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Results of Punch Prostatectomy1
RESULTS OF PUNCH PROSTATECTOMY1 HERMON C. BUMPUS, JR.
Section on Urology, Mayo Clinic, Rochester, Minnesota
In four years a century will have elapsed since Guthrie first called attention in his lecture before the Royal College of London to bar formation at the neck of the bladder. Y!;)t at the present time this recognized pathological entity, because of its situation, produces symptoms analogous to those of prostatic hypertrophy and is looked upon and treated by many surgeons as if due to such hypertrophy rather than, as Randall has so clearly demonstrated, to prostatic atrophy with associated inflammatory changes. Randall states: "One frequently hears reference made to the removal of a 'small sclerotic prostate.'" That this operation is fraught with many difficulties and some dangers hardly needs mention to anyone who has attempted it. To remove the clearly encapsulated lobes of the benign hypertropic prostate is a very simple procedure, but to drag from its bed the atrophic, adherent and sclerotic tissue which frequently forms a part of the condition of median bar formation is an operation taxing not only the energies, but the utmost skill and anatomical knowledge of the operator; while the dangers from injury to contiguous structures by hemorrhage and from actual failure to remove anything should contraindicate such a procedure. Young, commenting on such a surgical procedure, states: "The amount of tissue removed at suprapubic operation is so small that it seems ridiculous to have to perform suprapubic operation for its removal." To overcome these valid objections has been the object of the various instruments invented for intraurethral use. Although many of these are well known, 1 Read before the American Association of Genito-Urinary Surgeons, Hot Springs, Virginia, May 17 to 19, 1926.
59
60
HERMON C. BUMPUS, JR.
I shall briefly sketch their development, since several were employed in the series of operations the results of which I wish to report, and one in particular, designed by Braasch, seems to meet all the needs most satisfactorily. The various instruments classify themselves into two groups, those intended to incise the obstruction, and those that do excise it. Guthrie constructed the first instrument for incision, which consisted of a small knife-blade made to project at will from a catheter. In describing the operation he states: "The knife being projected just as the instrument is felt to be passing over the bar will cut it and, if after it has passed into the bladder it be withdrawn, the little knife in coming back will enlarge the original cut. Civiale elaborated this instrument, and it was brought to its greatest perfection by Geraghty in the form of his sphincterotome. These instruments, however, because they incised rather than excised the obstruction, never proved satisfactory in any considerable series of cases, although in individual cases success was not infrequent. Mercier was the first to design an instrument for excision. This resembled a Bigelow lithotrite, the movable jaw of which was constructed as is a circular knife. The instrument was clumsy and difficult to manipulate and, therefore, not generally adopted. In fact, being invented in 1841, it appears to have been forgotten until Young presented his punch in 1911, when, in a review of the older literature the description of Mercier's instrument was resurrected. Except as to uniformity of use they have no resemblance. The Young punch accomplished so thoroughly the work for which it was designed that it soon became the accepted instrument. However, it appeared to have two serious limitations: adequate vision of the field of operation was not possible, and only after application could the piece of tissue to be removed be seen protruding through the fenestra into the endoscopic tube. Even this delayed and limited view was not satisfactory after the first cut, because of resulting hemorrhage. In referring to this objection, Young states that in practice he has found this observation of the tissue projecting through
RESULTS OF PUNCH PROSTATECTOMY
61
the fenestra entirely unnecessary, as with experience one may be certain as to the portion of the prostate which has been caught within the tube. Caulk, on the other hand, is equally emphatic concerning the necessity of this preliminary inspection of the tissue to be excised in order to prevent cutting other portions of the bladder or urethra. An unfortunate accident occurred to me when I neglected to observe this precaution. Feeling that well over 50 cases had furnished the required experience to make this preliminary observation necessary, I dispensed with it and engaged the bar formation blindly. I was not mistaken regarding the application, but unfortunately, a fold of bladder was also engaged and death occurred. Young reports a similar accident in his series of 355 cases, although it vvas not encountered by himself. Recently I have learned that our own respective clinics are not unique in the experience of such unfortunate accidents. To avoid such a complication by rendering the operative field easily visible at all times, Braasch in 1918 added a knifepunch, after the model of Young, to his direct cystoscope. The difficulty of adequate vision during operation being thus overcome, the question of hemostasis remained. As Young says in his recent book, in the majority of cases this is not excessive, but is annoying and occasionally demands transfusion and has compelled suprapubic cystostomy for control. He, therefore, so modified his punch as to carry a cautery blade with a water cooling system. As serious bleeding occurred so seldom, he did not urge this modification for general use, and yet I think I am safe in saying that the fear of being unable to control hemorrhage following the punch operation has been the most serious obstacle to its more general adoption. In 1920 Caulk adapted to the Young punch a much simplified and efficient cautery-blade and at once practically eliminated the possibility of hemorrhage. To him is due all credit for popular:izing this method. In 72 of the cases reported here his instrument was used, and serious bleeding immediately following operation occurred but once. However, when one compares the records of these 72 cases with the 52 cases in which the knife punch of either Young or Braasch
62
HERMON C. BUMPUS, JR.
was used, a high incidence of two serious complications inherent to the use of a cautery is noted, which seems to us to offset the advantages of immediate hemostasis. I refer to the occurrence of delayed bleeding and prolonged febrile reaction. The delayed bleeding usually occurs from ten days to three weeks after the operation, at the time the slough comes away. If there has been no febrile reaction compelling the patient's extended stay in the hospital, one is usually informed of this unexpected hematuria by wire and is placed in the distressing position of trying to apply hemostasis by telegram. Fortunately, such bleeding is usually more alarming to the Pl;l,tient than serious. The occurrence of prolonged postoperative febrile reactions is more trying. In the 72 cases in which the cautery was used, febrile reactions lasting more than three days occurred in twentythree, a third of the cases. The short febrile reactions lasting from one to three days were far more severe than we experience when the knife is used. In the 42 cases of knife-excision there were only eight with febrile reactions lasting more than three days, the longest being twelve days, while when the cautery was used some of the reactions lasted for several weeks. It would seem that a cauterized area in the neck of the bladder is more prone to secondary infection than a cleanly incised one and hence a better focus for a secondary pyelonephritis. The increased time that it requires a burn to heal, in comparison to a dean incision, would more than double the time in which such an infection might take place. The incidence of epididymitis was also much greater in the series with treatment by cautery, occurring ten times, while it is mentioned but once after the use of the knife. In an endeavor to insure against hemorrhage following the knife-punch, I formed the habit of immediately cystoscoping the patient after the operation was completed. This made it possible to detect the bleeding points and, by applying the Bugbee electrode with the bipolar current, to stop the bleeding with electrocoagulation. Recently Tolson has introduced an insulated shaft, for electrocoagulation after a punch operation, with
RESULTS OF PUNCH PROSTATECTOMY
63
a contact point the size of the fenestra in the Young punch. This, of course, causes electrocoagulation of the entire excised area rather than just the bleeding points, and for this reason has the objections inherent to a cautery. In this series of 114 cases there are complete records concerning the final results in seventy-four. As Caulk's cautery-punch has been used in the last 72 cases, the records of those cases are more complete than those of the 42 earlier cases in which the knife punch was used. The final results are also much better, due, I believe, to the larger caliber of the Caulk instrument rather than to the cautery feature. Thirty-five of the seventy-two patients report complete relief of obstructive symptoms and are satisfied with the results of the treatment, although one-third of them still complain of nocturia and frequency. The persistence of these symptoms after the obstruction has been completely relieved is unexpected until it is remembered that median bar formation is an inflammatory process and not the result of glandular hypertrophy. The poor final results obtained following the knife punch (only four of twenty-two patients heard from expressed full satisfaction with the result of treatment) is due, I believe, to not having removed sufficiently large amounts of tissue; this was difficult to do with Braasch's original instrument. It may have been due, also, to the errors in technic invariably associated with the use of a new instrument. Of the 114 cases, prostatectomy had to be subsequently performed in six, in one after six months, in one after four months, and in four a few days following the original punch. Possibly these were ill-chosen cases; in one the operation had been performed for adenomatous hypertrophy while in the other five cases the removed tissue showed inflammatory changes only. We have not met with success when we have tried to remove prostatic tissue in the presence of lateral lobe involvement, although in the cases of true adenomatous enlargement of the median lobe its removal has met with good results. The punch was used in three cases of malignant neoplasm of the prostate with transitory and indifferent results. Possibly
64
HERMON C. BUMPUS, JR.
RESULTS OF PUNCH PROS'I'ATECTOMY
65
a larger series would show greater relief of sy1nptoms, but it has been our custom to effect suprapubic drainage when the obstruction from the growth is sufficient to demand surgical interference. In one case a neoplasm_ of the posterior urethra, was easily removed by the punch when technical difficulties made its electrocoagulation impossible. In two cases contracture of the neck of the bladder in association with cord bladder was treated, one with corn_plete relief of symptoms and residual urine and the other without result.
Fm. 2.
PORTIONS OF
J\;hmr.'\.\f
LOBE vVEIGHING
6
GuAMS; REMOVED WITH BRAASCH's
MEDIAN BAR ExcrsoR
In Braasch's original instrument the caliber of the knife was small and it was difficult to obtain pieces of tissue of adequate size. It was because of this fact that I used Caulk's cauterypunch in the series of 72 cases cited, for the size of the bites obtained made the removal of the entire median bar easy. Recently Braasch has remodeled his median bar excisor so that it
66
HERMON C. BUMPUS, JR.
now removes much larger pieces of tissue, and I believe that, by its use and its more accurate application under the guidance of the eye, results as excellent as we have obtained with Caulk's instrument may follow, without the annoyance of delayed bleeding or the high incidence of febrile reactions (figs. 1 and 2). REFERENCES (1) BRAASCH, W. F.: Median bar excisor. Jour. Amer . Med. Assoc ., 1918, Ix, 758- 759. (2) RANDALL, ALEXANDER: Prostatisme sans prostate . New York Med. Jour., 1915, cii, 1123- 1132; 1177- 1186. (3) TOLSON, H. L.: Electrode for use with Young's punch; diathermy as supplement to prostatic punch operation. Jour. Urol., 1925, xiv, 63- 65. (4) YouNG, H. H.: Practice of urology. Philadelphia, Saunders, 1926, ii, 481510.
Section on Urology, Mayo Clinic, Rochester, Minnesota
In four years a century will have elapsed since Guthrie first called attention in his lecture before the Royal College of London to bar formation at the neck of the bladder. Y!;)t at the present time this recognized pathological entity, because of its situation, produces symptoms analogous to those of prostatic hypertrophy and is looked upon and treated by many surgeons as if due to such hypertrophy rather than, as Randall has so clearly demonstrated, to prostatic atrophy with associated inflammatory changes. Randall states: "One frequently hears reference made to the removal of a 'small sclerotic prostate.'" That this operation is fraught with many difficulties and some dangers hardly needs mention to anyone who has attempted it. To remove the clearly encapsulated lobes of the benign hypertropic prostate is a very simple procedure, but to drag from its bed the atrophic, adherent and sclerotic tissue which frequently forms a part of the condition of median bar formation is an operation taxing not only the energies, but the utmost skill and anatomical knowledge of the operator; while the dangers from injury to contiguous structures by hemorrhage and from actual failure to remove anything should contraindicate such a procedure. Young, commenting on such a surgical procedure, states: "The amount of tissue removed at suprapubic operation is so small that it seems ridiculous to have to perform suprapubic operation for its removal." To overcome these valid objections has been the object of the various instruments invented for intraurethral use. Although many of these are well known, 1 Read before the American Association of Genito-Urinary Surgeons, Hot Springs, Virginia, May 17 to 19, 1926.
59
60
HERMON C. BUMPUS, JR.
I shall briefly sketch their development, since several were employed in the series of operations the results of which I wish to report, and one in particular, designed by Braasch, seems to meet all the needs most satisfactorily. The various instruments classify themselves into two groups, those intended to incise the obstruction, and those that do excise it. Guthrie constructed the first instrument for incision, which consisted of a small knife-blade made to project at will from a catheter. In describing the operation he states: "The knife being projected just as the instrument is felt to be passing over the bar will cut it and, if after it has passed into the bladder it be withdrawn, the little knife in coming back will enlarge the original cut. Civiale elaborated this instrument, and it was brought to its greatest perfection by Geraghty in the form of his sphincterotome. These instruments, however, because they incised rather than excised the obstruction, never proved satisfactory in any considerable series of cases, although in individual cases success was not infrequent. Mercier was the first to design an instrument for excision. This resembled a Bigelow lithotrite, the movable jaw of which was constructed as is a circular knife. The instrument was clumsy and difficult to manipulate and, therefore, not generally adopted. In fact, being invented in 1841, it appears to have been forgotten until Young presented his punch in 1911, when, in a review of the older literature the description of Mercier's instrument was resurrected. Except as to uniformity of use they have no resemblance. The Young punch accomplished so thoroughly the work for which it was designed that it soon became the accepted instrument. However, it appeared to have two serious limitations: adequate vision of the field of operation was not possible, and only after application could the piece of tissue to be removed be seen protruding through the fenestra into the endoscopic tube. Even this delayed and limited view was not satisfactory after the first cut, because of resulting hemorrhage. In referring to this objection, Young states that in practice he has found this observation of the tissue projecting through
RESULTS OF PUNCH PROSTATECTOMY
61
the fenestra entirely unnecessary, as with experience one may be certain as to the portion of the prostate which has been caught within the tube. Caulk, on the other hand, is equally emphatic concerning the necessity of this preliminary inspection of the tissue to be excised in order to prevent cutting other portions of the bladder or urethra. An unfortunate accident occurred to me when I neglected to observe this precaution. Feeling that well over 50 cases had furnished the required experience to make this preliminary observation necessary, I dispensed with it and engaged the bar formation blindly. I was not mistaken regarding the application, but unfortunately, a fold of bladder was also engaged and death occurred. Young reports a similar accident in his series of 355 cases, although it vvas not encountered by himself. Recently I have learned that our own respective clinics are not unique in the experience of such unfortunate accidents. To avoid such a complication by rendering the operative field easily visible at all times, Braasch in 1918 added a knifepunch, after the model of Young, to his direct cystoscope. The difficulty of adequate vision during operation being thus overcome, the question of hemostasis remained. As Young says in his recent book, in the majority of cases this is not excessive, but is annoying and occasionally demands transfusion and has compelled suprapubic cystostomy for control. He, therefore, so modified his punch as to carry a cautery blade with a water cooling system. As serious bleeding occurred so seldom, he did not urge this modification for general use, and yet I think I am safe in saying that the fear of being unable to control hemorrhage following the punch operation has been the most serious obstacle to its more general adoption. In 1920 Caulk adapted to the Young punch a much simplified and efficient cautery-blade and at once practically eliminated the possibility of hemorrhage. To him is due all credit for popular:izing this method. In 72 of the cases reported here his instrument was used, and serious bleeding immediately following operation occurred but once. However, when one compares the records of these 72 cases with the 52 cases in which the knife punch of either Young or Braasch
62
HERMON C. BUMPUS, JR.
was used, a high incidence of two serious complications inherent to the use of a cautery is noted, which seems to us to offset the advantages of immediate hemostasis. I refer to the occurrence of delayed bleeding and prolonged febrile reaction. The delayed bleeding usually occurs from ten days to three weeks after the operation, at the time the slough comes away. If there has been no febrile reaction compelling the patient's extended stay in the hospital, one is usually informed of this unexpected hematuria by wire and is placed in the distressing position of trying to apply hemostasis by telegram. Fortunately, such bleeding is usually more alarming to the Pl;l,tient than serious. The occurrence of prolonged postoperative febrile reactions is more trying. In the 72 cases in which the cautery was used, febrile reactions lasting more than three days occurred in twentythree, a third of the cases. The short febrile reactions lasting from one to three days were far more severe than we experience when the knife is used. In the 42 cases of knife-excision there were only eight with febrile reactions lasting more than three days, the longest being twelve days, while when the cautery was used some of the reactions lasted for several weeks. It would seem that a cauterized area in the neck of the bladder is more prone to secondary infection than a cleanly incised one and hence a better focus for a secondary pyelonephritis. The increased time that it requires a burn to heal, in comparison to a dean incision, would more than double the time in which such an infection might take place. The incidence of epididymitis was also much greater in the series with treatment by cautery, occurring ten times, while it is mentioned but once after the use of the knife. In an endeavor to insure against hemorrhage following the knife-punch, I formed the habit of immediately cystoscoping the patient after the operation was completed. This made it possible to detect the bleeding points and, by applying the Bugbee electrode with the bipolar current, to stop the bleeding with electrocoagulation. Recently Tolson has introduced an insulated shaft, for electrocoagulation after a punch operation, with
RESULTS OF PUNCH PROSTATECTOMY
63
a contact point the size of the fenestra in the Young punch. This, of course, causes electrocoagulation of the entire excised area rather than just the bleeding points, and for this reason has the objections inherent to a cautery. In this series of 114 cases there are complete records concerning the final results in seventy-four. As Caulk's cautery-punch has been used in the last 72 cases, the records of those cases are more complete than those of the 42 earlier cases in which the knife punch was used. The final results are also much better, due, I believe, to the larger caliber of the Caulk instrument rather than to the cautery feature. Thirty-five of the seventy-two patients report complete relief of obstructive symptoms and are satisfied with the results of the treatment, although one-third of them still complain of nocturia and frequency. The persistence of these symptoms after the obstruction has been completely relieved is unexpected until it is remembered that median bar formation is an inflammatory process and not the result of glandular hypertrophy. The poor final results obtained following the knife punch (only four of twenty-two patients heard from expressed full satisfaction with the result of treatment) is due, I believe, to not having removed sufficiently large amounts of tissue; this was difficult to do with Braasch's original instrument. It may have been due, also, to the errors in technic invariably associated with the use of a new instrument. Of the 114 cases, prostatectomy had to be subsequently performed in six, in one after six months, in one after four months, and in four a few days following the original punch. Possibly these were ill-chosen cases; in one the operation had been performed for adenomatous hypertrophy while in the other five cases the removed tissue showed inflammatory changes only. We have not met with success when we have tried to remove prostatic tissue in the presence of lateral lobe involvement, although in the cases of true adenomatous enlargement of the median lobe its removal has met with good results. The punch was used in three cases of malignant neoplasm of the prostate with transitory and indifferent results. Possibly
64
HERMON C. BUMPUS, JR.
RESULTS OF PUNCH PROS'I'ATECTOMY
65
a larger series would show greater relief of sy1nptoms, but it has been our custom to effect suprapubic drainage when the obstruction from the growth is sufficient to demand surgical interference. In one case a neoplasm_ of the posterior urethra, was easily removed by the punch when technical difficulties made its electrocoagulation impossible. In two cases contracture of the neck of the bladder in association with cord bladder was treated, one with corn_plete relief of symptoms and residual urine and the other without result.
Fm. 2.
PORTIONS OF
J\;hmr.'\.\f
LOBE vVEIGHING
6
GuAMS; REMOVED WITH BRAASCH's
MEDIAN BAR ExcrsoR
In Braasch's original instrument the caliber of the knife was small and it was difficult to obtain pieces of tissue of adequate size. It was because of this fact that I used Caulk's cauterypunch in the series of 72 cases cited, for the size of the bites obtained made the removal of the entire median bar easy. Recently Braasch has remodeled his median bar excisor so that it
66
HERMON C. BUMPUS, JR.
now removes much larger pieces of tissue, and I believe that, by its use and its more accurate application under the guidance of the eye, results as excellent as we have obtained with Caulk's instrument may follow, without the annoyance of delayed bleeding or the high incidence of febrile reactions (figs. 1 and 2). REFERENCES (1) BRAASCH, W. F.: Median bar excisor. Jour. Amer . Med. Assoc ., 1918, Ix, 758- 759. (2) RANDALL, ALEXANDER: Prostatisme sans prostate . New York Med. Jour., 1915, cii, 1123- 1132; 1177- 1186. (3) TOLSON, H. L.: Electrode for use with Young's punch; diathermy as supplement to prostatic punch operation. Jour. Urol., 1925, xiv, 63- 65. (4) YouNG, H. H.: Practice of urology. Philadelphia, Saunders, 1926, ii, 481510.