcinoma of the prostate can cause urethral obstruction or it may be present in a gland in which the benign prostatic hypertrophy is causing the obstruction. Carcinoma of the prostate should be treated for at least two weeks before an operation is considered on the prostate for obstruction. Under hormone therapy the carcinoma will frequently shrink enough to relieve the obstruction. Even when shrinkage is not this complete the surgeon is left with a smaller gland for surgery. Bladder irritation with frequency, urgency and nocturia is also present with acute infections, bladder tumors or foreign bodies in the bladder. A patient with borderline urinary compensation can be pushed into retention by administration of drugs such as atropine and Pro-Banthine in the treatment of ulcer disease. Effective voiding often can be restored by discontinuing the drugs. Retention can occur when a patient becomes debilitated by a serious illness or operation or whenever the bladder is allowed to become overdistended.
PREOPERATIVE EVALUATION AND PREPARATION
Surgery is the only definitive treatment for benign prostatic hypertrophy. After the need for therapy has been established it is determined whether or not this surgery may be done. A blood urea nitrogen determination is made to evaluate overall renal function. An elevated blood urea nitrogen may be secondary to lower urinary tract obstruction or to chronic, irreversible, renal parenchymal changes. The patient with residual urine and azotemia is treated with an indwelling catheter. The blood urea nitrogen is redetermined at weekly intervals until it returns to normal. Following the relief of chronic urinary retention the patient must be observed for excessive sodium diuresis. If the blood urea nitrogen stabilizes at an elevated value an operation still may be considered. However, a constant value above 40 mg. per 100 ml. of blood is a poor prognostic sign and surgery is contraindicated. An intravenous pyelogram reveals the status of the upper urinary tract. Following longstanding prostatic obstruction hydronephrosis and hydroureter are frequently seen and are treated with an indwelling catheter prior to operation. Most instances of hydronephrosis secondary to benign pros-
1446
EARL lIALTIWANGER
tatic hypertrophy will disappear following two to three weeks of bladder drainage. Anemia when present with benign prostatic hypertrophy is frequently related to an elevated blood urea nitrogen or to infections in the urinary tract. Before surgery the hemoglobin level should be raised to 13 grams or more. This may be done by removing the cause of anemia or by transfusion. An indwelling catheter is indicated for an elevated blood urea nitrogen or hydronephrosis and in the presence of a large residual urine in an attempt to allow the bladder to regain its normal tone. An indwelling catheter is not needed always in instances of less than 200 cc. of uninfected residual urine provided that surgical intervention is planned in the near future. However, a catheter must be used if infection is present. Antimicrobial therapy is used with the preoperative retention catheter. General medical evaluation of the patient is made, as is usual in other surgical candidates, to evaluate the anesthetic risk. Cardiovascular disorders as well as hemorrhagic tendencies are particularly important.
CHOICE OF OPERATION
At this point in the evaluation the type of surgery to be performed is determined. The choice here is between a closed prostatectomy (transurethral resection) and an open prostatectomy. This is based primarily upon the size of the prostatic adenoma. This size is first determined by rectal palpation which is done with the bladder empty. A distended bladder can force the prostate downward in such a manner as to cause the size of the adenoma to be overestimated. A transurethral resection is performed if the surgeon thinks that he can remove the adenoma in one hour or less with a resectoscope. This amount of tissue will vary somewhat according to the skill of the resectionist but will usually be 50 grams or less. A transurethral resection should not be prolonged over one hour because of the possibility of excessive absorption of fluid from the prostatic fossa causing water intoxication and sodium diuresis. Prolonged cutting time during a transurethral resection also allows an extended time for bleeding to occur from the adenoma. Transurethral resection of the prostate is carried out in patients with coexistent, incurable carcinoma of the prostate regardless of the size of the prostate. A cystoscopy is done immediately preceding the transurethral resection to evaluate any bladder disease that may be present. A bilateral vas ligation lowers the incidence of postoperative epididymitis. If the prostate feels large on rectal examination the patient is further evaluated by endoscopy for open surgery. At the same time the bladder is examined. Unless the adenoma is found to be large by both rectal examination and endoscopy an open prostatectomy should not be done. Open prostatectomy is best done when there is a well developed cleavage plane between the adenoma and the true prostatic tissue. This plane is poorly
MANAGEMENT OF BENIGN PROSTATIC HYPERTROPHY
1447
developed in small prostates and is often destroyed in patients with prostatic carcinoma. These patients should be treated by transurethral resection. Coexisting bladder disease requiring surgry allows open prostatectomy to be considered in a patient with a smaller prostate than is usually removed by open operation. If open prostatectomy is chosen for the patient the surgeon must then decide upon his approach. The three most common procedures are suprapubic prostatectomy, retropubic prostatectomy and perineal prostatectomy. The choice between these is primarily a matter of individual preference. The suprapubic prostatectomy is the easiest performed and allows surgery to be performed upon the bladder. The retropubic prostatectomy requires more operating time but allows hemostasis under direct visualization. The length of hospitalization in retropubic prostatectomy is shorter than in the other two open operations. The perineal operation is the least frequently used because there are few operators with adequate experience in working in the perineum. The distressing complications of urethrorectal fistula and incontinence turn many away from this approach. Bilateral vasectomy is done with open prostatectomies to lower the incidence of postoperative epididymitis.
COMPLICATIONS OF SURGERY
Incontinence can follow any type of surgery but decreases as the skill of the operator increases. The incidence is highest following transurethral resection and perineal prostatectomy but may follow an attempted suprapubic enucleation of a small adenoma. Secondary hemorrhage is not rare in any of the operations but is more frequent following transurethral resection. This usually occurs between 7 and 14 days postoperatively and in most instances is easily managed with evacuation of bladder clots followed by an indwelling catheter for one to two days. Impotence is most common following perineal prostatectomy and is seen least with transurethral resection. However, retrograde ejaculation frequently is seen following transurethral resection and this should be explained to the patient prior to discharge. Urethral stricture is a hazard of transurethral resection, and perforation of the bladder with extravasation of urine is a complication solely of this procedure. Osteitis pubis occasionally is seen following retropubic prostatectomy but on rare occasions had been reported after a transurethral resection. Urethrorectal fistula is seen almost exclusively with perineal prostatectomy and may be quite difficult to correct. Pyuria will follow all prostatectomies and patients are placed on antimicrobial treatment for at least two weeks.
1448
EARL HALTIWANGER
If patients are chosen for operation on the basis of the five indications given above the surgeon may expect to have a high success rate following the properly chosen operation.
SUMMARY Benign prostatic hypertrophy is seen frequently but often does not require therapy. The five indications for treatment are residual urine, symptoms, bladder changes, conditions made worse by increased intraabdominal pressure, and uncontrollable hemorrhage. Surgery is the only definitive treatment but is not done when the patient is uremic or anemic. The size of the prostate determines whether a transurethral resection or an open prostatectomy is done. Complications of surgery are incontinence, secondary hemorrhage, impotence, urethral stricture, osteitis pubis and urethrorectal fistula.
REFERENCES 1. Campbell, M. F.: Urology, Volume III, 2nd Ed. Philadelphia & London, W. B.
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