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Sump drainage in suprapubic prostatectomy
Qrlginal %Mcles SUMP DRAINAGE
IN SUPRAPUBIC LOWRAIN E. MCCREA, l’bild~lphi~,
S
UMP drainage has been used in industria1 fieIds for many decades, but the principle has been appIied to surgery only in recent vears. The eff1cienc.y of sump drainage foIIoGing prostatectomy has been shown to be highly effective due to rapid recovery of the patient. Stedman advocated the use of sump drainage of the bladder and introduced a motor suction pump. Ritter, McCarthy and others have advocated, designed and successfully used vesical sump drainage for several years. Babcock perfected and has successfully used the sump drain for intraperitoneal postoperative drainage. He observed that sump drains made of gIass were effective, but there was always danger of breakage within the wound. The writer observed that \-esical drains made of plated metal had a tendency to corrode when in contact with urine and were found to become very irritating to the tissue. Drains constructed of rubber, although ideal in some respects, were also found to be irritating to the freshly incised tissue. This irritation is undoubtedly due to a chemica1 reaction of the urine on the rubber. Considerable experimentation with drains constructed of Iucite proved that such drains possessed many disadvantages and they were soon discarded. Babcock was the first to prove conclusively the advantages and successfully used the sump drain constructed of stainless steel for intraperitonea1 drainage. It was foIlowing his observations that the stainless steel sump for postoperative vesical drainage, which has been so successfully used, was designed. No inference is to be drawn by this con&ri
1, 1949
PROSTATECTOMY M.D.
I’enns~~lvani~l
tribution among the merits of suprapubic prostatectomy, perineal prostatectomy or transurethral resection. Each of these procedures has its own individual indications and surgica1 adherents. No attempt is made to compare these surgica1 procedures nor to compare their Iength of postoperative hospitaIization. Nor is it intended to incite controversy as to the advisability of the different types of operation. This contribution is intended to be a description of sump drainage as it is used in suprapubic prostatectomy and the management of the patient having prostatic hyperplasia. There has been no seIection of patients on whom sump drainage has been used, but rather it has been the selection of the proper sump drainage tube to be used on the individual patient. The principIe of sump drainage is the same regardless of the size or length of the tube. The speed with which wound healing by primary intention occurs, the complete comfort of the patient during its use, the decrease in postoperative complications and shortened hospitaIization have been supporting factors for continued tria1 and error procedures and technics in the attempted perfection of vesical sump drainage. A stainless stee1 drain for vesical drainage was originaIIy introduced in 1944. A subsequent model was presented in 1945. After repeated use an improved model of the drain was devised which is herein described. The sump drain is now empIoyed routinely at the time of operation in a11 instances of cystotomy even when permanent suprapubic drainage is to be instituted later. Positive, effective postopera411
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FIG. I. Schematic drawing of the various steps of suprapubic prostatectomy. E, shows the relative position of the Dack and the sumD drain: F (a and b). the closure of the bladder and rectus fascia around the sump tube; F (c), the side view of tie sump holder on &e abdominal wall.
tive vesica1 drainage is assured with its use. (Fig. I.) It has been proven concIusiveIy that vesica1 sump drainage materiaIIy shortens postoperative convaIescence. In a comparative study of unseIected cases it was found that the average postoperative convaIescence was 32.6 days in one institution and 27.5 days in another institution when rubber tube drainage was used foIIowing suprapubic prostatectomy. When sump drainage was used, the postoperative hospita1 stay in uncompIicated cases is usuaIIy eIeven to thirteen days. The shortest period of convaIescence foIIowing prostatectomy in which sump drainage was used was eight days. In many cases cardiac or renaI complications, so frequentIy encountered in patients with prostatic hypertrophy, impeded norma convaIescence. For this reason many patients were forced to remain or chose to remain in the hospita1 after wound heaIing had occurred. As a result the average time of hospitaIization
for al1 patients was found to be 18.5 days, Inasmuch as the number of postoperative hospita1 days is of materia1 economic importance, not onIy from the patient’s standpoint but aIso from the standpoint of efficient hospitaf administration, it is a factor worthy of much consideration. PREOPERATIVE
CARE
OF
THE
PROSTATIC
PATIENT
It is beIieved that one of the most important factors in the management of the prostatic patient is meticuIous preoperative care. In prostatic disease it is usua1 that the heart and kidneys show defmite impairment by the time the patient is presented for surgery. In many instances it may be said that the heart and kidneys are tired and exhausted. A definite pathoIogic condition exists in the majority of instances. The age of the patient contributes to arterioscIerotic changes. These changes are proportionateIy just as great in the smaIIer bIood vesseIs of the kidney as in American
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blood vessels of larger caliber. The liltration process of the kidney cells is hampered by the arteriosclerotic changes. Back pressure, created by the ever-present residua1 urine in varying amounts, causes further impairment of renaI function. Increased nitrogen retention in the blood and a diminution of the excretory function, as revealed by: phenoIsuIphonphthaIein excretion, occurs as a resuIt of this impairment. It has been shown that excretion of nitrogenous waste products is increased by the maintenance of a urinary output of 2,500 to 3,000 cc. daily-. It is imperative to maintain it as high as can be toIerated by the patient. The heart frequentI? shows the effects of the retention of toxms by being lveaker in tone than normaI or independent cardiac impairment may exist. Electrocardiographic study is imperative to establish definitely; the nature and extent of any cardiac impanment. Every proven cardiac impairment should be subjected to treatment before surgery is contempIated. Repeated determinations of bIood urea nitrogen and phenoIsuIphonphthaIein elimination should be made unti1 a return to normal or safe leveIs occurs. Such IeveIs occur following vesica1 drainage which is continued for varying lengths of time. Such drainage should be maintained either by a suprapubic tube or by a retained urethral catheter. Use of the indweIIing urethral catheter is preferred inasmuch as it permits greater freedom of action by permitting the patient to be ambulatory. Continuous preoperative bIadder drainage by retained catheter may be employed successfull?- in the majority of instances without fear of infection if diIigent, meticulous care of the catheter and the patient is maintained. The exceptional occurrence of continuous, severe, intravesical hemorrhage, the presence of large vesical calculi, severe vesical infIammation or, in certain instances, subcervical or posterior commissural hypertrophy may prevent satisfactor); use of the retained catheter. Any con&ion causing spastic irritabiIity of the bladder prevents use of the retained April,
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catheter and requires cystotomy for preliminary drainage. It is beheved that long continued preoperative drainage by urethra1 catheter, even for a period of months in some instances if necessary, is essential to insure postoperative recovery. In those instances of Iong continued drainage the pH of the urine is maintained at a low level by- ora administration of sodium acid phosfate. An acid urine prevents the coIIection of urinary saIts on the catheter and Iessens the possibiIity of infection of the bIadder with BaciIIus proteus. Stabilization of the bIood urea nitrogen at normal IeveIs and eIevation of the percentage of excretion of phenoIsuIphonphthalein are imperative factors of adequate preoperative management. An unsatisfactory condition exists when the bIood urea nitrogen IeveIs are norma but the phenolsulphonphthaIein IeveIs of excretion are very low. It is obvious that the nearer the results of these tests approach norma levels the shorter the postoperative convalescence and the Iower the percentage of operative mortality. Operative accidents, such as cardiac failure, apoplexy, thrombosis or emboIus, occur occasionally in spite of the fact that every possible precaution has been taken before operation to prevent their occurrence. Fasting blood sugar determination shouId always be done during the preIiminary survey of the patient. It has been surprising to learn the number of eIderIy men who suffer not only with prostatism but aIso with diabetes. A proper diabetic regimen to estabIish normaI blood sugar Ievels should be instituted before surgery is contempIated. In a recent survey of one hundred consecutive individuals subjected to prostatectomy it was Iearned preoperatively that nine patients had diabetes without their knowledge. It is beIieved that indiscriminate haste in the preoperative preparation of the patient has and wiI1 account for needlessly high mortaIity in prostatectomy. In the early days of prostatic surgery the mortality was high, very high, but surgeons
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of that time did not have at their command the advantages of modern Iaboratory methods. Nor did they have the knowIedge of the deIeterious effects of partial or compIete urinary retention as the factors producing high bIood urea nitrogen retention and excessiveIy Iow phenoIsulphonphthaIein excretion. In direct proportion with the progress made in estimating and estabIishing the patient’s preoperative condition by routine tests the mortaIity rate in prostatic surgery has decIined. At the present time it is a conceded practice that the patient be pIaced in the best possibIe physical condition before surgery is performed. If the patient’s condition is such that his tests do not indicate a return to norma IeveIs, operation is deferred. It is generaIIy conceded that the onestage suprapubic prostatectomy, foIIowing use of the retained catheter, is more easily performed than the two-stage procedure. The tissues are more readiIy pIiabIe, the heaIing of the wound is more secure and a shorter postoperative hospitaIization is usua1. It has been proven concIusiveIy that sump drainage of the bIadder foIIowing the one-stage procedure has decreased stiI1 further postoperative hospitalization. TECHNIC
Anesthesia. The seIection and use of the proper anesthesia is considered to be a very important factor in prostatic surgery. Each patient shouId be judged individuaIIy as to the type or kind of anesthesia to be used. It is a we11 estabIished fact that no one type of anesthesia may be used routineIy in prostatic patients. It has been demonstrated repeatedIy that eIderIy prostatic patients toIerate poorIy a sudden faI1 in bIood pressure during any type of anesthesia, particuIarIy protracted genera1 anesthesia. SpinaI anesthesia, using 75 to 80 mg. procaine IO per cent, administered in the fourth interspace, has been found to be most ideal in the majority of instances. The anesthesia attained by use of this drug is rapid and the effects of such a
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dosage continue for thirty to forty-five minutes, more than suflicient time to perform the average prostatectomy. The IeveI of anesthesia shouId be controIIedso that it does not extend higher than the IeveI of the umbiIicus. It has aIso been found that the postoperative reaction to surgery is better when the preoperative bIood pressure IeveI can be maintained at a11 times. One great disadvantage of spinal anesthesia is an untoward drop of blood pressure in the presence of cardiac impairment or in hypertension. It has been repeatedIy shown that a faI1 of bIood pressure, when spina anesthesia is used, is frequentIy foIIowed by cardiac or cerebral embarrassment which may be fata or leave permanent damage. Any decline of preoperative bIood pressure IeveIs may be combatted by intramuscuIar injection of such pressor substances as ephedrine 25 to 30 mg. or methadrine IO to 20 mg. The amount of the drug to be given is dependent on the bIood pressure IeveIs or the degree of hypertension. Further efforts to maintain preoperative bIood pressure IeveIs are made by intravenous administration of gIucose in saIine soIution given immediateIy foIIowing administration of the anesthetic. It has aIso been found that oxygen, IOO per cent by inhaIation, is another adjunct in the maintainance of preoperative blood pressure IeveIs. CaudaI-trans-sacra1 bIock, using 30 to 60 cc. procaine I per cent with IocaI infiItration of the abdomina1 waI1, has proved to be of merit in those instances in which a faI1 in bIood pressure wouId be especiaIIy detrimenta to the patient. It is beIieved that either spina anesthesia or caudaI-trans-sacra1 bIock permit a rapid “come-back” so essentia1 to patients if morbidity is to be a considered factor of convaIescence. Intravenous Therapy. The percentage of hemogIobin is used as an index for the preoperative administration of whoIe blood. It is beIieved that any individua1 having marked secondary anemia or who is anemic foIIowing profuse intravesica1 hemorrhage shouId receive repeated transfusions of American
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whoIe blood to compensate for the blood loss during the preoperative preparation. It is further believed that administration of koagamin, a compound of oxalic acid and other di-carboxyIic acids, aids materially in increasing coaguIation time. The drug has been routinely administered one hour before operation and has been given GmuItaneousIy in z cc. doses both intravenous17 and intramuscuIarIy. The drug has agam been given in 3 cc. doses intravenously and intramuscuIarIy immediateIy after operation and repeated in such dosage after three hours. The drug has been further employed in 3 cc. doses intravenously and intramuscularly administered prior to removal of the pack from the prostatic cavity. It has been found that intravenous administration of 5 per cent glucose in isotonic saIine soIution begun immediateIy following administration of the anesthetic, except in diabetics, aids materiaIIy in maintaining preoperative blood pressure IeveIs. In the presence of diabetes isotonic saIine soIution without glucose shouId be administered. The calculated dosage of gIucose, having been computed by an internist, shouId be given intravenousIy before the patient is taken to the operating room. Intravenous administration of isotonic saIine or glucose in saline solution combats surgicaI shock, prevents excessive faI1 in bIood pressure and promotes continuous renal function so vitally necessary for speedy recovery. It has been established that a transfusion of 500 cc. of whole, matched, compatible bIood should be administered immediately after operation. The genera1 condition of the patient, Ioss of bIood and evidence of shock has governed the further use of transfusions. Preoperative Filling of the Bladder. The question of whether or not to 611 the bladder immediateIy prior to operation is considered to be an individua1 probIem with each surgeon. It is beIieved that fiIIing of the bladder immediately before operation is to be preferred. Boric acid solution is empIoyed routineIy for this April,
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procedure. Inadvertent opening of the peritoneum is obviated and the proper site of incision in the bladder wal1 is more readiIy assured. Retraction of the peritoneum and other tissue is more readily accomplished when the bladder is fuII than when it is empty. The one great disadvantage to preoperative filling of the bIadder is the soiling of the freshIy incised tissues and the surrounding surgical Iinen by the intravesical fluid. This disadvantage may be eliminated by prompt suction withdrawal of the bIadder contents by a suction tube introduced into the bladder through the incision. The suction tube regularIy employed is of origina design and is connected directIy to the standard operating room suction apparatus. The suction tube is so constructed that large openings at the distal end permit rapid evacuation of the fluid from the bIadder. (Fig. 2.) The air necessary for proper suction is admitted by a series of vent holes in the upper extremity of the tube. There is no danger of injury to the mucous membrane and the fluid contents of the bIadder are rapidIy evacuated. Speed of Procedure. It is contended that operative procedures are rapid, efficient high13 essentia1 factors in prostat.ic surgery. The e1derIy patient with a Iarge prostate who has had a definite residual for months and who has impaired renal and cardiac function is far from a first class surgicai risk. Surgery should be done rapidI?, with the Ieast possibIe trauma and wrthout shock, to provide the greatest degree of safety. It has been repeatedly shown that these elderly patients, when subjected to excessive trauma or surgica1 shock, recover sIowIy and are aIways subject to intercurrent complications. A well established technic of surgical procedure, speediIy yet efflcientIy applied, is a factor of prime importance. Incision. It is contended that the smaIIest possibIe incision for efficient work, both in the skin and fascia and in the bladder, is to be preferred. Contrary to the genera1 belief that a Iong incision wiI1
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FIG. 2. Author’s design of suction apparatus used in the operating room for rapid evacuation of the bladder. The apparatus is so constructed that it is impossible to “suck up” the mucous membrane or Ioose tissue, yet the inner or delivery tube is of such caliber as to evacuate the bIadder rapidly. It is 34 inch in diameter and may be inserted into the bladder through a small incision without danger of trauma to the mucosa.
heaI as rapidIy as a short one suprapubic cystotomy incisions are frequently infected, may break down and become necrotic. This is particuIarIy true when rubber tube drainage is used. There has been onIy one wound infection during the years of use of the sump drain. It is further concluded that a midIine linear incision in the skin and fascia, not more than 2 to 2% inches in Iength, is most satisfactory. The incision, started at the upper most IeveI of the is continued upward symphysis pubis, toward the umbilicus. In depth the incision is continued through the subcutaneous tissue and sheath of the rectus muscIe without dissection. AI1 bIeeding points are Iigated before continuing. The fibers of the rectus muscIe are separated IongitudinaIIy. The reflection of the peritoneum over the bIadder is pushed upward aIong the midIine toward the umbiIicus. Care is exercised to avoid unnecessary reflection of the tissues on the IateraI walIs of the bladder. It has been found that it is not necessary to disturb those tissues Iying between the posterior surface of the symphysis and the bIadder waI1. The incision into the bIadder is made suffIcientIy Iarge to admit the index finger readiIy. The bladder is evacuated of its ffuid contents by suction
immediateIy after incision. Rapid suction prevents the wound from being ffushed with the’ Auid used for distention of the viscus. A suture of heavy braided siIk or chromic catgut is appIied at each extremity of the incision in the bIadder to prevent tearing of the incised bIadder wound during enucIeation. These sutures are of sufficient Iength to be used as retractors. The smaI1 incision in the bIadder may be readiIy extended shouId more exposure become necessary. Seldom is such a procedure required. Enucleation of the Prostate. The enucIeation of the prostate is best accompIished by the index finger rather than by mechanica1 contrivance. An assistant eIevates and steadies the prostate by pIacing a finger in the rectum. The individua1 Iobes of the prostate are enucIeated and are removed through the smaI1 incision in the bladder. EnucIeation may be begun by incision of the mucous membrane overlying the most prominent projecting portion of the prostatic mass or by spIitting the mucosa between the cIefts of the hypertrophied IateraI Iobes at the vertex of the vesica1 orifice. The pIexus of Santorini Iies at the vertex of the vesica1 orifice. ConsiderabIe hemorrhage may resuIt from
American Journal of Surgery
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41”
FIG. 3. Prostatic forceps of origina design. The Iong ratchet at the hilt permits grasping of a large lobe of the prostatic tissue by the curved, toothed, circular jaws of the instrument. The curve is such as to permit the rbpcr.t~r’s fingers to pass behind the instrument without interference in rnucleating the prostatic lobes in the dwp
inadvertant injury to the plexus by the The enucIeation is enucleating finger. accomplished by sweeping the index finger along the line of cleavage unti1 the hyperplastic tissue is entireIy detached from the capsule of the prostate. Some difficuhy in enucIeation is aIways encountered in the area of the verumontanum. This area is the most distant point which the enucleating finger endeavors to reach. Such dificulty of enucleation may be eased considerabIy by eIevation of the prostate with forceps. ConsiderabIe success in this difficuIt maneuver has been afforded by an especialIy devised forceps of original design. (Fig. 3.) These forceps have sufficient spread that the partialIS enucIeated tissue may be grasped firm.Iy and are of such a shape that they do not interfere with manipuIation of the enucleating finger. The free edge of the enucleated Drostatic lobe is ErasDed and upward traciion is made wfiIe ‘the enucIeating finger passes beneath the Iobe to free the dista1 margin. FoIlowing remova of the hyperpIastic April,
1949
tissue, the orifice of the prostatic cavity is visuaIIy examined. Any remaining tabs of tissue are removed leaving the prostatic capsuIe smooth. The immediate hemorrhage is controlled by compression. A gauze sponge saturated with hot saIine soIution and heId in spongeforceps is inserted into the prostatic cavity. The sponge is removed after severa minutes of compression and the cavity packed with a 2 inch plain gauze pack. Gauze packing for the contra1 of hemorrhage is to be preferred to the use of the PiIcher or Hagner bag when sump drainage is used. A short nosed catheter with a 75 CC. balloon has been satisfactorily used but the gauze pack is preferred. The pack is removed in stages twenty-four to forty-eight hours foIIowing operation. It has been demonstrated that considerabIe bIeeding may continue in some instances during the entire time the puck is in silu, but that the bIeeding will abate quickly foIlowing complete removal of the pack permitting contraction of the vesica1 orifice. It has been advocated by others that
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FIG. 4. Small tapered meta tube used in operating room to connect vesica1 sump drain to operating room suction apparatus in order to maintain a dry fieId during cIosure. FIG. 3. Author’s design of sump drain which is made of stainIess steel, 6 inches long, 10 mm. in diameter, with waIIs 0.013 inch in thickness. The apertures at the tip are 34 inch in diameter and are adequate to evacuate vesical contents. ThelhoIder, which is movable, may be adjusted so that the sump may be held at any desired depth within the bIadder. The sums mav be rotated but cannot be raised or lowered without bringing the two hoIes of the device into perfect alignment.
cIosure of the bIadder without packing in the prostatic cavity may be done safeIy. The procedure of not packing the prostatic cavity has not been attempted as yet with sump drainage. It is beIieved that it couId not be done in every instance but couId be done occasionaIIy without detrimenta resuIts. Closure. The sump tube is inserted into the bIadder immediateIy after the prostatic cavity is packed. Connection of the sump to the suction apparatus with which the operating room is ordinarily equipped is made by a tapered meta connecting tip having a Iarge caliber. (Fig. 4.) Continuous suction during cIosure assures a dry operative fieId as any mixture of bIood and urine is immediateIy withdrawn. The bIadder incision is cIosed IooseIy around the sump tube and the pack with interrupted chromic catgut sutures. It is imperative in the cIosure of the wound that the sump tube be introduced and maintained in a true vertica1 position. The sump tube hoIder to be applied Iater must Iie on the anterior abdomina1 waI1 in such a fashion as to maintain a vertica1 position of the sump. If the wound is cIosed with the sump at an angle, continuous pressure wiI1 be made on the bIadder waI1 by the end of the sump or pressure on the abdomen wiI1 be made by the thin edge of the hoIder.
FoIIowing insertion of the sump tube and cIosure of the bladder, the fibers of the rectus muscIe are aIso IooseIy approximated with chromic catgut sutures. The cut edges of the fascia are approximated with interrupted aIIoy stee1 sutures. The incised skin edges are aIso approximated with aIIoy stee1 sutures. It has been found by numerous investigators that s;eeI aIIoy sutures are not irritating to the tissue and Iessen the possibiIity of infection. The danger of incisiona hernia is reduced and the patient may be permitted out of bed more quickIy when aIIoy sutures are used. Drainage. Th e sump drain is considered to be superior to rubber tube drainage of the bIadder in the postoperative management of suprapubic prostatectomy. In onIy one instance in which sump drainage has been empIoyed has infection or necrosis of the wound occurred. Such a compIication is of common occurrence when rubber tube drainage is empIoyed. It is beIieved that the sump tube having the greatest utiIity is one made of aIIoy or rustIess stee1 of 0.015 inch in thickness. (Fig. 5.) Tubes of varying sizes may be used but experience has shown that the most serviceabIe for immediate postoperative drainage is a tube IO mm. in diameter and 6 inches in Iength. This has been found to be Iarge enough for efficient drainage. A tube 36 inch in diamAmerican
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6 7 FIG. 6. Shows component parts of the sump drain. AI1 parts arc readiiy demountable to permit cleaning and sterilization yet are assembled easily and quickly in the operating room. FIG;. 7. Small, short drain used in conjunction with postoperative catheter drainage. This drain is held in situ with adhesive straps across pIate beneath the surgical dressings.
eter was originaIIy suggested but was found to be unnecessarily Iarge. These sump tubes are so constructed that a series of >i inch hoIes >i inch apart are pIaced 35 inch from the rounded or distaI end of the tube. A second series of Iike apertures are placed ?i inch above the first series of hoIes. The centra1 or suction tube is x inch in diameter and is of sufficient Iength to rest on the floor of the interior of the sump tube. This >i inch diameter tube has been shown to be most efficient. There are two notches on the end of the suction tube which afford an aperture for constant suction. It has been Iearned by experience that a smaI1 centra1 or suction tube is inefficient. SmaII tubes have a tendency to become encrusted quickIy with urinary saIts and become cIogged or easiIy cIosed by bIood and bIood clots. It is imperative that the glass connecting tip used in connecting the sump with the exhaust bottIe at the bedside be a square cut tube rather than the gIass tapered tube so frequentIy empIoyed. The tapered tube tends to cIog too readily. Maintenance of the sump at any desired depth within the bIadder has been a difflcurt problem. It was formerIy recommended that the tube be supported by a loop of surgical tape. WhiIe this method was satisfactory in the majority of instances, the sump wouId occasionaIIy sIip April,
1949
out of the bIadder. AIthough not serious, such an accident necessitated undesired manipulation of the wound in order to replace the tube. FoIIowing considerabIe experimentation, a contrivance was devised capable of offering positive support to the sump at any depth desired within the bIadder. The contrivance consists of two discs, one Iarge and one smaI1, made from a singIe piece of stainIess aIIoy steel. (Fig. 6.) In each disc is a hoIe accurately bored to the size of the individua1 sump tube. The metal of the intervening bridge is bent so that the two hoIes are nearIy in true alignment. A sump tube introduced through the two hoIes shouId be held in the same fashion as a transom rod. The two hoIes in the pieces of meta must be brought into absolute true aIignment for the sump tube either to be raised or Iowered but may be readiIy turned at a11 times in a clockwise or countercIockwise direction. A second but larger aperture in the base plate of this contrivance permits the end of the pack to be brought through, aIlowing the support to rest squareIy on the abdominal wall. It is customary to remove the large IO mm. sump tube at the time of remova of the pack, twenty-four to forty-eight hours after operation, if no bIeeding occurs. An indweIIing urethra1 catheter is instituted after twenty-four hours of cIear drainage and a smaI1, short, sump drain is inserted
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removed and the void every hour. THE
FIG. 8. Shows a motor suction pump, standard hospitaI equipment for individual use. It utihzes I IO voIts, 60 cycles, A. C. current, is fulIy encased and is self-Iubricating. Amount of vacuum required is regulated by smaI1 upright valve on frame of casting.
MOTOR
patient
SUCTION
instructed
to
PUMP
The motor suction pump routineIy used in sump drainage is self-starting, nonreversabIe and noiseIess, operating onIy on ahernating current of I IO voIts, 60 cycles., The motor and a11 moving parts are fuIIy encased and properIy insuIated to prevent accident or shock at the bedside. (Fig. 8.) The motor, reduction gear and pump are seIf-lubricating and wiI1 run continuously without attention for a period of approximateIy two weeks. The motor operates at a set speed exerting a continuous negative pressure in the reservoir. This negative pressure is in turn exerted at the distal end
FIG. 9. CompIete assembIy of motor-pump unit. It is imperative that the capacity of the drainage bottle be greater than the daily urine excretion. Damage to motor unit may occur if urine is drawn into its mechanism.
into the wound. (Fig. 7.) This tube is I inch in Iength and is pIaced in the wound beneath the surgica1 dressings. The patient is then permitted out of bed in a chair. Damage to the wound wiI1 not occur if the surgica1 dressing becomes sIightIy damp at this time. This smaI1 sump is permitted to remain unti1 al1 suprapubic Ieakage has ceased. The urethra1 catheter is permitted to drain continuousIy unti1 the wound in the bIadder is firm. The catheter is then
of the suction tube within the sump drain. The tota vacuum capacity of the pump is not used but a contro1 vaIve is reguIated so that a continua1 minimum vacuum is used. The creation of excessive vacuum wouId cause trauma to the mucous membrane of the bIadder. It is imperative that the drainage bottIe used be of such capacity as to be greater than the urinary output of tweIve hours. (Fig. 9.) FIuid must not be permitted to be drawn into the pump.
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Drainage CARE
Immediate postoperative care has been shown to be an important factor in speedy recovery. The sump drain must be rotated at least twice a day to prevent “freezing” to the mucous membrance. For efficient drainage the suction tubes must be open at all times. It is beIieved that individua1 nursing personnel especiaIIy trained in the management of postoperative prostatic surgery constitutes one of the greatest aids in the recovery of these patients. Constant attention to detail and the comfort of the patient, by an effcient nurse who is capabIe of recognition of the earIy onset of any complication greatIy eIiminates some of the hazards of prostatic surgery. Immediate postoperative transfusion of compatibIe whoIe blood combats shock and blood loss and is routineIy employed. The need of subsequent transfusion is guided by the general condition of the patient and his reaction to surgery. Estimation of the Rh factor is important. Only that bIood which is compatibIe and of the same Rh factor should be used. Transfusion reactions should be avoided. Profuse secondary hemorrhage foIIowing removal of the pack occasionaIIy occurs and is considered to be due to the marked :rrteriosclerosis which is so frequently manilest in these patients. Such a hemorrhage may be severe and may quickIy reach dangerous proportions. Such a compIicat ion necessitates immediate compression of the prostatic bed, transfusions of whoIe blood and administration of supporting measures. It has been found that such a secondar), hemorrhage may be controlIed effectiveIF. by the introduction of a FoIey catheter Into the bIadder through the urethra. The baIIoon having a capacity of -3 cc. is recommended and may be fiIIed to an)- desired amount depending on the reIative size of the cavity. FoIIowing introduction, the bafIoon is distended and gentle but continuous traction is made on the catheter for a period of one to two hours. The tension or traction on the catheter may then be gradually released. The distending
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medium of the baIIoon is then graduaIIy reduced if no further bIeeding occurs. The catheter may be “tied in ” and permitted to drain. Excessive traction is never exerted nor is traction continued for Iong periods of time. DISADVANTAGES
OF
THE
SUMP
Sump drainage may only be accompIished and successfuIIy operated by mechanical contrivances which must be understood by the nursing and intern staff. The sump must be rotated at Ieast twice a day to free the bIadder mucosa from the apertures of the drain. If the mucosa is permitted to enter the hoIes of the sump the tube will “freeze” in position. If such a condition is permitted to occur, not only wiI1 the efficiency of the sump be impaired but it can onIy be removed by force. Such remova is done with considerabIe pain and discomfort to the patient. ForcefuI removal of the sump is accompanied with considerabIe bleeding as the mucous membrane, which has entered the hoIes of the tube is sheared off. Constant pain may be experienced by the patient if the sump is introduced too deepIy into the bladder in such a fashion as to permit the tube to rest or presss on the trigone. Such d iscomfort may be eliminated by eIevation of the tube from the floor of the bIadder. ADVANTAGES
OF
SUMP
DRAINAGE
The patient is kept dry continuously. The surgica1 dressing and bed clothing are never soiIed or wet. The danger of pneumonia is materiaIIy Iessened. Ulceration of the skin of the buttocks or abdomen by contact with urine is prevented. Healing occurs by primary intention due to the fact that the wound is continuousIy dry. Postoperative hospitalization is materiaIIy Iessened. It has been found that the average Iength of postoperative hospitaIization was 32.6 days when rubber tube drainage was used a& compared with an average of I 8.5 days when sump drainage was used. The meta sump is Iess irritating to the
422
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freshIy incised tissue than is a rubber tube. There is no chance for irritating or infected urine to foIIow along the fascia1 pIanes with uItimate necrosis of the wound so commonly observed when rubber tubing is used. It has been repeatedIy demonstrated that rustIess steel does not irritate the tissue nor cause the tissue to show Iocalized necrosis of the incised wound as is frequentIy evident when rubber tube drainage is used. The sump may be removed readily for evacuation of cIots from the bIadder in the event of hemorrhage from the prostatic bed. Reinsertion of the meta tube may be readiIy accompIished without pain or discomfort to the patient. Due to the constant evacuation of the bIadder contents there is IittIe chance of retrograde fiIIing of the ureters. The occurrence of pyeIonephritis has apparentIy been reduced. Only one instance of pyelonephritis has been observed in seven years of repeated use of the sump drain. This instance occurred in a debiIitated oId gentIeman who was known to have chronic leukemia. The tissue removed at operation showed Ieukemic infiItration; the bIood pic-
in Prostatectomy
ture changed rapidIy foIIowing The man died of pyeIonephritis a11 measures to contro1 it.
operation. in spite of
SUMMARY I. A meta sump drain for vesica1 drainage is presented. A new method of hoIding the sump at a desired depth within the vesica1 cavity is described. 2. The contrasting figures of hospitaIization between suprapubic rubber tube drainage and sump drainage have been shown. Postoperative hospitaIization was reduced from 32.6 days to an average of 18.5 days when sump drainage was used. 3. The suprapubic wound heaIs rapidIy due to the fact that the wound is continuousIy dry. Decubitus uIcerations do not occur as the bed Iinen is dry. 4. The occurrence of pyeIonephritis and pneumonia as postoperative compIications has apparentIy been reduced.
Acknowledgment: I am indebted to Mr. James Davies, Research Machinist, TempIe University Medical School, for his aid and suggestions in the design of each piece of this origina equipment as well as the making of the equipment in use.
American
Journal of Surgery
IN SUPRAPUBIC LOWRAIN E. MCCREA, l’bild~lphi~,
S
UMP drainage has been used in industria1 fieIds for many decades, but the principle has been appIied to surgery only in recent vears. The eff1cienc.y of sump drainage foIIoGing prostatectomy has been shown to be highly effective due to rapid recovery of the patient. Stedman advocated the use of sump drainage of the bladder and introduced a motor suction pump. Ritter, McCarthy and others have advocated, designed and successfully used vesical sump drainage for several years. Babcock perfected and has successfully used the sump drain for intraperitoneal postoperative drainage. He observed that sump drains made of gIass were effective, but there was always danger of breakage within the wound. The writer observed that \-esical drains made of plated metal had a tendency to corrode when in contact with urine and were found to become very irritating to the tissue. Drains constructed of rubber, although ideal in some respects, were also found to be irritating to the freshly incised tissue. This irritation is undoubtedly due to a chemica1 reaction of the urine on the rubber. Considerable experimentation with drains constructed of Iucite proved that such drains possessed many disadvantages and they were soon discarded. Babcock was the first to prove conclusively the advantages and successfully used the sump drain constructed of stainless steel for intraperitonea1 drainage. It was foIlowing his observations that the stainless steel sump for postoperative vesical drainage, which has been so successfully used, was designed. No inference is to be drawn by this con&ri
1, 1949
PROSTATECTOMY M.D.
I’enns~~lvani~l
tribution among the merits of suprapubic prostatectomy, perineal prostatectomy or transurethral resection. Each of these procedures has its own individual indications and surgica1 adherents. No attempt is made to compare these surgica1 procedures nor to compare their Iength of postoperative hospitaIization. Nor is it intended to incite controversy as to the advisability of the different types of operation. This contribution is intended to be a description of sump drainage as it is used in suprapubic prostatectomy and the management of the patient having prostatic hyperplasia. There has been no seIection of patients on whom sump drainage has been used, but rather it has been the selection of the proper sump drainage tube to be used on the individual patient. The principIe of sump drainage is the same regardless of the size or length of the tube. The speed with which wound healing by primary intention occurs, the complete comfort of the patient during its use, the decrease in postoperative complications and shortened hospitaIization have been supporting factors for continued tria1 and error procedures and technics in the attempted perfection of vesical sump drainage. A stainless stee1 drain for vesical drainage was originaIIy introduced in 1944. A subsequent model was presented in 1945. After repeated use an improved model of the drain was devised which is herein described. The sump drain is now empIoyed routinely at the time of operation in a11 instances of cystotomy even when permanent suprapubic drainage is to be instituted later. Positive, effective postopera411
412
McCrea-Sump
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in Prostatectomy
FIG. I. Schematic drawing of the various steps of suprapubic prostatectomy. E, shows the relative position of the Dack and the sumD drain: F (a and b). the closure of the bladder and rectus fascia around the sump tube; F (c), the side view of tie sump holder on &e abdominal wall.
tive vesica1 drainage is assured with its use. (Fig. I.) It has been proven concIusiveIy that vesica1 sump drainage materiaIIy shortens postoperative convaIescence. In a comparative study of unseIected cases it was found that the average postoperative convaIescence was 32.6 days in one institution and 27.5 days in another institution when rubber tube drainage was used foIIowing suprapubic prostatectomy. When sump drainage was used, the postoperative hospita1 stay in uncompIicated cases is usuaIIy eIeven to thirteen days. The shortest period of convaIescence foIIowing prostatectomy in which sump drainage was used was eight days. In many cases cardiac or renaI complications, so frequentIy encountered in patients with prostatic hypertrophy, impeded norma convaIescence. For this reason many patients were forced to remain or chose to remain in the hospita1 after wound heaIing had occurred. As a result the average time of hospitaIization
for al1 patients was found to be 18.5 days, Inasmuch as the number of postoperative hospita1 days is of materia1 economic importance, not onIy from the patient’s standpoint but aIso from the standpoint of efficient hospitaf administration, it is a factor worthy of much consideration. PREOPERATIVE
CARE
OF
THE
PROSTATIC
PATIENT
It is beIieved that one of the most important factors in the management of the prostatic patient is meticuIous preoperative care. In prostatic disease it is usua1 that the heart and kidneys show defmite impairment by the time the patient is presented for surgery. In many instances it may be said that the heart and kidneys are tired and exhausted. A definite pathoIogic condition exists in the majority of instances. The age of the patient contributes to arterioscIerotic changes. These changes are proportionateIy just as great in the smaIIer bIood vesseIs of the kidney as in American
Journal of Surgery
McCrea-Sump
Drainage
blood vessels of larger caliber. The liltration process of the kidney cells is hampered by the arteriosclerotic changes. Back pressure, created by the ever-present residua1 urine in varying amounts, causes further impairment of renaI function. Increased nitrogen retention in the blood and a diminution of the excretory function, as revealed by: phenoIsuIphonphthaIein excretion, occurs as a resuIt of this impairment. It has been shown that excretion of nitrogenous waste products is increased by the maintenance of a urinary output of 2,500 to 3,000 cc. daily-. It is imperative to maintain it as high as can be toIerated by the patient. The heart frequentI? shows the effects of the retention of toxms by being lveaker in tone than normaI or independent cardiac impairment may exist. Electrocardiographic study is imperative to establish definitely; the nature and extent of any cardiac impanment. Every proven cardiac impairment should be subjected to treatment before surgery is contempIated. Repeated determinations of bIood urea nitrogen and phenoIsuIphonphthaIein elimination should be made unti1 a return to normal or safe leveIs occurs. Such IeveIs occur following vesica1 drainage which is continued for varying lengths of time. Such drainage should be maintained either by a suprapubic tube or by a retained urethral catheter. Use of the indweIIing urethral catheter is preferred inasmuch as it permits greater freedom of action by permitting the patient to be ambulatory. Continuous preoperative bIadder drainage by retained catheter may be employed successfull?- in the majority of instances without fear of infection if diIigent, meticulous care of the catheter and the patient is maintained. The exceptional occurrence of continuous, severe, intravesical hemorrhage, the presence of large vesical calculi, severe vesical infIammation or, in certain instances, subcervical or posterior commissural hypertrophy may prevent satisfactor); use of the retained catheter. Any con&ion causing spastic irritabiIity of the bladder prevents use of the retained April,
I949
in Prostatectomy
413
catheter and requires cystotomy for preliminary drainage. It is beheved that long continued preoperative drainage by urethra1 catheter, even for a period of months in some instances if necessary, is essential to insure postoperative recovery. In those instances of Iong continued drainage the pH of the urine is maintained at a low level by- ora administration of sodium acid phosfate. An acid urine prevents the coIIection of urinary saIts on the catheter and Iessens the possibiIity of infection of the bIadder with BaciIIus proteus. Stabilization of the bIood urea nitrogen at normal IeveIs and eIevation of the percentage of excretion of phenoIsuIphonphthalein are imperative factors of adequate preoperative management. An unsatisfactory condition exists when the bIood urea nitrogen IeveIs are norma but the phenolsulphonphthaIein IeveIs of excretion are very low. It is obvious that the nearer the results of these tests approach norma levels the shorter the postoperative convalescence and the Iower the percentage of operative mortality. Operative accidents, such as cardiac failure, apoplexy, thrombosis or emboIus, occur occasionally in spite of the fact that every possible precaution has been taken before operation to prevent their occurrence. Fasting blood sugar determination shouId always be done during the preIiminary survey of the patient. It has been surprising to learn the number of eIderIy men who suffer not only with prostatism but aIso with diabetes. A proper diabetic regimen to estabIish normaI blood sugar Ievels should be instituted before surgery is contempIated. In a recent survey of one hundred consecutive individuals subjected to prostatectomy it was Iearned preoperatively that nine patients had diabetes without their knowledge. It is beIieved that indiscriminate haste in the preoperative preparation of the patient has and wiI1 account for needlessly high mortaIity in prostatectomy. In the early days of prostatic surgery the mortality was high, very high, but surgeons
414
McCrea-Sump
Drainage
of that time did not have at their command the advantages of modern Iaboratory methods. Nor did they have the knowIedge of the deIeterious effects of partial or compIete urinary retention as the factors producing high bIood urea nitrogen retention and excessiveIy Iow phenoIsulphonphthaIein excretion. In direct proportion with the progress made in estimating and estabIishing the patient’s preoperative condition by routine tests the mortaIity rate in prostatic surgery has decIined. At the present time it is a conceded practice that the patient be pIaced in the best possibIe physical condition before surgery is performed. If the patient’s condition is such that his tests do not indicate a return to norma IeveIs, operation is deferred. It is generaIIy conceded that the onestage suprapubic prostatectomy, foIIowing use of the retained catheter, is more easily performed than the two-stage procedure. The tissues are more readiIy pIiabIe, the heaIing of the wound is more secure and a shorter postoperative hospitaIization is usua1. It has been proven concIusiveIy that sump drainage of the bIadder foIIowing the one-stage procedure has decreased stiI1 further postoperative hospitalization. TECHNIC
Anesthesia. The seIection and use of the proper anesthesia is considered to be a very important factor in prostatic surgery. Each patient shouId be judged individuaIIy as to the type or kind of anesthesia to be used. It is a we11 estabIished fact that no one type of anesthesia may be used routineIy in prostatic patients. It has been demonstrated repeatedIy that eIderIy prostatic patients toIerate poorIy a sudden faI1 in bIood pressure during any type of anesthesia, particuIarIy protracted genera1 anesthesia. SpinaI anesthesia, using 75 to 80 mg. procaine IO per cent, administered in the fourth interspace, has been found to be most ideal in the majority of instances. The anesthesia attained by use of this drug is rapid and the effects of such a
in Prostatectomy
dosage continue for thirty to forty-five minutes, more than suflicient time to perform the average prostatectomy. The IeveI of anesthesia shouId be controIIedso that it does not extend higher than the IeveI of the umbiIicus. It has aIso been found that the postoperative reaction to surgery is better when the preoperative bIood pressure IeveI can be maintained at a11 times. One great disadvantage of spinal anesthesia is an untoward drop of blood pressure in the presence of cardiac impairment or in hypertension. It has been repeatedIy shown that a faI1 of bIood pressure, when spina anesthesia is used, is frequentIy foIIowed by cardiac or cerebral embarrassment which may be fata or leave permanent damage. Any decline of preoperative bIood pressure IeveIs may be combatted by intramuscuIar injection of such pressor substances as ephedrine 25 to 30 mg. or methadrine IO to 20 mg. The amount of the drug to be given is dependent on the bIood pressure IeveIs or the degree of hypertension. Further efforts to maintain preoperative bIood pressure IeveIs are made by intravenous administration of gIucose in saIine soIution given immediateIy foIIowing administration of the anesthetic. It has aIso been found that oxygen, IOO per cent by inhaIation, is another adjunct in the maintainance of preoperative blood pressure IeveIs. CaudaI-trans-sacra1 bIock, using 30 to 60 cc. procaine I per cent with IocaI infiItration of the abdomina1 waI1, has proved to be of merit in those instances in which a faI1 in bIood pressure wouId be especiaIIy detrimenta to the patient. It is beIieved that either spina anesthesia or caudaI-trans-sacra1 bIock permit a rapid “come-back” so essentia1 to patients if morbidity is to be a considered factor of convaIescence. Intravenous Therapy. The percentage of hemogIobin is used as an index for the preoperative administration of whoIe blood. It is beIieved that any individua1 having marked secondary anemia or who is anemic foIIowing profuse intravesica1 hemorrhage shouId receive repeated transfusions of American
Journal
of Surgery
McCrea-Sump
Drainage
whoIe blood to compensate for the blood loss during the preoperative preparation. It is further believed that administration of koagamin, a compound of oxalic acid and other di-carboxyIic acids, aids materially in increasing coaguIation time. The drug has been routinely administered one hour before operation and has been given GmuItaneousIy in z cc. doses both intravenous17 and intramuscuIarIy. The drug has agam been given in 3 cc. doses intravenously and intramuscuIarIy immediateIy after operation and repeated in such dosage after three hours. The drug has been further employed in 3 cc. doses intravenously and intramuscularly administered prior to removal of the pack from the prostatic cavity. It has been found that intravenous administration of 5 per cent glucose in isotonic saIine soIution begun immediateIy following administration of the anesthetic, except in diabetics, aids materiaIIy in maintaining preoperative blood pressure IeveIs. In the presence of diabetes isotonic saIine soIution without glucose shouId be administered. The calculated dosage of gIucose, having been computed by an internist, shouId be given intravenousIy before the patient is taken to the operating room. Intravenous administration of isotonic saIine or glucose in saline solution combats surgicaI shock, prevents excessive faI1 in bIood pressure and promotes continuous renal function so vitally necessary for speedy recovery. It has been established that a transfusion of 500 cc. of whole, matched, compatible bIood should be administered immediately after operation. The genera1 condition of the patient, Ioss of bIood and evidence of shock has governed the further use of transfusions. Preoperative Filling of the Bladder. The question of whether or not to 611 the bladder immediateIy prior to operation is considered to be an individua1 probIem with each surgeon. It is beIieved that fiIIing of the bladder immediately before operation is to be preferred. Boric acid solution is empIoyed routineIy for this April,
1949
in Prostatectomy
415
procedure. Inadvertent opening of the peritoneum is obviated and the proper site of incision in the bladder wal1 is more readiIy assured. Retraction of the peritoneum and other tissue is more readily accomplished when the bladder is fuII than when it is empty. The one great disadvantage to preoperative filling of the bIadder is the soiling of the freshIy incised tissues and the surrounding surgical Iinen by the intravesical fluid. This disadvantage may be eliminated by prompt suction withdrawal of the bIadder contents by a suction tube introduced into the bladder through the incision. The suction tube regularIy employed is of origina design and is connected directIy to the standard operating room suction apparatus. The suction tube is so constructed that large openings at the distal end permit rapid evacuation of the fluid from the bIadder. (Fig. 2.) The air necessary for proper suction is admitted by a series of vent holes in the upper extremity of the tube. There is no danger of injury to the mucous membrane and the fluid contents of the bIadder are rapidIy evacuated. Speed of Procedure. It is contended that operative procedures are rapid, efficient high13 essentia1 factors in prostat.ic surgery. The e1derIy patient with a Iarge prostate who has had a definite residual for months and who has impaired renal and cardiac function is far from a first class surgicai risk. Surgery should be done rapidI?, with the Ieast possibIe trauma and wrthout shock, to provide the greatest degree of safety. It has been repeatedly shown that these elderly patients, when subjected to excessive trauma or surgica1 shock, recover sIowIy and are aIways subject to intercurrent complications. A well established technic of surgical procedure, speediIy yet efflcientIy applied, is a factor of prime importance. Incision. It is contended that the smaIIest possibIe incision for efficient work, both in the skin and fascia and in the bladder, is to be preferred. Contrary to the genera1 belief that a Iong incision wiI1
416
McCrea-Sump
Drainage
in Prostatectomy
FIG. 2. Author’s design of suction apparatus used in the operating room for rapid evacuation of the bladder. The apparatus is so constructed that it is impossible to “suck up” the mucous membrane or Ioose tissue, yet the inner or delivery tube is of such caliber as to evacuate the bIadder rapidly. It is 34 inch in diameter and may be inserted into the bladder through a small incision without danger of trauma to the mucosa.
heaI as rapidIy as a short one suprapubic cystotomy incisions are frequently infected, may break down and become necrotic. This is particuIarIy true when rubber tube drainage is used. There has been onIy one wound infection during the years of use of the sump drain. It is further concluded that a midIine linear incision in the skin and fascia, not more than 2 to 2% inches in Iength, is most satisfactory. The incision, started at the upper most IeveI of the is continued upward symphysis pubis, toward the umbilicus. In depth the incision is continued through the subcutaneous tissue and sheath of the rectus muscIe without dissection. AI1 bIeeding points are Iigated before continuing. The fibers of the rectus muscIe are separated IongitudinaIIy. The reflection of the peritoneum over the bIadder is pushed upward aIong the midIine toward the umbiIicus. Care is exercised to avoid unnecessary reflection of the tissues on the IateraI walIs of the bladder. It has been found that it is not necessary to disturb those tissues Iying between the posterior surface of the symphysis and the bIadder waI1. The incision into the bIadder is made suffIcientIy Iarge to admit the index finger readiIy. The bladder is evacuated of its ffuid contents by suction
immediateIy after incision. Rapid suction prevents the wound from being ffushed with the’ Auid used for distention of the viscus. A suture of heavy braided siIk or chromic catgut is appIied at each extremity of the incision in the bIadder to prevent tearing of the incised bIadder wound during enucIeation. These sutures are of sufficient Iength to be used as retractors. The smaI1 incision in the bIadder may be readiIy extended shouId more exposure become necessary. Seldom is such a procedure required. Enucleation of the Prostate. The enucIeation of the prostate is best accompIished by the index finger rather than by mechanica1 contrivance. An assistant eIevates and steadies the prostate by pIacing a finger in the rectum. The individua1 Iobes of the prostate are enucIeated and are removed through the smaI1 incision in the bladder. EnucIeation may be begun by incision of the mucous membrane overlying the most prominent projecting portion of the prostatic mass or by spIitting the mucosa between the cIefts of the hypertrophied IateraI Iobes at the vertex of the vesica1 orifice. The pIexus of Santorini Iies at the vertex of the vesica1 orifice. ConsiderabIe hemorrhage may resuIt from
American Journal of Surgery
McCrea-Sump
Drainage
in Prostatectomy
41”
FIG. 3. Prostatic forceps of origina design. The Iong ratchet at the hilt permits grasping of a large lobe of the prostatic tissue by the curved, toothed, circular jaws of the instrument. The curve is such as to permit the rbpcr.t~r’s fingers to pass behind the instrument without interference in rnucleating the prostatic lobes in the dwp
inadvertant injury to the plexus by the The enucIeation is enucleating finger. accomplished by sweeping the index finger along the line of cleavage unti1 the hyperplastic tissue is entireIy detached from the capsule of the prostate. Some difficuhy in enucIeation is aIways encountered in the area of the verumontanum. This area is the most distant point which the enucleating finger endeavors to reach. Such dificulty of enucleation may be eased considerabIy by eIevation of the prostate with forceps. ConsiderabIe success in this difficuIt maneuver has been afforded by an especialIy devised forceps of original design. (Fig. 3.) These forceps have sufficient spread that the partialIS enucIeated tissue may be grasped firm.Iy and are of such a shape that they do not interfere with manipuIation of the enucleating finger. The free edge of the enucleated Drostatic lobe is ErasDed and upward traciion is made wfiIe ‘the enucIeating finger passes beneath the Iobe to free the dista1 margin. FoIlowing remova of the hyperpIastic April,
1949
tissue, the orifice of the prostatic cavity is visuaIIy examined. Any remaining tabs of tissue are removed leaving the prostatic capsuIe smooth. The immediate hemorrhage is controlled by compression. A gauze sponge saturated with hot saIine soIution and heId in spongeforceps is inserted into the prostatic cavity. The sponge is removed after severa minutes of compression and the cavity packed with a 2 inch plain gauze pack. Gauze packing for the contra1 of hemorrhage is to be preferred to the use of the PiIcher or Hagner bag when sump drainage is used. A short nosed catheter with a 75 CC. balloon has been satisfactorily used but the gauze pack is preferred. The pack is removed in stages twenty-four to forty-eight hours foIIowing operation. It has been demonstrated that considerabIe bIeeding may continue in some instances during the entire time the puck is in silu, but that the bIeeding will abate quickly foIlowing complete removal of the pack permitting contraction of the vesica1 orifice. It has been advocated by others that
McCrea-Sump
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Drainage
4
in Prostatectomy
5
FIG. 4. Small tapered meta tube used in operating room to connect vesica1 sump drain to operating room suction apparatus in order to maintain a dry fieId during cIosure. FIG. 3. Author’s design of sump drain which is made of stainIess steel, 6 inches long, 10 mm. in diameter, with waIIs 0.013 inch in thickness. The apertures at the tip are 34 inch in diameter and are adequate to evacuate vesical contents. ThelhoIder, which is movable, may be adjusted so that the sump may be held at any desired depth within the bIadder. The sums mav be rotated but cannot be raised or lowered without bringing the two hoIes of the device into perfect alignment.
cIosure of the bIadder without packing in the prostatic cavity may be done safeIy. The procedure of not packing the prostatic cavity has not been attempted as yet with sump drainage. It is beIieved that it couId not be done in every instance but couId be done occasionaIIy without detrimenta resuIts. Closure. The sump tube is inserted into the bIadder immediateIy after the prostatic cavity is packed. Connection of the sump to the suction apparatus with which the operating room is ordinarily equipped is made by a tapered meta connecting tip having a Iarge caliber. (Fig. 4.) Continuous suction during cIosure assures a dry operative fieId as any mixture of bIood and urine is immediateIy withdrawn. The bIadder incision is cIosed IooseIy around the sump tube and the pack with interrupted chromic catgut sutures. It is imperative in the cIosure of the wound that the sump tube be introduced and maintained in a true vertica1 position. The sump tube hoIder to be applied Iater must Iie on the anterior abdomina1 waI1 in such a fashion as to maintain a vertica1 position of the sump. If the wound is cIosed with the sump at an angle, continuous pressure wiI1 be made on the bIadder waI1 by the end of the sump or pressure on the abdomen wiI1 be made by the thin edge of the hoIder.
FoIIowing insertion of the sump tube and cIosure of the bladder, the fibers of the rectus muscIe are aIso IooseIy approximated with chromic catgut sutures. The cut edges of the fascia are approximated with interrupted aIIoy stee1 sutures. The incised skin edges are aIso approximated with aIIoy stee1 sutures. It has been found by numerous investigators that s;eeI aIIoy sutures are not irritating to the tissue and Iessen the possibiIity of infection. The danger of incisiona hernia is reduced and the patient may be permitted out of bed more quickIy when aIIoy sutures are used. Drainage. Th e sump drain is considered to be superior to rubber tube drainage of the bIadder in the postoperative management of suprapubic prostatectomy. In onIy one instance in which sump drainage has been empIoyed has infection or necrosis of the wound occurred. Such a compIication is of common occurrence when rubber tube drainage is empIoyed. It is beIieved that the sump tube having the greatest utiIity is one made of aIIoy or rustIess stee1 of 0.015 inch in thickness. (Fig. 5.) Tubes of varying sizes may be used but experience has shown that the most serviceabIe for immediate postoperative drainage is a tube IO mm. in diameter and 6 inches in Iength. This has been found to be Iarge enough for efficient drainage. A tube 36 inch in diamAmerican
Journal of Surgery
McCrea-Sump
Drainage
in Prostatectomy
6 7 FIG. 6. Shows component parts of the sump drain. AI1 parts arc readiiy demountable to permit cleaning and sterilization yet are assembled easily and quickly in the operating room. FIG;. 7. Small, short drain used in conjunction with postoperative catheter drainage. This drain is held in situ with adhesive straps across pIate beneath the surgical dressings.
eter was originaIIy suggested but was found to be unnecessarily Iarge. These sump tubes are so constructed that a series of >i inch hoIes >i inch apart are pIaced 35 inch from the rounded or distaI end of the tube. A second series of Iike apertures are placed ?i inch above the first series of hoIes. The centra1 or suction tube is x inch in diameter and is of sufficient Iength to rest on the floor of the interior of the sump tube. This >i inch diameter tube has been shown to be most efficient. There are two notches on the end of the suction tube which afford an aperture for constant suction. It has been Iearned by experience that a smaI1 centra1 or suction tube is inefficient. SmaII tubes have a tendency to become encrusted quickIy with urinary saIts and become cIogged or easiIy cIosed by bIood and bIood clots. It is imperative that the glass connecting tip used in connecting the sump with the exhaust bottIe at the bedside be a square cut tube rather than the gIass tapered tube so frequentIy empIoyed. The tapered tube tends to cIog too readily. Maintenance of the sump at any desired depth within the bIadder has been a difflcurt problem. It was formerIy recommended that the tube be supported by a loop of surgical tape. WhiIe this method was satisfactory in the majority of instances, the sump wouId occasionaIIy sIip April,
1949
out of the bIadder. AIthough not serious, such an accident necessitated undesired manipulation of the wound in order to replace the tube. FoIIowing considerabIe experimentation, a contrivance was devised capable of offering positive support to the sump at any depth desired within the bIadder. The contrivance consists of two discs, one Iarge and one smaI1, made from a singIe piece of stainIess aIIoy steel. (Fig. 6.) In each disc is a hoIe accurately bored to the size of the individua1 sump tube. The metal of the intervening bridge is bent so that the two hoIes are nearIy in true alignment. A sump tube introduced through the two hoIes shouId be held in the same fashion as a transom rod. The two hoIes in the pieces of meta must be brought into absolute true aIignment for the sump tube either to be raised or Iowered but may be readiIy turned at a11 times in a clockwise or countercIockwise direction. A second but larger aperture in the base plate of this contrivance permits the end of the pack to be brought through, aIlowing the support to rest squareIy on the abdominal wall. It is customary to remove the large IO mm. sump tube at the time of remova of the pack, twenty-four to forty-eight hours after operation, if no bIeeding occurs. An indweIIing urethra1 catheter is instituted after twenty-four hours of cIear drainage and a smaI1, short, sump drain is inserted
420
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in Prostatectomy
removed and the void every hour. THE
FIG. 8. Shows a motor suction pump, standard hospitaI equipment for individual use. It utihzes I IO voIts, 60 cycles, A. C. current, is fulIy encased and is self-Iubricating. Amount of vacuum required is regulated by smaI1 upright valve on frame of casting.
MOTOR
patient
SUCTION
instructed
to
PUMP
The motor suction pump routineIy used in sump drainage is self-starting, nonreversabIe and noiseIess, operating onIy on ahernating current of I IO voIts, 60 cycles., The motor and a11 moving parts are fuIIy encased and properIy insuIated to prevent accident or shock at the bedside. (Fig. 8.) The motor, reduction gear and pump are seIf-lubricating and wiI1 run continuously without attention for a period of approximateIy two weeks. The motor operates at a set speed exerting a continuous negative pressure in the reservoir. This negative pressure is in turn exerted at the distal end
FIG. 9. CompIete assembIy of motor-pump unit. It is imperative that the capacity of the drainage bottle be greater than the daily urine excretion. Damage to motor unit may occur if urine is drawn into its mechanism.
into the wound. (Fig. 7.) This tube is I inch in Iength and is pIaced in the wound beneath the surgica1 dressings. The patient is then permitted out of bed in a chair. Damage to the wound wiI1 not occur if the surgica1 dressing becomes sIightIy damp at this time. This smaI1 sump is permitted to remain unti1 al1 suprapubic Ieakage has ceased. The urethra1 catheter is permitted to drain continuousIy unti1 the wound in the bIadder is firm. The catheter is then
of the suction tube within the sump drain. The tota vacuum capacity of the pump is not used but a contro1 vaIve is reguIated so that a continua1 minimum vacuum is used. The creation of excessive vacuum wouId cause trauma to the mucous membrane of the bIadder. It is imperative that the drainage bottIe used be of such capacity as to be greater than the urinary output of tweIve hours. (Fig. 9.) FIuid must not be permitted to be drawn into the pump.
American Journal of Surgery
McCrea-Sump IMMEDIATE
POSTOPERATIVE
Drainage CARE
Immediate postoperative care has been shown to be an important factor in speedy recovery. The sump drain must be rotated at least twice a day to prevent “freezing” to the mucous membrance. For efficient drainage the suction tubes must be open at all times. It is beIieved that individua1 nursing personnel especiaIIy trained in the management of postoperative prostatic surgery constitutes one of the greatest aids in the recovery of these patients. Constant attention to detail and the comfort of the patient, by an effcient nurse who is capabIe of recognition of the earIy onset of any complication greatIy eIiminates some of the hazards of prostatic surgery. Immediate postoperative transfusion of compatibIe whoIe blood combats shock and blood loss and is routineIy employed. The need of subsequent transfusion is guided by the general condition of the patient and his reaction to surgery. Estimation of the Rh factor is important. Only that bIood which is compatibIe and of the same Rh factor should be used. Transfusion reactions should be avoided. Profuse secondary hemorrhage foIIowing removal of the pack occasionaIIy occurs and is considered to be due to the marked :rrteriosclerosis which is so frequently manilest in these patients. Such a hemorrhage may be severe and may quickIy reach dangerous proportions. Such a compIicat ion necessitates immediate compression of the prostatic bed, transfusions of whoIe blood and administration of supporting measures. It has been found that such a secondar), hemorrhage may be controlIed effectiveIF. by the introduction of a FoIey catheter Into the bIadder through the urethra. The baIIoon having a capacity of -3 cc. is recommended and may be fiIIed to an)- desired amount depending on the reIative size of the cavity. FoIIowing introduction, the bafIoon is distended and gentle but continuous traction is made on the catheter for a period of one to two hours. The tension or traction on the catheter may then be gradually released. The distending
April, I+~J
in Prostatectomy
421
medium of the baIIoon is then graduaIIy reduced if no further bIeeding occurs. The catheter may be “tied in ” and permitted to drain. Excessive traction is never exerted nor is traction continued for Iong periods of time. DISADVANTAGES
OF
THE
SUMP
Sump drainage may only be accompIished and successfuIIy operated by mechanical contrivances which must be understood by the nursing and intern staff. The sump must be rotated at Ieast twice a day to free the bIadder mucosa from the apertures of the drain. If the mucosa is permitted to enter the hoIes of the sump the tube will “freeze” in position. If such a condition is permitted to occur, not only wiI1 the efficiency of the sump be impaired but it can onIy be removed by force. Such remova is done with considerabIe pain and discomfort to the patient. ForcefuI removal of the sump is accompanied with considerabIe bleeding as the mucous membrane, which has entered the hoIes of the tube is sheared off. Constant pain may be experienced by the patient if the sump is introduced too deepIy into the bladder in such a fashion as to permit the tube to rest or presss on the trigone. Such d iscomfort may be eliminated by eIevation of the tube from the floor of the bIadder. ADVANTAGES
OF
SUMP
DRAINAGE
The patient is kept dry continuously. The surgica1 dressing and bed clothing are never soiIed or wet. The danger of pneumonia is materiaIIy Iessened. Ulceration of the skin of the buttocks or abdomen by contact with urine is prevented. Healing occurs by primary intention due to the fact that the wound is continuousIy dry. Postoperative hospitalization is materiaIIy Iessened. It has been found that the average Iength of postoperative hospitaIization was 32.6 days when rubber tube drainage was used a& compared with an average of I 8.5 days when sump drainage was used. The meta sump is Iess irritating to the
422
McCrea-Sump
Drainage
freshIy incised tissue than is a rubber tube. There is no chance for irritating or infected urine to foIIow along the fascia1 pIanes with uItimate necrosis of the wound so commonly observed when rubber tubing is used. It has been repeatedIy demonstrated that rustIess steel does not irritate the tissue nor cause the tissue to show Iocalized necrosis of the incised wound as is frequentIy evident when rubber tube drainage is used. The sump may be removed readily for evacuation of cIots from the bIadder in the event of hemorrhage from the prostatic bed. Reinsertion of the meta tube may be readiIy accompIished without pain or discomfort to the patient. Due to the constant evacuation of the bIadder contents there is IittIe chance of retrograde fiIIing of the ureters. The occurrence of pyeIonephritis has apparentIy been reduced. Only one instance of pyelonephritis has been observed in seven years of repeated use of the sump drain. This instance occurred in a debiIitated oId gentIeman who was known to have chronic leukemia. The tissue removed at operation showed Ieukemic infiItration; the bIood pic-
in Prostatectomy
ture changed rapidIy foIIowing The man died of pyeIonephritis a11 measures to contro1 it.
operation. in spite of
SUMMARY I. A meta sump drain for vesica1 drainage is presented. A new method of hoIding the sump at a desired depth within the vesica1 cavity is described. 2. The contrasting figures of hospitaIization between suprapubic rubber tube drainage and sump drainage have been shown. Postoperative hospitaIization was reduced from 32.6 days to an average of 18.5 days when sump drainage was used. 3. The suprapubic wound heaIs rapidIy due to the fact that the wound is continuousIy dry. Decubitus uIcerations do not occur as the bed Iinen is dry. 4. The occurrence of pyeIonephritis and pneumonia as postoperative compIications has apparentIy been reduced.
Acknowledgment: I am indebted to Mr. James Davies, Research Machinist, TempIe University Medical School, for his aid and suggestions in the design of each piece of this origina equipment as well as the making of the equipment in use.
American
Journal of Surgery