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Recurrent Benign Prostatic Obstruction1
RECURRENT BENIGN PROSTATIC OBSTRUCTION1 JOHN H. CUNNINGHAM Boston, Massachusetts
Until the recent experiences which form the basis of this communication, I had no idea that after a complete removal of a benign hypertrophied prostate, regeneration of prostatic tissue could take place to the degree of forming a typical benign prostatic hypertrophy with the return of the clinical symptoms of prostatitism. I think the belief is generally held that following the complete removal of a benign prostate, a similar obstruction does not recur. That this is possible seems to be a matter of primary importance. · It is for this reason that I wish to record these recent instances and to ,get an expression of the experiences of other members of this society. It is a matter of passing interest that two of my patients with this condition were operated upon within a few days of each other, and also when this condition, unique in my experience led to inquiry, I found that Dr. Bransford Lewis had recorded a similar observation before the American Urologic Association at the Vancouver meeting last year, and that many other examples of the same phenomenon were on record. Thanks to the kindness of Dr. Lewis in letting me read his paper which has not yet been published, I have been made conversant with the details of his report and also with other examples of this condition recorded by Andre, Bazt, Blum. Bryan (3 cases) Casariego, Constantineseu, Fronstein and Meschebowski, Federoff, Hadinger (2 cases), Honegger, von Illyes, Loumeau, Lumpert, Orth, Takahaski, Tandler and Zuckerkandl, Tangwall 1 Read at the Annual Meeting of the American Association of Genito-Urinary Surgeons, French Lick Springs, Indiana, May, 1930.
271
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JOHN H. CUNNINGHAM
and Young (3 cases). I find that Gregoras records 1 per cent of recurrences in 300 suprapubic prostatectomies in the clinic of Rafin, and Illyes has observed 3 occurrences in a series of 470 patients. Gregora has collected 30 examples, including mostly the reports just mentioned. It would seem, therefore, from this array of reported instances that recurrence of benign prostatic hypertrophy following a radical p:rostatectomy should be more generally appreciated and I am particularly interested to know the experiences of other members of this society in order that this matter, which to me was unknown until recently, may be more generally appreciated. The cause of recurrence of benign prostatic hypertrophy seems to be a matter of theory. Takahaski advances the idea that the prostatic capsule is a tissue composed of flattened glands which will take on an activity of regeneration of the gland structure when the pressure has been removed by prostatectomy. Hadinger rather substantiates this view by finding distinct recurrence of glandular tissue in autopsy specimens two and four months after prostatectomy. This theory also has the support of Taudler, Zukerkandl, Honneger and Blum. Fraudenberg, at first a supporter of this theory, later came to believe that the regeneration did not take place from the glandular tissue of the so-called capsule, but from small, adenomatous nodules left at the time of the first prostatectomy. Still another explanation is offered by Jacoby. He divides the glands of the prostatic urethra into mucous (which does not concern us), submucous, and prostatic. He points out that the submucous glands form the cervical group about the vesical neck and may give rise to the pathological middle lobe, and that they are also located on the anterior or ventral wall of the urethra. He claims that he has demonstrated by histological study that these 2 groups can develop even into the muscularis. Jacoby believes that these urethral glands are not the only ones to undergo hypertrophy, but on each side of the ventral group there is a particular gl~dular zone, often continuous with the prostatic glands. These urethral prostatic glands, he believes, are the site of the hypertrophic centers and suggests that as they are continuous with the prostatic glands in the prostatic capsule, "nuclei
RECURRENT BENIGN PROSTATIC OBSTRUCTION
273
of hypertrophy" may . exist. He believes that these so called nuclei of hypertrophy normally play but a secondary part but become active after extirpation of the central glandular tumor, which has compressed them, and may undergo such expansion as to form new prostatic tissue even to the point of producing obstruction by overgrowth. Whatever may be the true explanation, the fact that prostatic tissue reappears within the prostatic capsule, and may continue to grow to the point of producing obstruction of the true hypertrophy type, seems to be a fact. We have occasionally examined patients after prostatectomy, who seems to have a prostate and in whom we would not believe that the gland had been removed unless we had removed it ourselves. None of these patients, however, have had the recurrent symptoms of prostatism. This observation, however, :fits in with the matter under consideration and it may be that recurrent prostatic tissue is quite common and that the reason we do not see more evidence of recurrent obstruction from such hypertrophy is that the prostatic patient is usually so aged that he dies before there is sufficient time for the regrowing gland to reach the point of obstruction. In this connection it is of interest to note the ages of the patients and the time elapsed between the :first prostatectomy and the recurrent symptoms of obstruction. Dr. Lewis' patient was · 61. Recurrent obstruction symptoms appeared in approximately 12 years. My patients were: First: 59 years with recurrent symptoms in 8 years. Second: 64 years with recurrent symptoms in 7 years. Third: 53 years with recurrent symptoms in 13 years.
I think it may be said that the ages of these 4 patients place them among the younger group requiring prostatectomy and that the recurrent symptoms at 12, 8, 7, and 13 years is a rather longer period of time than most prostatics live after operation. So it may be that if those having prostatectomy live long enough we would see more recurrent growths. Whether or not this be true, it certainly suggests that in the younger group, that is about
274
JOHN H. CUNNINGHAM
60 or below, with the probably greater expectancy of life, we find more recurrences. Since becoming aware of the possibility of regrowth this is a matter about which we will check more carefully in the future than in the past. Dr. Lewis' patient, which he records in detail, had a suprapubic prostatectomy performed by Dr. Lewis in April, 1916. The gland was enucleated in one piece and the patient made an uneventful convalescence and remained well for approximately 12 years. He then again had the symptoms of prostatism. Rectal examination showed what Dr. Lewis terms a ''renewed" prostate, and cystoscopy revealed a large, intravesical intrusion. The gland was removed by a two-stage suprapubic operation. Dr. Lewis states that the enucleation was easily performed, as it was also in our cases. In other words, there seems to be no added difficulty in the technical procedure because the gland had previously been enucleated. Our patients' histories and findings are quite similar. Case 1. This patient, sixty-seven years of age, had a two-stage suprapubic prostatectomy performed by Dr. Hugh Cabot in October, 1919, he then being fifty-nine years of age. He remained well for eight years, when he began to have increased frequency and difficulty in emptying the bladder. Two weeks prior to our seeing him he had retention and was catheterized several times by Dr. Seldom B. Overlock of Pomfret, Conn., who sent him to us. The general examination showed nothing extraordinary. Rectal examination showed a very large, benign, hypertrophied prostate. A coude catheter was tight in the prostatic urethra and there were 6 ounces of foul residual urine. The urinalysis was that of cystitis. There were no real elements. Cystoscopy showed that the prostate projected in all quadrants and presented the usual picture of a considerable intravesical enlargement. There was moderate bladder trabeculation and the capacity was 8 ounces. On February 13, 1929, approximately ten years after Dr. Cabot had done the suprapubic prostatectomy, we did a suprapubic cystotomy for drainage. It was not until March 19, 1929, approximately four weeks, that the patient was in condition for prostatectomy. At operation, the prostate gave the typical picture of a moderate intravesical hypertrophy, the left lobe being slightly larger than the right. The
RECURRENT BENIGN PROSTATIC OBSTRUCTION
27 5
gland enucleated easily and there were many small concretions between the gland and the capsule. There was nothing about the appearance of the gland or the features of the operation that differ from the condition usually observed, with the exception of the presence of the concretions between the gland and capsule. The patient made an uneventful recovery and is well at present. Case 2. This patient aged seventy-four, had a two-stage suprapubic prostatectomy by Dr. John Bottomly in April, 1919, being then sixtyfour years old. He remained well for seven years and then, three years before we saw him, began to have frequency, which gradually increased until it occurred every two hours during the day and night. The frequency became so distressing that he finally consulted Dr. Walter Mansfield, who referred him to us. The general examination showed nothing of importance. Rectal examination showed the prostate to be a moderately large, benign, hypertrophied gland. A No. 20 Coude catheter was passed to the bladder with but little obstruction. There were 10 ounces of residual urine, however. The urine was that of a chronic cystitis. There were no renal elements. Cystoscopy was very unsatisfactory because of the patient's nervousness, but enough was observed to establish the fact that that there was considerable intravesical projection. X-ray was negative. On February 28, 1929, approximately ten years following Dr. Bottomly's prostatectomy, we did a cystotomy for drainage. Twenty days later the patient was in satisfactory condition for the removal of the gland. At operation, the gland was found to project in all quadrants to a considerable degree. Enucleation was simple and a very large gland was enucleated in one piece. The picture at operation was that usually observed and the technique of the operation presented no unusual features. The patient made an uneventful recovery and has remained well. Case 3. Physician, aged sixty-eight. Had symptoms of obstruction for several months. Was operated upon by Dr. Hugh Cabot on September 20, 1915, by a one-stage prostatectomy. (Patient was then fifty-three years of age.) He had a severe attack of phlebitis following operation and had to use crutches for several months. In 1918, practically three years after prostatectomy, patient had a perforating ulcer
276
JOHN H. CUNNINGHAM
of the stomach which was successfully operated upon by Dr. Samuel Mixter. Patient for several years has suffered from myocardiac attacks and has been under the care of Dr. Paul White. In December, 1929, approximately fourteen years after the prostatectomy, patient had acute retention of urine. Entered the DayKimball Hospital in Putnam, Conn., where he was catheterized by Dr. Overlock, who found that he had 40 ounces of residual urine. At that time it was learned that he had had symptoms of prostatism for a few months only. The cardiac distress which was frequent and severe, was the explanation given by the patient as a probable reason for his not complaining of the bladder disturbance before the retention. The patient was referred to us by Dr. Overlock on January 15, 1930. Residual urine was 20 ounces infected and urinalysis gave evidence of chronic renal disease. There was a moderate sized benign prostate by rectal examination. Cystoscopically, there was a considerable middle lobe and moderate sized intravesical lateral lobe projections. The musculature was thin, the left ureteral orifice was gaping and the right ureteral orifice was not seen. The rectal palpation did not give an idea of the size of the gland, which was largely intravesical in its regrowth. The cystoscopic picture was typically that of a benign prostatic hypertrophy. He was placed on urethral drainage and the bladder decompressed. The patient was not subjected to prostatectomy again because of the cardiac condition which was considered too severe to make operation advisable. Beside the defective circulation, his urinalysis, blood chemistry and renal function tests were poor. Fortunately, a catheter entered the bladder easily. The patient was placed on urethral catheter drainage and bladder lavage for about two weeks and then returned home. A report from this patient dated April 19, 1930, states that he is "seeing some patients in his office but continues to be very weak and has a lot of dyspnea." His doctor stated on May 9 that he still has a "moderate" residual urine.
This case has been included because it is a typical recurrent prostatic hypertrophy and operative indications would be definite were it not for the other physical defects which render it inadvisable. As previously stated, the object of this communication is not only to place these three patients on record but also to establish
RECURRENT BENIGN PROSTATIC OBSTRUCTION
277
insofar as possible a proper idea of the probability of recurrent prostatic obstruction following prostatectomy by an expression from this society regarding this matter. 46 Gloucester Street, Boston, Mass. REFERENCES BAzy, P . : Bull. Acad. de med ., Paris, 1927, xcvii, 843. BLUM, V. : Ztschr. f. urol. Chir., Berl., 1920, v, 77. CASARIEGO : Rev. espan. de urol. y dermat., Madrid, 1924, xxvi, 254--256. CASPER, L.: Berl. klin. Wchnschr., 1911, xlviii, 1500. FREUDENBERG, A. : Verhandl. d. deutsch. Gesellsch . f. Chir., Berl., 1907, iv, 36 Kongr. 6, Pt. 1, 182-183. FRONSTEIN, R., AND MESCHEBOWSKI, G. : Ztschr. f. urol. Chir., Berl., 1926, xx, 222-229. HEDINGER : Cor. Bl. f. schweiz. Aerzte, Basel, 1906, xxxvi, 277. HONEGGER, R.: Ztschr. f. Urol., Leipz, 1922, xvi, 425-440. VoN lLLYES: Geza., Ztschr. f. urol. Chir., Berl., 1925, xvii, 229- 242. LouMEAU: Gaz. hebd. d . sc. med. de Bourdeauz, 1912, xxxiii, 437--439. LuMPERT, E.: Cor. Bl. f. Schweiz. Aerzte, Basel, 1911, xli, 99-102. ORTH, 0. : Ztschr. f . urol. Chir., Berl., 1921, viii, 83- 86. TAKAHASKI, A.: Ztschr. f. urol. Chir., Berl., 1927, xxii, 167- 169; Urol. and Cutan. Rev., St. Louis, 1928, xxxii, 597. TANDLER, J ., AND ZucKERKANDL, 0.: Berl., 1922, J. Springer, 130 p., 40. YouNG, H. H . : Johns Hopkins Hosp. Rep., Baltimore, 1906, xiv, 1--476. LEWIS, BRANSFORD : Jour. Urol., 1930, xxiv, 319. GREGOR.A: Ztsch. fur Urol., December, 1928. JACOBY: Ztsch. fur Urol., December, 1928.
Until the recent experiences which form the basis of this communication, I had no idea that after a complete removal of a benign hypertrophied prostate, regeneration of prostatic tissue could take place to the degree of forming a typical benign prostatic hypertrophy with the return of the clinical symptoms of prostatitism. I think the belief is generally held that following the complete removal of a benign prostate, a similar obstruction does not recur. That this is possible seems to be a matter of primary importance. · It is for this reason that I wish to record these recent instances and to ,get an expression of the experiences of other members of this society. It is a matter of passing interest that two of my patients with this condition were operated upon within a few days of each other, and also when this condition, unique in my experience led to inquiry, I found that Dr. Bransford Lewis had recorded a similar observation before the American Urologic Association at the Vancouver meeting last year, and that many other examples of the same phenomenon were on record. Thanks to the kindness of Dr. Lewis in letting me read his paper which has not yet been published, I have been made conversant with the details of his report and also with other examples of this condition recorded by Andre, Bazt, Blum. Bryan (3 cases) Casariego, Constantineseu, Fronstein and Meschebowski, Federoff, Hadinger (2 cases), Honegger, von Illyes, Loumeau, Lumpert, Orth, Takahaski, Tandler and Zuckerkandl, Tangwall 1 Read at the Annual Meeting of the American Association of Genito-Urinary Surgeons, French Lick Springs, Indiana, May, 1930.
271
272
JOHN H. CUNNINGHAM
and Young (3 cases). I find that Gregoras records 1 per cent of recurrences in 300 suprapubic prostatectomies in the clinic of Rafin, and Illyes has observed 3 occurrences in a series of 470 patients. Gregora has collected 30 examples, including mostly the reports just mentioned. It would seem, therefore, from this array of reported instances that recurrence of benign prostatic hypertrophy following a radical p:rostatectomy should be more generally appreciated and I am particularly interested to know the experiences of other members of this society in order that this matter, which to me was unknown until recently, may be more generally appreciated. The cause of recurrence of benign prostatic hypertrophy seems to be a matter of theory. Takahaski advances the idea that the prostatic capsule is a tissue composed of flattened glands which will take on an activity of regeneration of the gland structure when the pressure has been removed by prostatectomy. Hadinger rather substantiates this view by finding distinct recurrence of glandular tissue in autopsy specimens two and four months after prostatectomy. This theory also has the support of Taudler, Zukerkandl, Honneger and Blum. Fraudenberg, at first a supporter of this theory, later came to believe that the regeneration did not take place from the glandular tissue of the so-called capsule, but from small, adenomatous nodules left at the time of the first prostatectomy. Still another explanation is offered by Jacoby. He divides the glands of the prostatic urethra into mucous (which does not concern us), submucous, and prostatic. He points out that the submucous glands form the cervical group about the vesical neck and may give rise to the pathological middle lobe, and that they are also located on the anterior or ventral wall of the urethra. He claims that he has demonstrated by histological study that these 2 groups can develop even into the muscularis. Jacoby believes that these urethral glands are not the only ones to undergo hypertrophy, but on each side of the ventral group there is a particular gl~dular zone, often continuous with the prostatic glands. These urethral prostatic glands, he believes, are the site of the hypertrophic centers and suggests that as they are continuous with the prostatic glands in the prostatic capsule, "nuclei
RECURRENT BENIGN PROSTATIC OBSTRUCTION
273
of hypertrophy" may . exist. He believes that these so called nuclei of hypertrophy normally play but a secondary part but become active after extirpation of the central glandular tumor, which has compressed them, and may undergo such expansion as to form new prostatic tissue even to the point of producing obstruction by overgrowth. Whatever may be the true explanation, the fact that prostatic tissue reappears within the prostatic capsule, and may continue to grow to the point of producing obstruction of the true hypertrophy type, seems to be a fact. We have occasionally examined patients after prostatectomy, who seems to have a prostate and in whom we would not believe that the gland had been removed unless we had removed it ourselves. None of these patients, however, have had the recurrent symptoms of prostatism. This observation, however, :fits in with the matter under consideration and it may be that recurrent prostatic tissue is quite common and that the reason we do not see more evidence of recurrent obstruction from such hypertrophy is that the prostatic patient is usually so aged that he dies before there is sufficient time for the regrowing gland to reach the point of obstruction. In this connection it is of interest to note the ages of the patients and the time elapsed between the :first prostatectomy and the recurrent symptoms of obstruction. Dr. Lewis' patient was · 61. Recurrent obstruction symptoms appeared in approximately 12 years. My patients were: First: 59 years with recurrent symptoms in 8 years. Second: 64 years with recurrent symptoms in 7 years. Third: 53 years with recurrent symptoms in 13 years.
I think it may be said that the ages of these 4 patients place them among the younger group requiring prostatectomy and that the recurrent symptoms at 12, 8, 7, and 13 years is a rather longer period of time than most prostatics live after operation. So it may be that if those having prostatectomy live long enough we would see more recurrent growths. Whether or not this be true, it certainly suggests that in the younger group, that is about
274
JOHN H. CUNNINGHAM
60 or below, with the probably greater expectancy of life, we find more recurrences. Since becoming aware of the possibility of regrowth this is a matter about which we will check more carefully in the future than in the past. Dr. Lewis' patient, which he records in detail, had a suprapubic prostatectomy performed by Dr. Lewis in April, 1916. The gland was enucleated in one piece and the patient made an uneventful convalescence and remained well for approximately 12 years. He then again had the symptoms of prostatism. Rectal examination showed what Dr. Lewis terms a ''renewed" prostate, and cystoscopy revealed a large, intravesical intrusion. The gland was removed by a two-stage suprapubic operation. Dr. Lewis states that the enucleation was easily performed, as it was also in our cases. In other words, there seems to be no added difficulty in the technical procedure because the gland had previously been enucleated. Our patients' histories and findings are quite similar. Case 1. This patient, sixty-seven years of age, had a two-stage suprapubic prostatectomy performed by Dr. Hugh Cabot in October, 1919, he then being fifty-nine years of age. He remained well for eight years, when he began to have increased frequency and difficulty in emptying the bladder. Two weeks prior to our seeing him he had retention and was catheterized several times by Dr. Seldom B. Overlock of Pomfret, Conn., who sent him to us. The general examination showed nothing extraordinary. Rectal examination showed a very large, benign, hypertrophied prostate. A coude catheter was tight in the prostatic urethra and there were 6 ounces of foul residual urine. The urinalysis was that of cystitis. There were no real elements. Cystoscopy showed that the prostate projected in all quadrants and presented the usual picture of a considerable intravesical enlargement. There was moderate bladder trabeculation and the capacity was 8 ounces. On February 13, 1929, approximately ten years after Dr. Cabot had done the suprapubic prostatectomy, we did a suprapubic cystotomy for drainage. It was not until March 19, 1929, approximately four weeks, that the patient was in condition for prostatectomy. At operation, the prostate gave the typical picture of a moderate intravesical hypertrophy, the left lobe being slightly larger than the right. The
RECURRENT BENIGN PROSTATIC OBSTRUCTION
27 5
gland enucleated easily and there were many small concretions between the gland and the capsule. There was nothing about the appearance of the gland or the features of the operation that differ from the condition usually observed, with the exception of the presence of the concretions between the gland and capsule. The patient made an uneventful recovery and is well at present. Case 2. This patient aged seventy-four, had a two-stage suprapubic prostatectomy by Dr. John Bottomly in April, 1919, being then sixtyfour years old. He remained well for seven years and then, three years before we saw him, began to have frequency, which gradually increased until it occurred every two hours during the day and night. The frequency became so distressing that he finally consulted Dr. Walter Mansfield, who referred him to us. The general examination showed nothing of importance. Rectal examination showed the prostate to be a moderately large, benign, hypertrophied gland. A No. 20 Coude catheter was passed to the bladder with but little obstruction. There were 10 ounces of residual urine, however. The urine was that of a chronic cystitis. There were no renal elements. Cystoscopy was very unsatisfactory because of the patient's nervousness, but enough was observed to establish the fact that that there was considerable intravesical projection. X-ray was negative. On February 28, 1929, approximately ten years following Dr. Bottomly's prostatectomy, we did a cystotomy for drainage. Twenty days later the patient was in satisfactory condition for the removal of the gland. At operation, the gland was found to project in all quadrants to a considerable degree. Enucleation was simple and a very large gland was enucleated in one piece. The picture at operation was that usually observed and the technique of the operation presented no unusual features. The patient made an uneventful recovery and has remained well. Case 3. Physician, aged sixty-eight. Had symptoms of obstruction for several months. Was operated upon by Dr. Hugh Cabot on September 20, 1915, by a one-stage prostatectomy. (Patient was then fifty-three years of age.) He had a severe attack of phlebitis following operation and had to use crutches for several months. In 1918, practically three years after prostatectomy, patient had a perforating ulcer
276
JOHN H. CUNNINGHAM
of the stomach which was successfully operated upon by Dr. Samuel Mixter. Patient for several years has suffered from myocardiac attacks and has been under the care of Dr. Paul White. In December, 1929, approximately fourteen years after the prostatectomy, patient had acute retention of urine. Entered the DayKimball Hospital in Putnam, Conn., where he was catheterized by Dr. Overlock, who found that he had 40 ounces of residual urine. At that time it was learned that he had had symptoms of prostatism for a few months only. The cardiac distress which was frequent and severe, was the explanation given by the patient as a probable reason for his not complaining of the bladder disturbance before the retention. The patient was referred to us by Dr. Overlock on January 15, 1930. Residual urine was 20 ounces infected and urinalysis gave evidence of chronic renal disease. There was a moderate sized benign prostate by rectal examination. Cystoscopically, there was a considerable middle lobe and moderate sized intravesical lateral lobe projections. The musculature was thin, the left ureteral orifice was gaping and the right ureteral orifice was not seen. The rectal palpation did not give an idea of the size of the gland, which was largely intravesical in its regrowth. The cystoscopic picture was typically that of a benign prostatic hypertrophy. He was placed on urethral drainage and the bladder decompressed. The patient was not subjected to prostatectomy again because of the cardiac condition which was considered too severe to make operation advisable. Beside the defective circulation, his urinalysis, blood chemistry and renal function tests were poor. Fortunately, a catheter entered the bladder easily. The patient was placed on urethral catheter drainage and bladder lavage for about two weeks and then returned home. A report from this patient dated April 19, 1930, states that he is "seeing some patients in his office but continues to be very weak and has a lot of dyspnea." His doctor stated on May 9 that he still has a "moderate" residual urine.
This case has been included because it is a typical recurrent prostatic hypertrophy and operative indications would be definite were it not for the other physical defects which render it inadvisable. As previously stated, the object of this communication is not only to place these three patients on record but also to establish
RECURRENT BENIGN PROSTATIC OBSTRUCTION
277
insofar as possible a proper idea of the probability of recurrent prostatic obstruction following prostatectomy by an expression from this society regarding this matter. 46 Gloucester Street, Boston, Mass. REFERENCES BAzy, P . : Bull. Acad. de med ., Paris, 1927, xcvii, 843. BLUM, V. : Ztschr. f. urol. Chir., Berl., 1920, v, 77. CASARIEGO : Rev. espan. de urol. y dermat., Madrid, 1924, xxvi, 254--256. CASPER, L.: Berl. klin. Wchnschr., 1911, xlviii, 1500. FREUDENBERG, A. : Verhandl. d. deutsch. Gesellsch . f. Chir., Berl., 1907, iv, 36 Kongr. 6, Pt. 1, 182-183. FRONSTEIN, R., AND MESCHEBOWSKI, G. : Ztschr. f. urol. Chir., Berl., 1926, xx, 222-229. HEDINGER : Cor. Bl. f. schweiz. Aerzte, Basel, 1906, xxxvi, 277. HONEGGER, R.: Ztschr. f. Urol., Leipz, 1922, xvi, 425-440. VoN lLLYES: Geza., Ztschr. f. urol. Chir., Berl., 1925, xvii, 229- 242. LouMEAU: Gaz. hebd. d . sc. med. de Bourdeauz, 1912, xxxiii, 437--439. LuMPERT, E.: Cor. Bl. f. Schweiz. Aerzte, Basel, 1911, xli, 99-102. ORTH, 0. : Ztschr. f . urol. Chir., Berl., 1921, viii, 83- 86. TAKAHASKI, A.: Ztschr. f. urol. Chir., Berl., 1927, xxii, 167- 169; Urol. and Cutan. Rev., St. Louis, 1928, xxxii, 597. TANDLER, J ., AND ZucKERKANDL, 0.: Berl., 1922, J. Springer, 130 p., 40. YouNG, H. H . : Johns Hopkins Hosp. Rep., Baltimore, 1906, xiv, 1--476. LEWIS, BRANSFORD : Jour. Urol., 1930, xxiv, 319. GREGOR.A: Ztsch. fur Urol., December, 1928. JACOBY: Ztsch. fur Urol., December, 1928.