- Email: [email protected]
Surgical endothermy in suprapubic prostatectomy
SURGICAL
ENDOTHERMY IN SUPRAPUBIC PROSTATECTOMY * PAUL W. ASCHNER, M.D., F.A.C.S. NEW YORK
q an anaIysis of a series of 277 suprapubic prostatectomies, 44 performed in one step and 233 in two steps, the
favored secondary hemorrhage. Despite transurethra1 irrigation and carefu1 remova1 of the gauze it has been my experi-
FIG. I.
FIG. 2.
most frequent compIications entaiIed by the disease process and the operative procedure for its cure were as foIIows: renaI insuffIciency, renaI infection, hemorrhage, epididymo-orchitis, vesica1 infection, deIayed heaIing of the fistuIa, and secondary stenosis of the vesica1 neck.l To combat renaI insuffIciency and infection catheter drainage or cystostomy was empIoyed. Catheter drainage carried with it the risk of epididymo-orchitis. Cystostomy necessitated a bIind enucIeation of the adenomatous mass at a second stage. For the contro1 of bIeeding surgica1 measures were impossibIe and reIiance was pIaced upon gauze packing of the prostatic bed. WhiIe this usuaIIy Iessened immediate bIeeding it
ence that hemorrhage has occurred al1 too frequentIy from one to ten days Iater, requiring repacking of the prostatic bed. OccasionaIIy the remove1 of the second packing has been foIlowed subsequentjy by renewed bIeeding. It is my firm conviction that the eIement of infection pIays an important rBIe in these secondary hemorrhages and that packing introduced into the prostatic bed and bIadder is conducive thereto. It is probabIy a factor in the other phenomena of infection, nameIy intense cystitis which may be gangrenous or diphtheritic, and viruIent ascending infection of the ureters, peIves and renaI parenchyma. It may aIso be responsibIe for bIockage of the ejacuIatory ducts and infection of the epididymes. Blind laceration of
‘Aschner,
P. W. J. Ural., 12: 251, 1924. * Submitted
for pubIication
321
May 8, 1931.
322
American Journal of Surgery
Aschner-SurgicaI
the vesica1 mucosa, the Ieaving of Ioose tabs, the faiIure to properIy reconstruct the vesica1 neck and the fear of passing instru-
FIG. 3.
ments through the urethra are responsibIe for the occurrence of Iate obstructing stenoses, even compIete occIusions at the upper end of the prostatic pouch. To overcome these various compIications of the surgery of benign prostatic adenomatous hypertrophy I have graduaIIy deveIoped the foIIowing course of procedure. The tentative diagnosis of obstructing hypertrophy having been made by history and physica examination, incIuding the demonstration of residua1 urine amounting to 120 C.C. or more, the patient is admitted to the hospita1. Under IocaI infiItration anaIgesia, a smaI1 incision is made just beIow either externa1 ring, the spermatic cord deIivered, and vas deferens isoIated and about haIf an inch resected between catgut Iigatures on both sides. Hemostasis being meticuIousIy assured, the wounds are cIosed with siIk and a smaI1 ~gauze coIIodion dressing appIied. FaiIure to attend to hemostasis may resuIt in an enormous hematoma of the scrotum.
Endothermy
FEBRUARY. 193~.
A soft rubber indweIIing catheter is now pIaced to secure vesica1 drainage. If there is great retention gradua1 decompression shouId be carried out. BIadder irrigation twice daiIy and changing of the catheter every fourth day after proper urethra1 irrigation are ordered, There need be no fear of epididymitis, as the vas resection prevents it. The usua1 functiona studies are now made. X-ray examination and cystography are carried out in every case to excIude caIcuIus and diverticuIum. The cystogram wiI1 aIso indicate the degree of prostatic encroachment upon the bIadder neck. Cystoscopy gives further information as to the prostate and bIadder, and the intravenous injection of indigo carmine permits observations upon the renaI function and uretera patency. It is inadvisabIe to catheterize the ureters unIess supravesica1 caIcuIus is suspected. Intravenous urography (Swick’s method) wiI1 give much knowIedge of the state of the kidneys and ureters. VesicaI drainage having been maintained for seven to ten days and there being no functiona or pathoIogica1 contraindications, the sutures are removed from the inguina1 wounds and the prostatectomy is proceeded with. AnaIgesia is obtained either by combination of sacra1 nerve bIock (epidura1) and abdomina1 waI1 infiItration or by Iow subdura1 injection of neocaine, I00 mg., or nupercaine I0 mg. My own preference is for neocaine spina anaIgesia as the proIonged action of nuperCaine is not necessary here. The indifferent (Iarge) eIectrode of the endotherm apparatus is pIaced under the buttocks and sacra1 region. A 5 inch median hypogastric incision is made, the Iinea aIba is incised and the peritoneum stripped back from the distended bIadder. Guy sutures being passed the water is aIIowed to empty out through the catheter. The bIadder is now opened IiberaIIy in the midIine of its anterior aspect and its interior inspected. This incision may be made with the scaIpe1 or the endotherm knife. The seIf-retaining Judd BaI-
Aschner-SurgicaI
New SERIES VOL. XV, No. z
four retractor is pIaced. A broad fIexibIe ribbon retractor over a packing hoIds the posterior waII taut. A narrow ribbon re-
FIG.
4.
tractor exposes the anterior commissure of the interna urethra1 orifice, ‘and the catheter is now ordered withdrawn (Fig. I). With the endotherm needIe the anterior commissure is divided and an appropriate incision made through the mucosa overIying the projecting prostate and circumcising the urethra1 orifice. This incision is carried down to the prostatic capsuIe (Fig. 2). A tenacuIum is appIied to the prostate and with gentIe traction the mass is enucIeated under direct vision using a cIosed bIunt curved scissors as a dissector (Fig. 3). As much of the Iower part of the posterior urethra is preserved as is possibIe; it is cut across with the endotherm knife. By the use of AIIis forceps to hoId open the vesica1 mucosa rimming the cavity, bIeeding vesseIs are caught with Iong artery forceps and immediateIy seaIed by touching the forceps with the endotherm needIe (Fig. 4). It is not necessary to change the type of current employed. Tabs of tissue are also readiIy removed with this cutting needIe. Hemostasis being secured in this manner the cut edge of vesical mucosa with its underIying muscuIaris is sutured down into the prostatic cavity, bringing the mucosa
Endothermy
American Journal of Surgery
323
down to that of the urethral stump but not attempting to pass sutures through the Iatter. The first suture brings down the
FIG. 3.
posterior margin (6 o’cIock) using a mattress stitch of zero catgut. One on either
FIG. 6.
side (3 and g o’cIock) compIetes the repair converting the prostatic pouch into a funneI wide open above and Ieading to the
324
Americnn
Journal
of Surgery
Aschner-SurgicaI
urethra1 stump (Fig. 5). No bag or packing is used. Hunt, Deaver, Thomson-WaIker and Lower use Iigatures for bIeeding vessels in the prostatic bed, but eIectrocoaguIation is much simpIer. Hunt inserts a bag for further hemostasis but I see no necessity for this and it may.be harmful. Lower approximates the vesica1 mucosa1 rim from side to side Ieaving just room enough for a urethra1 catheter, but this, I believe, tends to convert the prostatic cavity and bIadder into an hourgIass form. It is preferabIe to convert the prostatic cavity into a funneI, wide open above and tapering down to the urethra (Fig. 6.) as is done by Hunt, Deaver and Thomson-WaJker. The bIadder is now cIosed with interrupted pIain catgut sutures around a tube 1.5 cm. in diameter Ied out from the vertex of the bIadder. Reinforcing sutures of chromic catgut are then pIaced approximating the outer Iayers of the bIadder waI1. A packing to the space of Retzius, and another to the peritonea1 reffection are inserted and the abdomina1 waI1 cIosed about the drains. A week Iater the tube
REFERENCES 5. MAGNUSON,P. B., and COULTER, J. S. Compression
fracture of the spine with referred pain, Ioss of balance and Iow back pain. Znternat. Clin., I I I : IOO--10s.1420: Compression fracture of the spine compIicated by many things. Ibid., I I I: of the fifth Iumbar 117-I IO. 1020: Fracture vertebra w$h injury to the cauda equina. Ibid., I I I : 120-124, 1920. 6. KIRCHNER, W. C. G. Surg. Gynec. Obst., 36:830, 1923. 7. OSGOOD,R. B. J. A.M. 8. DAVIS. A. G. Fractures 9.
IO. II.
12.
13. 14.
15.
16.
Endothermy
FEBRUARY.rojz
and packings are removed and a urethral catheter may be inserted as before operation. Irrigation is then used onIy to maintain free drainage. The wound is found to cIose compIeteIy in from fourteen to twenty-one days. There has been no more bIeeding than is frequentIy seen after simpIe cystostomy. In one of the earlier cases, not having compIete confidence in the procedure as a preventive of bIeeding, I pIaced a packing in the funne1 area. This patient was sIow in heaIing and Iater deveIoped some stenosis. The worst risk was a man of seventy-one with bIood urea of go mg. and bIood sugar of 500 mg. on admission with compIete retention. The procedure is not appIicabIe to those patients in whom indweIIing catheter drainage cannot be empIoyed and in whom cystostomy must be resorted to for adequate preparation. The presence of vesica1 caIcuIi aIso necessitates the two-stage procedure. In the event that a two-step prostatectomy is necessary packing of the prostatic bed may be frequentIy dispensed with, and shouId be avoided whenever possible.
OF
DR.
DAVIS*
SPGED, K. Compression fracture of the dorsofumbar vertebrae, pathoIogy and treatment. S. Clin. North America, 3: 1083, 1923. 18. MIXTER, W. J. J. Bone ti Joint Surg., 5: 21, 1923. 19. BURRELL and CRANDON. Tr. Am. Surg. Ass., 1905. 20. HOY, C. DA C. Fractures of the Iumbar spine. Znternat. C&n., 4: 245-280, 1924. 21. ALLEN, A. R. Injuries of spinal cord. J. A. M. A., 50: 940, 1908. Iaminectomy for 22. ELSBERG, C. A. Exploratory fracture disIocation of the spine. Internat. Clin., II: 73. 23. ELSBERG, C. A. Some surgica1 features of injuries of the spine, with specia1 reference to spinal fracture. Ann. Surg., 58: 206, 1913. 24. ALLEN, A. R. J. A. M. A., rgrr. 25. FRAZIER, C. H., and ALI.EN, A. R. Surgery of Spine and SpinaI Cord. N. Y., AppIeton, 1918, pp. 8449-8450. 26. WILSON, G. E. Canada M. A. J., p. 1054, 1911. 27. BUZZARD, F., and SARGENT, P. In: Robert Jones, Orthopedic Surgery of Injuries. Oxford Univ. Press, 192 I. 28. KOCHER. Mitt. a. d. Grenzgeb. d. Med. u. Cbir. I: 4. 1896. 29. ROGERS, W. A. An extension frame for the reduction of fracture of the vertebra1 body. Surg. Gynec. Obst., 50: IOI, 1930. of 30. DUNLOP, J. and PARKER, C. H. Correction compressed fractures of the vertebrae. J. A. M. A., 94: 89. Ig3o‘7.
A., 89: 1563, 1927. of the spine. J. Bone @ Joint Surg., I I : 133-156, 1929. _ MCCUTCHEON. L. G. Compression fracture of spine-their x-ray. Radio&y. 5: 490-494. 1925. CLEARY. E. W. Fractures of the spina coIumn. Calijornia c!r West. Med., 22: Igr-zoo, 1924. ELSBERG. C. A, Diagnosis and Treatment of Surgica1 Diseases of the SpinaI Cord, etc. Phila., Saunders, 1916. SHARPE, N. The chief Iesions foIIowing spina fracture. AM. J. SURG., 35: r52--I5g, 1921. SHARPE, N. Transverse lesion fohowing spina fracture. AM. J. SURG., 35: 152. 1921. TAYLOR, A. S. EarIy operation indicated in fractures of the spine with cord symptoms. N. York M. J., 117: 583, 1918. HARTWELL, J. S. Indications for Iaminectomy in fractures of the spine, with cord symptoms. Boston M. & S. J., 177: 513, 1917. PLAGGEMEYER, H. W. FinaI report on fractures of the spine, in relation to changes in kidney and bIadder function. J. %oZ., 6: 183-193, 1921. *Continued from p. 335.
ENDOTHERMY IN SUPRAPUBIC PROSTATECTOMY * PAUL W. ASCHNER, M.D., F.A.C.S. NEW YORK
q an anaIysis of a series of 277 suprapubic prostatectomies, 44 performed in one step and 233 in two steps, the
favored secondary hemorrhage. Despite transurethra1 irrigation and carefu1 remova1 of the gauze it has been my experi-
FIG. I.
FIG. 2.
most frequent compIications entaiIed by the disease process and the operative procedure for its cure were as foIIows: renaI insuffIciency, renaI infection, hemorrhage, epididymo-orchitis, vesica1 infection, deIayed heaIing of the fistuIa, and secondary stenosis of the vesica1 neck.l To combat renaI insuffIciency and infection catheter drainage or cystostomy was empIoyed. Catheter drainage carried with it the risk of epididymo-orchitis. Cystostomy necessitated a bIind enucIeation of the adenomatous mass at a second stage. For the contro1 of bIeeding surgica1 measures were impossibIe and reIiance was pIaced upon gauze packing of the prostatic bed. WhiIe this usuaIIy Iessened immediate bIeeding it
ence that hemorrhage has occurred al1 too frequentIy from one to ten days Iater, requiring repacking of the prostatic bed. OccasionaIIy the remove1 of the second packing has been foIlowed subsequentjy by renewed bIeeding. It is my firm conviction that the eIement of infection pIays an important rBIe in these secondary hemorrhages and that packing introduced into the prostatic bed and bIadder is conducive thereto. It is probabIy a factor in the other phenomena of infection, nameIy intense cystitis which may be gangrenous or diphtheritic, and viruIent ascending infection of the ureters, peIves and renaI parenchyma. It may aIso be responsibIe for bIockage of the ejacuIatory ducts and infection of the epididymes. Blind laceration of
‘Aschner,
P. W. J. Ural., 12: 251, 1924. * Submitted
for pubIication
321
May 8, 1931.
322
American Journal of Surgery
Aschner-SurgicaI
the vesica1 mucosa, the Ieaving of Ioose tabs, the faiIure to properIy reconstruct the vesica1 neck and the fear of passing instru-
FIG. 3.
ments through the urethra are responsibIe for the occurrence of Iate obstructing stenoses, even compIete occIusions at the upper end of the prostatic pouch. To overcome these various compIications of the surgery of benign prostatic adenomatous hypertrophy I have graduaIIy deveIoped the foIIowing course of procedure. The tentative diagnosis of obstructing hypertrophy having been made by history and physica examination, incIuding the demonstration of residua1 urine amounting to 120 C.C. or more, the patient is admitted to the hospita1. Under IocaI infiItration anaIgesia, a smaI1 incision is made just beIow either externa1 ring, the spermatic cord deIivered, and vas deferens isoIated and about haIf an inch resected between catgut Iigatures on both sides. Hemostasis being meticuIousIy assured, the wounds are cIosed with siIk and a smaI1 ~gauze coIIodion dressing appIied. FaiIure to attend to hemostasis may resuIt in an enormous hematoma of the scrotum.
Endothermy
FEBRUARY. 193~.
A soft rubber indweIIing catheter is now pIaced to secure vesica1 drainage. If there is great retention gradua1 decompression shouId be carried out. BIadder irrigation twice daiIy and changing of the catheter every fourth day after proper urethra1 irrigation are ordered, There need be no fear of epididymitis, as the vas resection prevents it. The usua1 functiona studies are now made. X-ray examination and cystography are carried out in every case to excIude caIcuIus and diverticuIum. The cystogram wiI1 aIso indicate the degree of prostatic encroachment upon the bIadder neck. Cystoscopy gives further information as to the prostate and bIadder, and the intravenous injection of indigo carmine permits observations upon the renaI function and uretera patency. It is inadvisabIe to catheterize the ureters unIess supravesica1 caIcuIus is suspected. Intravenous urography (Swick’s method) wiI1 give much knowIedge of the state of the kidneys and ureters. VesicaI drainage having been maintained for seven to ten days and there being no functiona or pathoIogica1 contraindications, the sutures are removed from the inguina1 wounds and the prostatectomy is proceeded with. AnaIgesia is obtained either by combination of sacra1 nerve bIock (epidura1) and abdomina1 waI1 infiItration or by Iow subdura1 injection of neocaine, I00 mg., or nupercaine I0 mg. My own preference is for neocaine spina anaIgesia as the proIonged action of nuperCaine is not necessary here. The indifferent (Iarge) eIectrode of the endotherm apparatus is pIaced under the buttocks and sacra1 region. A 5 inch median hypogastric incision is made, the Iinea aIba is incised and the peritoneum stripped back from the distended bIadder. Guy sutures being passed the water is aIIowed to empty out through the catheter. The bIadder is now opened IiberaIIy in the midIine of its anterior aspect and its interior inspected. This incision may be made with the scaIpe1 or the endotherm knife. The seIf-retaining Judd BaI-
Aschner-SurgicaI
New SERIES VOL. XV, No. z
four retractor is pIaced. A broad fIexibIe ribbon retractor over a packing hoIds the posterior waII taut. A narrow ribbon re-
FIG.
4.
tractor exposes the anterior commissure of the interna urethra1 orifice, ‘and the catheter is now ordered withdrawn (Fig. I). With the endotherm needIe the anterior commissure is divided and an appropriate incision made through the mucosa overIying the projecting prostate and circumcising the urethra1 orifice. This incision is carried down to the prostatic capsuIe (Fig. 2). A tenacuIum is appIied to the prostate and with gentIe traction the mass is enucIeated under direct vision using a cIosed bIunt curved scissors as a dissector (Fig. 3). As much of the Iower part of the posterior urethra is preserved as is possibIe; it is cut across with the endotherm knife. By the use of AIIis forceps to hoId open the vesica1 mucosa rimming the cavity, bIeeding vesseIs are caught with Iong artery forceps and immediateIy seaIed by touching the forceps with the endotherm needIe (Fig. 4). It is not necessary to change the type of current employed. Tabs of tissue are also readiIy removed with this cutting needIe. Hemostasis being secured in this manner the cut edge of vesical mucosa with its underIying muscuIaris is sutured down into the prostatic cavity, bringing the mucosa
Endothermy
American Journal of Surgery
323
down to that of the urethral stump but not attempting to pass sutures through the Iatter. The first suture brings down the
FIG. 3.
posterior margin (6 o’cIock) using a mattress stitch of zero catgut. One on either
FIG. 6.
side (3 and g o’cIock) compIetes the repair converting the prostatic pouch into a funneI wide open above and Ieading to the
324
Americnn
Journal
of Surgery
Aschner-SurgicaI
urethra1 stump (Fig. 5). No bag or packing is used. Hunt, Deaver, Thomson-WaIker and Lower use Iigatures for bIeeding vessels in the prostatic bed, but eIectrocoaguIation is much simpIer. Hunt inserts a bag for further hemostasis but I see no necessity for this and it may.be harmful. Lower approximates the vesica1 mucosa1 rim from side to side Ieaving just room enough for a urethra1 catheter, but this, I believe, tends to convert the prostatic cavity and bIadder into an hourgIass form. It is preferabIe to convert the prostatic cavity into a funneI, wide open above and tapering down to the urethra (Fig. 6.) as is done by Hunt, Deaver and Thomson-WaJker. The bIadder is now cIosed with interrupted pIain catgut sutures around a tube 1.5 cm. in diameter Ied out from the vertex of the bIadder. Reinforcing sutures of chromic catgut are then pIaced approximating the outer Iayers of the bIadder waI1. A packing to the space of Retzius, and another to the peritonea1 reffection are inserted and the abdomina1 waI1 cIosed about the drains. A week Iater the tube
REFERENCES 5. MAGNUSON,P. B., and COULTER, J. S. Compression
fracture of the spine with referred pain, Ioss of balance and Iow back pain. Znternat. Clin., I I I : IOO--10s.1420: Compression fracture of the spine compIicated by many things. Ibid., I I I: of the fifth Iumbar 117-I IO. 1020: Fracture vertebra w$h injury to the cauda equina. Ibid., I I I : 120-124, 1920. 6. KIRCHNER, W. C. G. Surg. Gynec. Obst., 36:830, 1923. 7. OSGOOD,R. B. J. A.M. 8. DAVIS. A. G. Fractures 9.
IO. II.
12.
13. 14.
15.
16.
Endothermy
FEBRUARY.rojz
and packings are removed and a urethral catheter may be inserted as before operation. Irrigation is then used onIy to maintain free drainage. The wound is found to cIose compIeteIy in from fourteen to twenty-one days. There has been no more bIeeding than is frequentIy seen after simpIe cystostomy. In one of the earlier cases, not having compIete confidence in the procedure as a preventive of bIeeding, I pIaced a packing in the funne1 area. This patient was sIow in heaIing and Iater deveIoped some stenosis. The worst risk was a man of seventy-one with bIood urea of go mg. and bIood sugar of 500 mg. on admission with compIete retention. The procedure is not appIicabIe to those patients in whom indweIIing catheter drainage cannot be empIoyed and in whom cystostomy must be resorted to for adequate preparation. The presence of vesica1 caIcuIi aIso necessitates the two-stage procedure. In the event that a two-step prostatectomy is necessary packing of the prostatic bed may be frequentIy dispensed with, and shouId be avoided whenever possible.
OF
DR.
DAVIS*
SPGED, K. Compression fracture of the dorsofumbar vertebrae, pathoIogy and treatment. S. Clin. North America, 3: 1083, 1923. 18. MIXTER, W. J. J. Bone ti Joint Surg., 5: 21, 1923. 19. BURRELL and CRANDON. Tr. Am. Surg. Ass., 1905. 20. HOY, C. DA C. Fractures of the Iumbar spine. Znternat. C&n., 4: 245-280, 1924. 21. ALLEN, A. R. Injuries of spinal cord. J. A. M. A., 50: 940, 1908. Iaminectomy for 22. ELSBERG, C. A. Exploratory fracture disIocation of the spine. Internat. Clin., II: 73. 23. ELSBERG, C. A. Some surgica1 features of injuries of the spine, with specia1 reference to spinal fracture. Ann. Surg., 58: 206, 1913. 24. ALLEN, A. R. J. A. M. A., rgrr. 25. FRAZIER, C. H., and ALI.EN, A. R. Surgery of Spine and SpinaI Cord. N. Y., AppIeton, 1918, pp. 8449-8450. 26. WILSON, G. E. Canada M. A. J., p. 1054, 1911. 27. BUZZARD, F., and SARGENT, P. In: Robert Jones, Orthopedic Surgery of Injuries. Oxford Univ. Press, 192 I. 28. KOCHER. Mitt. a. d. Grenzgeb. d. Med. u. Cbir. I: 4. 1896. 29. ROGERS, W. A. An extension frame for the reduction of fracture of the vertebra1 body. Surg. Gynec. Obst., 50: IOI, 1930. of 30. DUNLOP, J. and PARKER, C. H. Correction compressed fractures of the vertebrae. J. A. M. A., 94: 89. Ig3o‘7.
A., 89: 1563, 1927. of the spine. J. Bone @ Joint Surg., I I : 133-156, 1929. _ MCCUTCHEON. L. G. Compression fracture of spine-their x-ray. Radio&y. 5: 490-494. 1925. CLEARY. E. W. Fractures of the spina coIumn. Calijornia c!r West. Med., 22: Igr-zoo, 1924. ELSBERG. C. A, Diagnosis and Treatment of Surgica1 Diseases of the SpinaI Cord, etc. Phila., Saunders, 1916. SHARPE, N. The chief Iesions foIIowing spina fracture. AM. J. SURG., 35: r52--I5g, 1921. SHARPE, N. Transverse lesion fohowing spina fracture. AM. J. SURG., 35: 152. 1921. TAYLOR, A. S. EarIy operation indicated in fractures of the spine with cord symptoms. N. York M. J., 117: 583, 1918. HARTWELL, J. S. Indications for Iaminectomy in fractures of the spine, with cord symptoms. Boston M. & S. J., 177: 513, 1917. PLAGGEMEYER, H. W. FinaI report on fractures of the spine, in relation to changes in kidney and bIadder function. J. %oZ., 6: 183-193, 1921. *Continued from p. 335.