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Problems Encountered in the Treatment of Prostatism
THE JOURNAL OF UROLOGY
Vol. 78, No. 6, December 1957 Printed in U.S.A.
PROBLEMS ENCOUNTERED IN THE TREATMENT OF PROSTATISM CHARLES H. DET. SHIVERS From the Department of Urology, Atlantic City Hospital, Atlantic City, N. J.
To the author, the subject of prostatism is of special interest because the treatment of this purely sexual gland has been largely responsible for the separation of urology as a specialty from general surgery. Not only did the urologist demonstrate to the general surgeon that he could handle diseases of the prostate much better, but he impressed upon the surgeon the importance of a careful urological survey and the proper preparation of a case before operation. The condition of prostatism, no doubt, has been suffered by the same percentage of elderly men since time immemorial, or at least since the time at which men lived sufficiently long to enter the so-called prostatic age. Not until about the middle of the sixteenth century was the prostate gland considered the cause of obstruction at the neck of the bladder. This discovery was attributed to Nicolo Ulassa, a Venetian physician. Following the discovery of the gland and the knowledge that enlargement caused obstruction at the vesical neck, methods of treating this condition up to the time of the strictly surgical era, consisted for the most part of tunneling through the gland as practiced by John Hunter. Very little progress ,vas made in the treatment of prostatic obstruction until the middle of the eighteenth century when surgical procedures were instituted for removal of stones from the bladder. Such men as Sir Henry Thompson, Gouley, Desault, Guthrie, Mercier and Sir 1Villiam Blizzard played a prominent part in the evolution of the management of this condition through the pre-surgical years. It appears that the modern surgical procedures for removal of the prostate gland are the ultimate results of perineal lithotomy for stone. Belfield must be considered one of the pioneers of modern surgery of the prostate gland. It is probable that perineal prostatectomy preceded the suprapubic operation by several years. Deaver stated that it was employed first for malignant disease by Billroth in 1867. Little progress was made in the perineal operation for the removal of the obstruction at the vesical neck until Goodfellow in 1891 performed perineal enucleation of the lateral lobes with removal of the median lobe. Young, in 1903, described his perineal operation, which has endured in principle, with certain modifications made by himself, Hinman, Geraghty, Lowsley and others, up until the present time. To Fuller, it seems, belongs the credit for first accomplishing not only the removal of the intravesical enlargement of the prostate gland but the intra urethral enlargement as well, by the process of suprapubic enucleation. Freyer of England claimed in 1900 priority for the method of total enucleation suprapubically of the hypertrophied prostate, but according to Fuller, it was brought to Freyer's attention in the same year by Guiteras, who explained to Freyer his own and Read at a meeting of the New York Section of the American Urological Association in :,,,;ew York City, November 21, 1956. 780
PROBLEMS ENCOUNTERED IN TREA'l'MENT OF PROSTATISM
781
Fuller's technique at that time. J. Bentley Squier and J. W. Thomson-Walker further modified Fuller's and Freyer's technique for suprapubic prostatectomy and since then, there have been various modifications by different men too numerous to mention. In regard to transurethral surgery, Guthrie, in 18:34, described a prostatic catheter which enclosed a blade that could be projected from within the instrument that cut the bar as the instrument was passed into the bladder. Methods of reducing the size of the prostate gland by use of the galvanocautery were introduced about 1873 with the Bottini operation. A few of the more prominent men who have played a part in the further development of transurethral prostatic resection are Chetwood, Young, Caulk; Collings, Stern, Alcock; Braasch, McCarthy, Kirwin; Theodore M. Davis, Nesbit and G. J. Thompson. It might be of interest to review the management of prostatism over the past 43 years, during which time the author has had the opportunity of observing the methods of handling this disease, including various changes in operative technique and the pitfalls which one may encounter as a urological surgeon. Malignancy of the prostate will be eliminated from this paper, as this condition, by its very nature, is fraught with more complications than is prostatism arising from benign enlargement. Graduation from the University of Pennsylvania Medical School was in 1913. No operation on the prostate was done before the class during the four-year period. The author's initiation in the treatment of this disease was in the first two months of internship. At that time, practically all prostatic surgery, in and about Philadelphia, was handled by the general surgeon. It was very difficult then, as it is now, to obtain accurate information regarding mortality and morbidity, but as some of you may recall, it was extremely high-probably 50 per cent or more. In those days, no preparation of the patient was considered important. He was admitted to the hospital in retention; he was promptly operated upon and the following day or so, ready for the tender care of the undertaker. Young was probably one of the first to observe the benefits described from preliminary drainage of the bladder. In 1899, in a case in which there was deep uremic coma and a hugely distended bladder, catheterization was attempted without success and supra pubic drainage was carried out. Young witnessed the amazing disappearance of the coma and restoration of an apparently normal condition as a result of drainage. One month later, Young carried out his first suprapubic prostatectomy, removing a huge prostate gland successfully through the previous cystotomy incision. This was the first recorded two-stage suprapubic prostatectomy. Deming and Axilrod compared a group of 100 patients admitted to the New Haven Hospital for the treatment of prostatism from 1878 to 1908, with a second group of 100 cases admitted over a period of nine months, from December 6, 1947 to September 5, 1948. The operative mortality in the first group was 32 per cent. The morbidity was extremely high as the records show that only 3 cases operated upon were discharged from the hospital as well. The mortality rate in the second group was 4 per cent. This included perinea!, transurethral, retropubic
782
CHARLES H.
DET.
SHIVERS
and suprapubic surgery and malignant prostates as well as benign. Of this group 96 per cent were entirely relieved of obstruction against 8 per cent of the early series. Even if these latter figures represent only the condition of the patients at the time of their discharge from the hospital, it demonstrates the marked advancement that has been made in the treatment of prostatism. The patient who consults the urologist today for relief of distressing symptoms of prostatism expects and is entitled to a good functional postoperative result. If residual prostatic tissue is left behind, associated with infection, or traumatic strictures from injury to the urethra, the patient may be worse off in many cases than if surgery had been omitted. We all agree that the present day urologist should be well trained in the four surgical procedures for the removal of the prostate gland and select the operation which is best suited for the individual case, rather than to fit the case into one type of operation. However, this is not true in the majority of instances because the average urologist will perfect one technique over another and will use the one in which he feels he is most capable of performing, and sometimes is apt to recommend the operation which appeals to the patient and to the referring physician as a more minor procedure with a shorter hospital stay. This is important from an economic standpoint for the average individual, although the various medical-surgical plans throughout the states aid to a large extent. However, we feel we owe our patient a permanent rather than a temporary result and if it is necessary for him to return for treatment of a stricture or the removal of residual tissue, associated with infection, the time gained by the shorter stay in the hospital is hardly worthwhile. It was shown in our statistical survey on prolonged morbidity following prostatic surgery, published in 1948, that the most popular operation of all wastransurethral prostatic resection. That was a report on 14,865 operations with a mortality rate of 3 per cent and a total morbidity of 8.4 per cent. Of the supi-apubic operations, the two-stage procedure showed a 4.8 per cent morbidity in comparison to the 11.6 per cent morbidity in the one-stage operation. Perineal operations showed a morbidity of 5.9 per cent, single resections a morbidity of 8.4 per cent and multiple resections, 10.9 per cent. The lowest morbidity was following the two-stage suprapubic prostatectomy. As of today, we can be proud of our low mortality, but should we be satisfied with the morbidity, as it is reasonable to assume that these represent minimal figures, since many patients do not return to the original surgeon when complications persist or arise. We should all strive to reduce the morbidity, which, in the author's opinion, is still too high. Our aim should be comfort in voiding for the remainder of the patient's life, provided malignancy does not develop. We still adhere, more or less, to our method of selecting cases for operation, published in 1937, under the heading of "New Methods of Preoperative Study in Prostatic Hyperplasia," in which we recommend a most careful medical and urological survey of the case, with intraurethral and intravesical cystoscopic grading (unless contraindicated), and grouping of these cases for operation according to the findings. In selecting cases for transurethral resection, we include those with a contracted vesical outlet, fibrous bar or s~all middle lobe;
PROBLEMS EXCOUNTERED I_N" TREATMENT OF PROST.-"TIS:\I
783
avoiding the intramethral and large vascular subcervical glandular hyperplasias, At the present time, we have a number of outstanding "rcsectionist:c;'' in this country 1Yho do a magnificent job and can handle most any type of enlargement, but, the author has not had the opportunity of seeing any of their cases becaui:ie ,vhere good results are obtained, it is not necessary for the patient to consult another physician. On the other hand, among those cases that have corne under our ob:oe1Tation from various sections of the country, ,rn have noted the following: That ,vhere attempt:o have been made to resect large prostates, especially the intraurethral lateral lobes, there still remains residual tissue, with fe,,· exceptiou:o. This often means persistent pyuria, beC'ause the remaining portion of the hyperplastic tissue has been largely deprived of its blood supply. The:oe patieuts may or may not have residual urine, but the symptoms of prostafann per;-;ist. Probably one of the frequent compliC'ations fo!lm,·ing trausurethral resection is stricture which has been attributed, by a number of men, to the us2 of the inlying catheter with subsequent infection. Howeyer, ,,.e feel as most or these stric:tures can be classified as traumatic, they are due to the lack of preparation of the urethra, in the form of dilatation and meatotomy, to rec:eive the resectoscope, and the back and forward motion of the instrument with the generation of heat in an improperly lubricated urethra. These strictures are most commonly found at the meatus and in the penile-scrotal portion of the anterior urethra. At the present time, we have a number of cases with extensive traumatic stric:tures following transurethral resection whic:h \\'ill probably require a lifetime of treatment in the form of dilatation, as operation for the correction of a stricture in this location is frequently unsuccessful. H is our opinion that where the meatus is small, a meatotorny should be performed, and, in doing so, the cut margin of the mucosa and glans penis should be brought together by interrupted plain fine catgut sutures. Any other narrow-ing of the urethra, \Yhether physiological or organic, should he dilated a suffic:ient time before operation to allow the passage of a 30.F sound to the bladder with ease, prnvided that a 28F resectoscope is to be used for the operation. In cases ,Yith a r,;hort penile ligament and small caliber urethra, it is best to do an external urethrotomy and to enter the bladder from the bulb, as recommended by~esbit, hmrnver, where a transurethral resection is the operation of choice, ,rn prefer iD such cases, a transvesical approach, and if C'ontraction of the bladder neC'k or bar is present, sharp dissection with repair. In the early and mid-twenties, the author had the opportunity of spending some time ,Yith Sir John Thomson-'7Valker and observing, at first hand, his technique of suprapubic prostatectomy. In 1919, Sir John presented his ideas of the cam,es for postoperative obstruction and his own operation for its prevention. He stressed t,Yo danger points for the development of stricture after suprapubic prostatectomy; namely, at the membranous urethra where the mucouf" membrane is severed, and at the outlet of the bladder, where the mucosB, of the neck of the bladder is torn across. He stated there ,ms little tendenc:y to contraction at the membranom, urethra in the prese11C'e of an inlying catheter or intermittent catheterization, hut at the entrance from the prostatic cavity into
784
CHARLES H. DET. SHIVERS
the bladder the danger is greater. It has been the observation of many surgeons that closure of the internal urethral orifice or marked narrowing has occurred as the result of cohesion of irregular tags and flaps of mucous membrane that have previously overlain the intravesical portion of the gland and which have been torn in the enucleation, with the formation of a diaphragm separating the prostatic cavity from the bladder. His operation was presented to prevent such obstruction by cutting a wedge shaped piece of tissue from the fold lying at the posterior lip of the prostatovesical opening and the control of hemorrhage, by suture, as previously advocated by Judd and Cabot. We still follow the technique of this operation in a modified form. Goldstein and Rubin reported on 3 cases of complete occlusion of the vesical orifice following suprapubic prostatectomy and quoted Thomson-Walker on the method of preventing this complication. They further state that a review of the literature reveals that occlusions have only occurred at the vesical orifice. We have observed one case in which complete obstruction occurred at the junction of the apex of the prostate and membranous urethra, due, we feel, principally to the fact that an inlying catheter was not used following surgery nor was there any dilatation of the urethra or intermittent catheterization. We have not experienced any stricture at the location aforementioned since carrying out this technique. Following enucleation, one should carefully inspect the prostatovesical outlet. This is probably more adequately accomplished in retropubic surgery; however, if one has been well trained in suprapubic technique, there is no difficulty in repairing the vesical outlet following a one-stage operation, except in very obese individuals. The prostate, in addition to its intrusion into the urethral lumen, enlarges in two directions, namely, into the bladder through the lumen of the vesical sphincter or below the base of the bladder, so-called subvesical type of hyperplasia. In the latter, following enucleation, unless a small V shaped piece is excised from the apex of the trigone, there exists at the posterior lip of the vesical outlet a shelf with a depressed area below. This does not interfere with voiding, but it sometimes makes the introduction of a catheter difficult, unless one elevates the tip with a finger in the rectum, as it enters the bladder cavity. We are still old-fashioned enough to use the two-stage suprapubic prostatectomy for cases in which we feel this procedure is indicated. Ours was one of the first clinics to emphasize the importance of excretory urography in the preoperative study of the upper urinary tract in the presence of obstruction at the vesical outlet. We still find this procedure most valuable, as not infrequently one encounters unilateral renal disease in cases that would pass unnoticed with the usual routine studies. Knowing that definite disease exists in the upper urinary tract, the surgeon may select the operation best suited for the patient. However, since the advent of chemotherapy and antibiotics, we have become bolder in the handling of such cases. We would like to emphasize the danger of forcefully using the fingers or forceps in removing the mobilized gland from the prostatic cavity, as frequently
PHOBLEMS E,\'COB"NTERED IN 'I'REA'rl.VLK\f'l' OF PIWSTATIS;I;[
tags of mucous membume remain adherent to the apex and base of the hyperplastic tissue, and if forcibly removed, may injure the mmnbranous urethra and tear the mucosa at the base of the bladder. Attachments of the muco,;a to the prostate, following mobilization, should be Sffl'ered by sharp di:-;scction under direct vi:,;iou. If thiR iR not possible, then by the sense of touch, using long, blunt pointed, cmTed scis,;or:-', as injury to the membranous urethra may lead tc, incontinence and that of the bladder, to prolong bleeding unless repairnd. The fear of hemorrhage following prostatic surgery has brought forth niaily suggestiom, for its control. In the early dayr-;, we were particularly comerned about postoperati\'e bleeding because of onr inability to replace the blood lose: and packing of the prostatic cavity was a common procedure. Thic: packing ffas generally remcffed ffithin -18 to 72 hours. The presence of the foreig1t body produced severe bladder ;,pasm which required, in many instances, heavy ,;eclation There is alm1ys some infection of the bladder and proc:tat.ic cavity following surgery; hmrnyer, in the old days, ar-; the rer-;ult of prolonged pretlsure from game packing, interfering with the blood supply to the vesical neck and pro,;tate, thto infection wac:s much more ::,eyere and frequently involved thc upper urinary tract. We nO\Y feel that prolonged preflflure, by gauie packing or bag hemosta:c:is, following enudeation of the gland, not only inc:reaRes infection, but may lw a factor in carn,ing exe:e.ssi\-e bleeding by prm-enting th<, normal contraetme of the ve::,ical neck and the pro:otatic capsule, as they han, an almndance of smooth muscle which, like all smooth muscle, posses::;es the inherent propertiec; of toni('ity and resistance to extem,ion. In the twenties, ,Yhen the author wa" visiting Dr. Edmund Papin'i:: elinie m Paris, France, he noted that following enucleatiou of the prostate gland notl1i11g was placed in the prostatie cavity. A J\Iarion tube war-; used for suprnpubic drainage and bladder irrigation. At that time ,,-e ,rnre most coneen1ed about postoperatin~ hemorrhage and inquired of t,he clinic ,Yhy some means of herno:otasis was not uti!i½ed. The reply ,Yas, "The patient seldom, if e,,er, bleeds to death and that nature contracts the \'esical neck and prostatic capsule, following enncleation of the glai1d, similar to the contraction of the uterus following ckliYery of the placenta." It took a number of year::: for us to be comincnd that this was true in the majority of case,; and that any hag or paC"king pla('ed in the pro::;tatic caYity, following enuclc:atiou, 11·as a mi:otake; howe,'er, ,Ye nnrnt admit that there are exceptional ca:sec: ,Yhere such a procednre is nece:,;sary. lt is onr present opinion that if any enlarged prostate is properly cnucleated, \\'ith cont.roJ of the major arterial bleeding at the operating table, the contracture of the ve,;ical neck and proc:static captiule will take care of the rest, and that keeping the prostatic fossa dilated may cause excessive hemorrhage. \Ve have used most of the methods recommended for the control of hemorrhage, l<'or many yearn, the Pilcher bag was onr procedme of choice, and then the Pi!-· eher bag surrounded by gelfoam OJ" oxidized cellulose. Gelfoarn caused a lot of trouble in the form of postoperative obstruction, which required remm'al before the patient could void, so these have long since been discontinued. A.t the prer-;ent t,imn, a 22F Foley catheter, ,Yith a 30 cc bag capacity, is placed in the bladckr and
786
CHARLES H. DET. SHIVERS
taped to the shaft of the penis prior to operation. Following mobilization and delivery of the gland, the bladder is irrigated with a solution of silver nitrate 1: 20,000. The prostatovesical outlet is carefully inspected for the removal of all remaining strips of mucous membrane and nodules of prostatic tissue along with any obstruction at the posterior lip of the vesical outlet, and the control of arterial bleeding, if excessive, either by a continuous suture (taking in the posteiior ½ of the vesical outlet) or by individual ligation. However, this can only be completely accomplished if one obtains a clear view of the base of the bladder with access to the same. Black silk is then threaded through the eye of the catheter and brought out suprapubically with the drainage tube. (This is for the purpose of changing the position of the catheter, if necessary, without causing any trauma.) The balloon is never distended unless bleeding continues to be active and cannot be otherwise controlled. After the patient reaches the recovery room, a continuous drip of silver nitrate, 1: 20,000 is given through the urethral catheter, which drains suprapubically. This is continued for a period of from 48 to 72 hours, at which time the suprapubic tube is removed. The urethral catheter is withdrawn within 48 hours after the patient becomes dry. This is usually within 8 to 10 days. We realize that the mortality and morbidity in prostatic surgery are influenced by the loss of blood, both at the time of surgery and during the immediate postoperative period. As we have previously mentioned, the time to control hemorrhage is at the operating table, where one should not be in too much of a hurry to close the bladder, with the immediate replacement of blood loss whenever necessary; however, these old men seem to do better with a lower blood loss, regardless of replacement. It has been shown by Goldstein and Rubin, in their article on "Blood Loss in Open Prostatic Surgery," that there is a lower blood loss in the two-stage prostatectomy than in the one-stage procedure, which may account for a lower morbidity in the former operation. \Vhile the two-stage suprapubic prostatectomy has lost to a large degree its popularity, because of the additional time the patient must spend in the hospital, we feel, after many years of experience, that it still holds an important place in urological surgery, and, many times, is best suited for large intravesical vascular prostates and those cases with upper urinary tract disease associated with cardiovascular changes. In a one-stage suprapubic prostatectomy, there is unquestionably more shock than in the two-stage procedure. We must admit, however, that in the latter, the first operation frequently causes the most concern, especially in poor risk patients. We have never completely closed the bladder following suprapubic prostatectomy; however, we do, in some cases, bring the suprapubic drainage tube out lateral to the original incision. This aids greatly in the rapid healing of the fistulous tract. We have not been called upon to reoperate for the closure of a fistulous tract for many years. Occasionally, in very obese individuals (we have had two), in which a very small opening persisted, the injection of a few drops of 10 per cent silver nitrate, using a blunt, pointed needle, caused prompt closure without any ill effect.
PROBLI~MS ENCOUNTirnED I'{ TREATMJ,~N'r OF PROSTATISM
787
It was formerly customary for ufi, following prostatic surgery, to irrigate the bladder frequently to clear up residual infection, and to cystoscope the before discharge to determine the result of the procedure. At present, we feel the less one does in the average case, following surgery, the better off the patiellt will be. The author can ,veil remember in reading a paper on prostatism, before the New Jersey State lV[edical Society in 1930, the comments made by the late Stanley R. Woodruff of City, who said in part: "]\fy own individual experience with patients i:,; that I do not like to fuss with them after operation." It took us sometime to agree with this statement; however, there are certain cases, regardless of the type of procedure which is used, that require some postoperative treatment, but the majority respond to internal medication alone, provided the operation has been properly accomplished. If one is concerned about the possibility of residual urine, it can easily be determined by urography, with a film taken before and after voiding. In clm,ing, we would like to emphasize that the same care should be used in the selection of cases for operation on the prostate as we did prior to the advent of chemotherapy and antibiotics and that in prostatic hyperplasia with urinary retention, associated with uppm urinary tiact lesions, whether unilateral or bilateral_, and cardiovascular disease, drainage is an important factor, regardless of the technique used for the removal of the obstruction; and that the improvement in the patient's general condition is often in direct proportion to the type and duration of such drainage. Iu this fast moving world, haste is often resorted to; but more time and proper evaluation of the patient's condition might attain for us more permanent results. 121 S. Illinois
Atlantic City, N J.
REFERENCES DEMING, C. L. AND H. D.: Prostatism then and now in New Haven Hospital.-·· 1878-1948. Conn. State J., 14: 1003, 1950. GOLDSTEIN, A. E. A'.':D RuBIN, S. W.: Blood loss in open prostatic surgery. J. Urol., 60: 743, 1048. GOLDSTEIN, A. E. AND Rum:-.:, S. W.: Occlusion of vesical orifice after suprapubic prostatectomy. J. Urol., 60:.499-507, 1948. HUNT, VERNE C.: Prostatism and Prostatic Surgery, in History of Urology, edited by Bransford Lewis. Baltimore: William, & Wilkins, 1933, vol. 2, clrnpt. 4, pp. 91-117. NESBIT, R. JVI.: The advantagce< of perinea! urethrot.omy in prostat.ic resection. South. Surg., 7: 501-504, 1938. Smvims, C. H. DET.: Diagnosis, preparation, operation and after-treatment of benign enlargement of the prostate gland. J. J\ied. Soc. New Jersey, 27: 195-206, 1930. SmvERS, C.H. DET.: New methods of preoperative study in prostatic hypertrophy . .J Urol 38: 288, 19:37 SmvERS, H. nET. A:
Vol. 78, No. 6, December 1957 Printed in U.S.A.
PROBLEMS ENCOUNTERED IN THE TREATMENT OF PROSTATISM CHARLES H. DET. SHIVERS From the Department of Urology, Atlantic City Hospital, Atlantic City, N. J.
To the author, the subject of prostatism is of special interest because the treatment of this purely sexual gland has been largely responsible for the separation of urology as a specialty from general surgery. Not only did the urologist demonstrate to the general surgeon that he could handle diseases of the prostate much better, but he impressed upon the surgeon the importance of a careful urological survey and the proper preparation of a case before operation. The condition of prostatism, no doubt, has been suffered by the same percentage of elderly men since time immemorial, or at least since the time at which men lived sufficiently long to enter the so-called prostatic age. Not until about the middle of the sixteenth century was the prostate gland considered the cause of obstruction at the neck of the bladder. This discovery was attributed to Nicolo Ulassa, a Venetian physician. Following the discovery of the gland and the knowledge that enlargement caused obstruction at the vesical neck, methods of treating this condition up to the time of the strictly surgical era, consisted for the most part of tunneling through the gland as practiced by John Hunter. Very little progress ,vas made in the treatment of prostatic obstruction until the middle of the eighteenth century when surgical procedures were instituted for removal of stones from the bladder. Such men as Sir Henry Thompson, Gouley, Desault, Guthrie, Mercier and Sir 1Villiam Blizzard played a prominent part in the evolution of the management of this condition through the pre-surgical years. It appears that the modern surgical procedures for removal of the prostate gland are the ultimate results of perineal lithotomy for stone. Belfield must be considered one of the pioneers of modern surgery of the prostate gland. It is probable that perineal prostatectomy preceded the suprapubic operation by several years. Deaver stated that it was employed first for malignant disease by Billroth in 1867. Little progress was made in the perineal operation for the removal of the obstruction at the vesical neck until Goodfellow in 1891 performed perineal enucleation of the lateral lobes with removal of the median lobe. Young, in 1903, described his perineal operation, which has endured in principle, with certain modifications made by himself, Hinman, Geraghty, Lowsley and others, up until the present time. To Fuller, it seems, belongs the credit for first accomplishing not only the removal of the intravesical enlargement of the prostate gland but the intra urethral enlargement as well, by the process of suprapubic enucleation. Freyer of England claimed in 1900 priority for the method of total enucleation suprapubically of the hypertrophied prostate, but according to Fuller, it was brought to Freyer's attention in the same year by Guiteras, who explained to Freyer his own and Read at a meeting of the New York Section of the American Urological Association in :,,,;ew York City, November 21, 1956. 780
PROBLEMS ENCOUNTERED IN TREA'l'MENT OF PROSTATISM
781
Fuller's technique at that time. J. Bentley Squier and J. W. Thomson-Walker further modified Fuller's and Freyer's technique for suprapubic prostatectomy and since then, there have been various modifications by different men too numerous to mention. In regard to transurethral surgery, Guthrie, in 18:34, described a prostatic catheter which enclosed a blade that could be projected from within the instrument that cut the bar as the instrument was passed into the bladder. Methods of reducing the size of the prostate gland by use of the galvanocautery were introduced about 1873 with the Bottini operation. A few of the more prominent men who have played a part in the further development of transurethral prostatic resection are Chetwood, Young, Caulk; Collings, Stern, Alcock; Braasch, McCarthy, Kirwin; Theodore M. Davis, Nesbit and G. J. Thompson. It might be of interest to review the management of prostatism over the past 43 years, during which time the author has had the opportunity of observing the methods of handling this disease, including various changes in operative technique and the pitfalls which one may encounter as a urological surgeon. Malignancy of the prostate will be eliminated from this paper, as this condition, by its very nature, is fraught with more complications than is prostatism arising from benign enlargement. Graduation from the University of Pennsylvania Medical School was in 1913. No operation on the prostate was done before the class during the four-year period. The author's initiation in the treatment of this disease was in the first two months of internship. At that time, practically all prostatic surgery, in and about Philadelphia, was handled by the general surgeon. It was very difficult then, as it is now, to obtain accurate information regarding mortality and morbidity, but as some of you may recall, it was extremely high-probably 50 per cent or more. In those days, no preparation of the patient was considered important. He was admitted to the hospital in retention; he was promptly operated upon and the following day or so, ready for the tender care of the undertaker. Young was probably one of the first to observe the benefits described from preliminary drainage of the bladder. In 1899, in a case in which there was deep uremic coma and a hugely distended bladder, catheterization was attempted without success and supra pubic drainage was carried out. Young witnessed the amazing disappearance of the coma and restoration of an apparently normal condition as a result of drainage. One month later, Young carried out his first suprapubic prostatectomy, removing a huge prostate gland successfully through the previous cystotomy incision. This was the first recorded two-stage suprapubic prostatectomy. Deming and Axilrod compared a group of 100 patients admitted to the New Haven Hospital for the treatment of prostatism from 1878 to 1908, with a second group of 100 cases admitted over a period of nine months, from December 6, 1947 to September 5, 1948. The operative mortality in the first group was 32 per cent. The morbidity was extremely high as the records show that only 3 cases operated upon were discharged from the hospital as well. The mortality rate in the second group was 4 per cent. This included perinea!, transurethral, retropubic
782
CHARLES H.
DET.
SHIVERS
and suprapubic surgery and malignant prostates as well as benign. Of this group 96 per cent were entirely relieved of obstruction against 8 per cent of the early series. Even if these latter figures represent only the condition of the patients at the time of their discharge from the hospital, it demonstrates the marked advancement that has been made in the treatment of prostatism. The patient who consults the urologist today for relief of distressing symptoms of prostatism expects and is entitled to a good functional postoperative result. If residual prostatic tissue is left behind, associated with infection, or traumatic strictures from injury to the urethra, the patient may be worse off in many cases than if surgery had been omitted. We all agree that the present day urologist should be well trained in the four surgical procedures for the removal of the prostate gland and select the operation which is best suited for the individual case, rather than to fit the case into one type of operation. However, this is not true in the majority of instances because the average urologist will perfect one technique over another and will use the one in which he feels he is most capable of performing, and sometimes is apt to recommend the operation which appeals to the patient and to the referring physician as a more minor procedure with a shorter hospital stay. This is important from an economic standpoint for the average individual, although the various medical-surgical plans throughout the states aid to a large extent. However, we feel we owe our patient a permanent rather than a temporary result and if it is necessary for him to return for treatment of a stricture or the removal of residual tissue, associated with infection, the time gained by the shorter stay in the hospital is hardly worthwhile. It was shown in our statistical survey on prolonged morbidity following prostatic surgery, published in 1948, that the most popular operation of all wastransurethral prostatic resection. That was a report on 14,865 operations with a mortality rate of 3 per cent and a total morbidity of 8.4 per cent. Of the supi-apubic operations, the two-stage procedure showed a 4.8 per cent morbidity in comparison to the 11.6 per cent morbidity in the one-stage operation. Perineal operations showed a morbidity of 5.9 per cent, single resections a morbidity of 8.4 per cent and multiple resections, 10.9 per cent. The lowest morbidity was following the two-stage suprapubic prostatectomy. As of today, we can be proud of our low mortality, but should we be satisfied with the morbidity, as it is reasonable to assume that these represent minimal figures, since many patients do not return to the original surgeon when complications persist or arise. We should all strive to reduce the morbidity, which, in the author's opinion, is still too high. Our aim should be comfort in voiding for the remainder of the patient's life, provided malignancy does not develop. We still adhere, more or less, to our method of selecting cases for operation, published in 1937, under the heading of "New Methods of Preoperative Study in Prostatic Hyperplasia," in which we recommend a most careful medical and urological survey of the case, with intraurethral and intravesical cystoscopic grading (unless contraindicated), and grouping of these cases for operation according to the findings. In selecting cases for transurethral resection, we include those with a contracted vesical outlet, fibrous bar or s~all middle lobe;
PROBLEMS EXCOUNTERED I_N" TREATMENT OF PROST.-"TIS:\I
783
avoiding the intramethral and large vascular subcervical glandular hyperplasias, At the present time, we have a number of outstanding "rcsectionist:c;'' in this country 1Yho do a magnificent job and can handle most any type of enlargement, but, the author has not had the opportunity of seeing any of their cases becaui:ie ,vhere good results are obtained, it is not necessary for the patient to consult another physician. On the other hand, among those cases that have corne under our ob:oe1Tation from various sections of the country, ,rn have noted the following: That ,vhere attempt:o have been made to resect large prostates, especially the intraurethral lateral lobes, there still remains residual tissue, with fe,,· exceptiou:o. This often means persistent pyuria, beC'ause the remaining portion of the hyperplastic tissue has been largely deprived of its blood supply. The:oe patieuts may or may not have residual urine, but the symptoms of prostafann per;-;ist. Probably one of the frequent compliC'ations fo!lm,·ing trausurethral resection is stricture which has been attributed, by a number of men, to the us2 of the inlying catheter with subsequent infection. Howeyer, ,,.e feel as most or these stric:tures can be classified as traumatic, they are due to the lack of preparation of the urethra, in the form of dilatation and meatotomy, to rec:eive the resectoscope, and the back and forward motion of the instrument with the generation of heat in an improperly lubricated urethra. These strictures are most commonly found at the meatus and in the penile-scrotal portion of the anterior urethra. At the present time, we have a number of cases with extensive traumatic stric:tures following transurethral resection whic:h \\'ill probably require a lifetime of treatment in the form of dilatation, as operation for the correction of a stricture in this location is frequently unsuccessful. H is our opinion that where the meatus is small, a meatotorny should be performed, and, in doing so, the cut margin of the mucosa and glans penis should be brought together by interrupted plain fine catgut sutures. Any other narrow-ing of the urethra, \Yhether physiological or organic, should he dilated a suffic:ient time before operation to allow the passage of a 30.F sound to the bladder with ease, prnvided that a 28F resectoscope is to be used for the operation. In cases ,Yith a r,;hort penile ligament and small caliber urethra, it is best to do an external urethrotomy and to enter the bladder from the bulb, as recommended by~esbit, hmrnver, where a transurethral resection is the operation of choice, ,rn prefer iD such cases, a transvesical approach, and if C'ontraction of the bladder neC'k or bar is present, sharp dissection with repair. In the early and mid-twenties, the author had the opportunity of spending some time ,Yith Sir John Thomson-'7Valker and observing, at first hand, his technique of suprapubic prostatectomy. In 1919, Sir John presented his ideas of the cam,es for postoperative obstruction and his own operation for its prevention. He stressed t,Yo danger points for the development of stricture after suprapubic prostatectomy; namely, at the membranous urethra where the mucouf" membrane is severed, and at the outlet of the bladder, where the mucosB, of the neck of the bladder is torn across. He stated there ,ms little tendenc:y to contraction at the membranom, urethra in the prese11C'e of an inlying catheter or intermittent catheterization, hut at the entrance from the prostatic cavity into
784
CHARLES H. DET. SHIVERS
the bladder the danger is greater. It has been the observation of many surgeons that closure of the internal urethral orifice or marked narrowing has occurred as the result of cohesion of irregular tags and flaps of mucous membrane that have previously overlain the intravesical portion of the gland and which have been torn in the enucleation, with the formation of a diaphragm separating the prostatic cavity from the bladder. His operation was presented to prevent such obstruction by cutting a wedge shaped piece of tissue from the fold lying at the posterior lip of the prostatovesical opening and the control of hemorrhage, by suture, as previously advocated by Judd and Cabot. We still follow the technique of this operation in a modified form. Goldstein and Rubin reported on 3 cases of complete occlusion of the vesical orifice following suprapubic prostatectomy and quoted Thomson-Walker on the method of preventing this complication. They further state that a review of the literature reveals that occlusions have only occurred at the vesical orifice. We have observed one case in which complete obstruction occurred at the junction of the apex of the prostate and membranous urethra, due, we feel, principally to the fact that an inlying catheter was not used following surgery nor was there any dilatation of the urethra or intermittent catheterization. We have not experienced any stricture at the location aforementioned since carrying out this technique. Following enucleation, one should carefully inspect the prostatovesical outlet. This is probably more adequately accomplished in retropubic surgery; however, if one has been well trained in suprapubic technique, there is no difficulty in repairing the vesical outlet following a one-stage operation, except in very obese individuals. The prostate, in addition to its intrusion into the urethral lumen, enlarges in two directions, namely, into the bladder through the lumen of the vesical sphincter or below the base of the bladder, so-called subvesical type of hyperplasia. In the latter, following enucleation, unless a small V shaped piece is excised from the apex of the trigone, there exists at the posterior lip of the vesical outlet a shelf with a depressed area below. This does not interfere with voiding, but it sometimes makes the introduction of a catheter difficult, unless one elevates the tip with a finger in the rectum, as it enters the bladder cavity. We are still old-fashioned enough to use the two-stage suprapubic prostatectomy for cases in which we feel this procedure is indicated. Ours was one of the first clinics to emphasize the importance of excretory urography in the preoperative study of the upper urinary tract in the presence of obstruction at the vesical outlet. We still find this procedure most valuable, as not infrequently one encounters unilateral renal disease in cases that would pass unnoticed with the usual routine studies. Knowing that definite disease exists in the upper urinary tract, the surgeon may select the operation best suited for the patient. However, since the advent of chemotherapy and antibiotics, we have become bolder in the handling of such cases. We would like to emphasize the danger of forcefully using the fingers or forceps in removing the mobilized gland from the prostatic cavity, as frequently
PHOBLEMS E,\'COB"NTERED IN 'I'REA'rl.VLK\f'l' OF PIWSTATIS;I;[
tags of mucous membume remain adherent to the apex and base of the hyperplastic tissue, and if forcibly removed, may injure the mmnbranous urethra and tear the mucosa at the base of the bladder. Attachments of the muco,;a to the prostate, following mobilization, should be Sffl'ered by sharp di:-;scction under direct vi:,;iou. If thiR iR not possible, then by the sense of touch, using long, blunt pointed, cmTed scis,;or:-', as injury to the membranous urethra may lead tc, incontinence and that of the bladder, to prolong bleeding unless repairnd. The fear of hemorrhage following prostatic surgery has brought forth niaily suggestiom, for its control. In the early dayr-;, we were particularly comerned about postoperati\'e bleeding because of onr inability to replace the blood lose: and packing of the prostatic cavity was a common procedure. Thic: packing ffas generally remcffed ffithin -18 to 72 hours. The presence of the foreig1t body produced severe bladder ;,pasm which required, in many instances, heavy ,;eclation There is alm1ys some infection of the bladder and proc:tat.ic cavity following surgery; hmrnyer, in the old days, ar-; the rer-;ult of prolonged pretlsure from game packing, interfering with the blood supply to the vesical neck and pro,;tate, thto infection wac:s much more ::,eyere and frequently involved thc upper urinary tract. We nO\Y feel that prolonged preflflure, by gauie packing or bag hemosta:c:is, following enudeation of the gland, not only inc:reaRes infection, but may lw a factor in carn,ing exe:e.ssi\-e bleeding by prm-enting th<, normal contraetme of the ve::,ical neck and the pro:otatic capsule, as they han, an almndance of smooth muscle which, like all smooth muscle, posses::;es the inherent propertiec; of toni('ity and resistance to extem,ion. In the twenties, ,Yhen the author wa" visiting Dr. Edmund Papin'i:: elinie m Paris, France, he noted that following enucleatiou of the prostate gland notl1i11g was placed in the prostatie cavity. A J\Iarion tube war-; used for suprnpubic drainage and bladder irrigation. At that time ,,-e ,rnre most coneen1ed about postoperatin~ hemorrhage and inquired of t,he clinic ,Yhy some means of herno:otasis was not uti!i½ed. The reply ,Yas, "The patient seldom, if e,,er, bleeds to death and that nature contracts the \'esical neck and prostatic capsule, following enncleation of the glai1d, similar to the contraction of the uterus following ckliYery of the placenta." It took a number of year::: for us to be comincnd that this was true in the majority of case,; and that any hag or paC"king pla('ed in the pro::;tatic caYity, following enuclc:atiou, 11·as a mi:otake; howe,'er, ,Ye nnrnt admit that there are exceptional ca:sec: ,Yhere such a procednre is nece:,;sary. lt is onr present opinion that if any enlarged prostate is properly cnucleated, \\'ith cont.roJ of the major arterial bleeding at the operating table, the contracture of the ve,;ical neck and proc:static captiule will take care of the rest, and that keeping the prostatic fossa dilated may cause excessive hemorrhage. \Ve have used most of the methods recommended for the control of hemorrhage, l<'or many yearn, the Pilcher bag was onr procedme of choice, and then the Pi!-· eher bag surrounded by gelfoam OJ" oxidized cellulose. Gelfoarn caused a lot of trouble in the form of postoperative obstruction, which required remm'al before the patient could void, so these have long since been discontinued. A.t the prer-;ent t,imn, a 22F Foley catheter, ,Yith a 30 cc bag capacity, is placed in the bladckr and
786
CHARLES H. DET. SHIVERS
taped to the shaft of the penis prior to operation. Following mobilization and delivery of the gland, the bladder is irrigated with a solution of silver nitrate 1: 20,000. The prostatovesical outlet is carefully inspected for the removal of all remaining strips of mucous membrane and nodules of prostatic tissue along with any obstruction at the posterior lip of the vesical outlet, and the control of arterial bleeding, if excessive, either by a continuous suture (taking in the posteiior ½ of the vesical outlet) or by individual ligation. However, this can only be completely accomplished if one obtains a clear view of the base of the bladder with access to the same. Black silk is then threaded through the eye of the catheter and brought out suprapubically with the drainage tube. (This is for the purpose of changing the position of the catheter, if necessary, without causing any trauma.) The balloon is never distended unless bleeding continues to be active and cannot be otherwise controlled. After the patient reaches the recovery room, a continuous drip of silver nitrate, 1: 20,000 is given through the urethral catheter, which drains suprapubically. This is continued for a period of from 48 to 72 hours, at which time the suprapubic tube is removed. The urethral catheter is withdrawn within 48 hours after the patient becomes dry. This is usually within 8 to 10 days. We realize that the mortality and morbidity in prostatic surgery are influenced by the loss of blood, both at the time of surgery and during the immediate postoperative period. As we have previously mentioned, the time to control hemorrhage is at the operating table, where one should not be in too much of a hurry to close the bladder, with the immediate replacement of blood loss whenever necessary; however, these old men seem to do better with a lower blood loss, regardless of replacement. It has been shown by Goldstein and Rubin, in their article on "Blood Loss in Open Prostatic Surgery," that there is a lower blood loss in the two-stage prostatectomy than in the one-stage procedure, which may account for a lower morbidity in the former operation. \Vhile the two-stage suprapubic prostatectomy has lost to a large degree its popularity, because of the additional time the patient must spend in the hospital, we feel, after many years of experience, that it still holds an important place in urological surgery, and, many times, is best suited for large intravesical vascular prostates and those cases with upper urinary tract disease associated with cardiovascular changes. In a one-stage suprapubic prostatectomy, there is unquestionably more shock than in the two-stage procedure. We must admit, however, that in the latter, the first operation frequently causes the most concern, especially in poor risk patients. We have never completely closed the bladder following suprapubic prostatectomy; however, we do, in some cases, bring the suprapubic drainage tube out lateral to the original incision. This aids greatly in the rapid healing of the fistulous tract. We have not been called upon to reoperate for the closure of a fistulous tract for many years. Occasionally, in very obese individuals (we have had two), in which a very small opening persisted, the injection of a few drops of 10 per cent silver nitrate, using a blunt, pointed needle, caused prompt closure without any ill effect.
PROBLI~MS ENCOUNTirnED I'{ TREATMJ,~N'r OF PROSTATISM
787
It was formerly customary for ufi, following prostatic surgery, to irrigate the bladder frequently to clear up residual infection, and to cystoscope the before discharge to determine the result of the procedure. At present, we feel the less one does in the average case, following surgery, the better off the patiellt will be. The author can ,veil remember in reading a paper on prostatism, before the New Jersey State lV[edical Society in 1930, the comments made by the late Stanley R. Woodruff of City, who said in part: "]\fy own individual experience with patients i:,; that I do not like to fuss with them after operation." It took us sometime to agree with this statement; however, there are certain cases, regardless of the type of procedure which is used, that require some postoperative treatment, but the majority respond to internal medication alone, provided the operation has been properly accomplished. If one is concerned about the possibility of residual urine, it can easily be determined by urography, with a film taken before and after voiding. In clm,ing, we would like to emphasize that the same care should be used in the selection of cases for operation on the prostate as we did prior to the advent of chemotherapy and antibiotics and that in prostatic hyperplasia with urinary retention, associated with uppm urinary tiact lesions, whether unilateral or bilateral_, and cardiovascular disease, drainage is an important factor, regardless of the technique used for the removal of the obstruction; and that the improvement in the patient's general condition is often in direct proportion to the type and duration of such drainage. Iu this fast moving world, haste is often resorted to; but more time and proper evaluation of the patient's condition might attain for us more permanent results. 121 S. Illinois
Atlantic City, N J.
REFERENCES DEMING, C. L. AND H. D.: Prostatism then and now in New Haven Hospital.-·· 1878-1948. Conn. State J., 14: 1003, 1950. GOLDSTEIN, A. E. A'.':D RuBIN, S. W.: Blood loss in open prostatic surgery. J. Urol., 60: 743, 1048. GOLDSTEIN, A. E. AND Rum:-.:, S. W.: Occlusion of vesical orifice after suprapubic prostatectomy. J. Urol., 60:.499-507, 1948. HUNT, VERNE C.: Prostatism and Prostatic Surgery, in History of Urology, edited by Bransford Lewis. Baltimore: William, & Wilkins, 1933, vol. 2, clrnpt. 4, pp. 91-117. NESBIT, R. JVI.: The advantagce< of perinea! urethrot.omy in prostat.ic resection. South. Surg., 7: 501-504, 1938. Smvims, C. H. DET.: Diagnosis, preparation, operation and after-treatment of benign enlargement of the prostate gland. J. J\ied. Soc. New Jersey, 27: 195-206, 1930. SmvERS, C.H. DET.: New methods of preoperative study in prostatic hypertrophy . .J Urol 38: 288, 19:37 SmvERS, H. nET. A: