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Transurethral Prostatic Resection: A Comparison of Two Series of Cases1
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JouRNAL OF U.aoi:.oc,y
VoL 63, No. l, January, 1950 Primed in U.S.A.
TRANSURETHRAL PROSTATIC RESECTION: A COMPARISON OF TWO SERIES OF CASES 1 MAXWELL A.•JOHNSON
AND
ALF H. GUNDERSEN
From the Departments of Urology of the LaCrosse Lutheran Hospital and the Gundersen Clinic, LaCrosse, Wis.
Almost twelve years ago, one of us (A. H. G.) presented an analysis of 100 consecutive transurethral resections on the prostate gland which he had performed during the preceding 1½ years. It is of interest to inquire as to the progress, or lack of it, which has been obtained in connection with this operation since that time. Therefore, a second series of 100 consecutive cases treated transurethrally was studied with view to making possible comparisons, This second series was operated upon during the period June 1, 1947 to January 1, 1948. AGE DISTRIBUTION
The average age of all patients operated on transurethally for prostatic obstruction remains at about. 70 years (table 1). It should be observed, however, that the age distribution has undergone a change. About twice as many patients are being resected in the 81 to 90 year age group and in the .51 to 60 year age group today as compared with the situation 12 years ago. There is, therefore, a spreading out of the ages at which resection is undertaken; produced on the one hand by a general increase in the old age population, and on the other hand by a tendency to have patients seek urological help at an earlier age. The largest number of cases are now found in the 61 to 70 age group as against the peak in the 71 to 80 age group previously. PREOPERATIVE CARE AND COMPLICATIONS
Apparently due to the tendency to have patients seek urological help sooner we are now seeing less complicated cases (table 2). While in the first series 31 patients were completely obstructed when first seen, only 16 in the second series had this complaint. Also, in the first series 24 cases had elevation of the nonprotein nitrogen while only 8 in the second series had this complication. Oddly enough, the incidence of large diverticula remains at 5 to 7 per cent. The resection of recurrent cases remains at 8 to 9 per cent. While the number of resections for recurrent benign growths decreases, the cases of prostatic carcinoma live longer on estrogenic therapy and more carcinornatous local .recurrences need resection. Preoperative hospitalization has decreased slightly (table 4). While the average preoperative stay was 3½ days 12 years ago, it is now 2½ days. Again, this reflects the fact that we are seeing less advanced and less complicated cases. 1 Read at annual meeting, Wisconsin Urological Society, Lacrosse, Wis., April 24, 1948, and also at first annual meeting of Southwestern Surgical Congress, Houston, Texas, September 27, 1949.
147
148
MAXWELL A. JOHNSON AND ALF H. GUNDERSEN TREATMENT
The introduction of the routine administration of sulfonamides as well as the invention of the bag catheter have brought about a change in our preoperative care. All patients except those with gross elevation of the nonprotein nitrogen TABLE
1.-Age groups
200 cases of prostatic obstruction AGE GROUPS
100 CONSECUTIVE CASES TREATED BY 100 CONSECUTIVE CASES TREATED BY TRANSURETHRAL RESECTION- JUNE 1, 1935 TRANSURETHRAL RESECTION- JUNE 1, 1947
TO AUGUST I, 1936
TO JANUARY I, 1948
Average age ............ .
69¾ years
70½ years
Eldest case .............. .
90 years
89 years
Youngest case ........... .
33 years (median bar)
42 years (median bar)
Age groups:
15 cases cases cases cases cases 0 cases
8 cases 44 cases 41 cases 6 cases 0 cases 1 case
81-90 .................. . 71-80 .................. . 61-70 .................. . 51-60 .................. . 41-50 .................. . 31-40 .................. . TABLF.
33 37 12 3
2.-Preoperative findings SEll!ES
1
SEIUES
2
Completely obstructed on admission ........ .
31 cases
Elevated N.P.N. (36 mg.% or higher): Without symptoms ........................ . With symptoms ........................... .
Not given 24 cases
Recurrent cases ............................ . Adenomata ................................ . Carcinoma. ............................... .
8 cases 6 cases 2 cases
4 cases*
Papillomata ................................. .
2 cases
1 case
Diverticula ................................. .
7 cases
5 cases
Urinary calculi: Ureter .................................... . Bladder .................................. .
2 cases 4 cases
0 cases
16 cases
4 cases 4 cases
9 cases 5 cases
6 cases
* One done elsewhere. One with alkaline incrustations.
are started on small doses of sulfadiazine on admission. At the same time those with large amounts of residual urine or acutely obstructed are placed on catheter drainage with a No. 16, 5 cc bag catheter. They may be carried along this way for several days while necessary preoperative studies are made. Penicillin or other antibiotics are not used except for some special consideration.
149
TRANSURETHRAL PROSTATIC RESECTION
Probably because of the ease and safety with which catheter drainage can now be carried out, the number of such cases has increased from 21 per cent to 28 per cent in spite of the above noted decreases in patients acutely obstructed or with high nonprotein nitrogen determinations (table 3). Of the 28 per cent, 3 cases had drainage instituted before admission to the hospital and 25 cases had catheters placed after admission. Only 1 patient in the current series had a suprapubic cystostomy; this was done to remove a large bladder calculus. Three suprapubic cystostomies were done in the series 12 years ago. TABLE
3 .-Treatment SERIES
1
SERIES
2
One resection ................................ . Two resections .............................. . Three resections ............................. . Four resections .............................. .
82 14 1 3
cases cases case cases
92 cases 6 cases
Cystostomy ................................. . Catheter drainage (preoperative) ............. . No drainage (preoperative) .................. .
3 cases 21 cases 76 cases
1 case 28 cases 71 cases
TABLE
2 cases 0 cases
4.-Hospitalization SERIES
1
SERIES
2
Hospitalization Preoperative: Average . . ................................ . Shortest ................................... . Longest .................................. .
3½ days 0 days 40 days
Postoperative: Average . . ................................ . Shortest .................................. . Longest . . ................................ .
10½ days 2 days 69 days
3 days 56 days
13¾ days
11 days
3 days 63 days
3½ days 60 days
Total hospitalization: Average .................................. . Shortest ................................... . Longest .................................. .
2½
days
0 days 20 days
8½ days
Ninety-two cases in this recent series had 1 resection, while 6 cases had 2 resections and 2 cases had 3 resections. This compares with 82 cases with 1 resection, 14 cases with 2 resections, 1 case with 3 resections, and 3 cases with 4 resections 12 years ago. POSTOPERATIVE CARE
In comparing the postoperative reactions in our two groups, one must consider that on one hand we now have the aid of the sulfonamides and penicillin, formerly not available, while on the other hand we now produce a much larger wound area for the absorption of bacteria and products of tissue destruction.
150
MAXWELL A. JOHNSON AND ALF H. GUNDERSEN
It may be said that temperature reactions up to 102 F (rectally) have been reduced while the more severe reactions remain about the same (table 5). Catheter drainage has remained at 2 days postoperatively, with an occasional case being drained for 3 days. A trend toward shorter postoperative hospitalization continues. The already low average postoperative hospitalization 12 years ago of 10½ days has now been reduced to 8½ days. Except in those cases where alkaline incrustations have been present and where their recurrence is feared, patients are not sent home on sulfa drug. An adequate resection with good "funnelization" insures a minimum of infection and also an absence of fever or constitutional symptoms. Annoying dysuria during the postoperative and post-hospitalization period is controlled with small doses of methylene blue. TABLE
5.-Posloperative temperatures SERIES
Highest postoperative temperature (rectal): 98.6-100 .................................. . 100 -101 .................................. . 101 -102 .................................. . 102 -103 .................................. . 103 -104 .................................. . 104 -105 .................................. . 105 -106 ................................. ..
1
SERIES
44 34 22
50 16 14
7
10
8 5 2
5
2
4 1
POSTOPERATIVE COMPLICATIONS
Hemorrhage, both of the immediate and of the delayed varieties, continues to be an occasionally troublesome complication of the transurethral resection (table 6). Immediate hemorrhage is most often noted on the afternoon of the operative day. While formerly about 3 per cent of these cases had to be returned to the operating room for evaculation of clots and fulguration of bleeding points, we almost never see bleeding of this severity now. We believe that this is due to a more adequate resection together with meticulous control of bleeding before closing the operative procedure. We do not believe continuous irrigation to be necessary or desirable; the vast majority of our resections are never irrigated. Further, transfusion of blood is seldom required unless the patient was previously anemic. However, it would appear that the number of patients returning in 15 to 25 days postoperatively with a bladder full of clots has not been decreased but remains at from 4 to 6 per cent. This type of secondary hemorrhage has been thought to be due to sloughing tissue which was inadequately resected. That this is not the entire answer is indicated by the fact that we now leave less avascularized tissue than ever before. During the past year we have discontinued the routine bilateral vasectomy formerly practiced. It has been our impression that the incidence of epididymitis
151
TRANSURETHRAL PROSTATJC RESECTION
is unchanged whether vasectomy is performed or not. However, comparison of our two groups indicates that 12 years ago 2 per cent of patients developed this complication, whereas today about 5 per cent of patients develop it. This latt.~c figure is close to that reported by Lynn and Nesbit for 300 consecutive transurcthral resections done without vasectomy. The complications of peri-urethral abscess, phlebitis, and incontinence were TABLE
6.-Complicalions SERIES 1
SERIES 2
I. Hemorrhage A. Immediate ....................... . Requiring re-operation ......... . Requiring irrigating catheter ... . B. Delayed .......................... . Requiring anesthesia and reoperation .................... . Requiring catheter drainage .... . II. Epididymitis .......................... .
8 3 5 4
cases cases cases cases
2 cases 2 cases
2 cases (vas tie)
8 cases 0 cases
8 cases 6 cases
4 cases 2 cases
5 cases (no vas tie)
III. Perforation of bladder (extravasation of urine) .......................... . Periurethral abscess ................... . Phlebitis .............................. . Embolus .............................. . Incontinence .......................... . Prolonged frequency and urgency ...... . Relieved after 60 days ............... . Unrelieved of frequency (carcinoma) .. IX. Inability to empty bladder ............ . Diverticula .......................... . Atony ............................... . Insufficient tissue removal ........... . X. Stricture following operation .......... . XL Pyuria continuous after 3 months ...... . Diverticula .......................... . Chronic pyelonephritis .............. . Carcinoma with recurring obstruction ............................... . Atony of bladder .................... . Cystitis (unrelieved) ................ .
IV. V. VI. VII. VIII.
0 cases
1 case
1 case 1 case 0 cases 1 case 8 cases 4 cases 4 cases 6 cases 4 cases 1 case 1 case 3 cases 18 cases 7 cases l. case
0 cases
6 cases
0 cases
1 case 0 cases
5 cases
1 case 4 cases
13 cases 4 cases 9 cases 0 cases 1 case 6 cases 2 cases 1 case
2 cases
3 cases 0 cases
2 cases
0 cases
avoided in the recent series whereas 12 years ago 3 per cent of the cases developed one of these. However, I case of bladder neek perforation and 1 case of pulmonary embolus occurred in the recent series while none were recorded 12 years ago. Fortunately, neither of these patients died. One postoperative stricture was encountered in the current series as against 3 cases previously. We believe the reduction in stricture formation to be due to an increased appreciation of the limit to which the urethra can be stretched without forming a stricture. We freely use meatotomy and occasionally a perinea! urethrotomy.
152
MAXWELL A. JOHNSON AND ALF H, GUNDERSEN PATHOLOGY
Twelve years ago the average amount of tissue removed was 13.72 gm. (table 7). Now the average weight is 30.95 gm. It is interesting that we now routinely remove an average weight of tissue which equals the average reported from a large series of suprapubic prostatectomies. Also, 41 per cent of our resections are in the class which Creevy has designated "the large prostate"; that is, those over 30 gm. Study of the statistics for the pathological diagnosis of the two series suggests that the viewpoint of the pathologists rather than the distribution of the disease 7.-Pathology
TABLE
SERIES
Average weight of tissue removed ............ . gm
100-150 .................................... . 90-100 ..................... 80- 90 ...... 70- 80 .... 0
0.
0
0
•••••••••
0.
0
••••
•••••
0
•••••
0.
60- 70 ... 50403020100-
0
0
0
0
••••
0
0.
0.
0
0
••
0.
0
••
0
0
0
••
0.
0
0
0
0.
0
0
•••
0
••
0
••
0.
•••
0
0
0
••••
••
0
••
0.
0
0
••••••••
0
0
0
•••
1
SERIES
13.72 gm.
30.95 gm.
cases
cases
0 0
1
0
1
1
3
0
9 2 11
2
60 .. 50 .................................... . 40 .................................. 30 .................. ·............... 20 ................................... 10 ....
10 38 41
12 12 30 17
Benign hypertrophy ......................... .
74
77
Malignant ................................... . Grade I ................................... . Grade II .................................. .
26
23 1
0.
0.
0
0
••••
0
••••••••••••
0
•••••••••••
0
0
••
•••
0.
0
••••••••••••••••••••
0
•••••••••••
Grade III ................................. . Grade IV .................................. .
2
1 3 6
17 6
3 0
5
(Leukemia 1) 16 0
processes has changed. Apparently tissue which 12 years ago we called grade 1 carcinoma, today, with more experience, we would label as benign or as grade 2 or grade 3 carcinomas. In other words, our division of "grade 1 carcinoma" was too broad. In both series somewhere around 75 per cent of cases were benign and around 25 per cent were malignant. It is of passing interest that 2 of our recent patients had leukemia. One case showed leukemic infiltration in the prostatic tissue while the other did not. RESULTS
An insufficient amount of time has elapsed to completely evaluate our recent series. Since the more complete resection should show its superiority in a decrease in the number of resections for recurrent adenomata, the full evaluation of the second series cannot be made now. The situation today is summarized in table 8.
153
TRANSURETHRAL PROSTATIC RESECTION
It is to be noted that on a short term basis the change from 12 years ago is not so great as one might guess. Some 81 per cent of patients now obtain excellent results as against 74 per cent previously. The percentage of patients obtaining good results has decreased from 17 per cent to 12 per cent; this change has been reflected in the increase in the percentage of patients obtaining an excellent result. The percentage of patients with fair results remains unchanged at (i per cent. While the percentage of poor results fell to none in the recent series, it was only l per cent in the 12 year old series. The mortality rates for both series are shown in table 8 as well as a summary of the 1 death in the recent series. Included in the recent series are 3 patients TABLE
8.-Results and mortality
RESULTS
Excellent, grade 1 Free, easy, painless urinary stream. No residual. Nocturia 1-2 times. Infection absent. Good, grade 2 Free, easy, painless stream. No residual. N octuria 2-4 times. Infection or pyuria usually present. Fair, grade 3 Residual 1 to 4 ounces. Infected. Good control. Nocturia 4--6 times. Poor, grade 4 Incontinent. MORTALITY
SERIES
1
SERIES
2
per ce11I
Per cent
74
81
17
12
6 1 2
0
1
Death-Case 0.0. Age 80. Disoriented, hemiparesis. Blood pressure 210/140. 60 gm. resected. Died of sepsis and broncho-pneumonia-3 days.
who have died at home of various causes (heart disease, 2 cases; mental deterioration and cachexia, 1 case). These cruses are classified as to their prostatic conditions shortly before death. SUMMARY
It would seem that the changes and improvements in the transurethral resection during the past 1.2 years have not Leen so great as one might at first imagine. We believe that definite improvement in all phases has been made but this has not been so great as that seen in some other surgical fields. A general trend for resecting younger men with less complicated cases together with a more complete resection and a shorter hospitalization period can be noted. Febrile reactions and the majority of complications are slightly less frequent now but such complications as late secondary hemorrhage, epididymitis, and atony of the bladder continue to be troublesome problems. The ratio of benign
154
MAXWELL A. JOHNSON AND ALF H. GUNDERSEN
to malignant glands continues about the same through the years. While we are now resecting a greatly increased average weight of tissue, the results on a short term basis are not strikingly improved. It may, however, be that as fewer patients niturn with benign recurrences over a period of years the actual superiority of om present day operation will more dramatically be shown. 2020 S. Xanthus St., Tulsa, Okla. (M.A.J.) 1936 Smdh Ave., La Crosse, Wis. (A.H.G.) REFERENCES CREEVY, C. D.: Resection of the "large" prostate: technique and results. J. Urol., 45: 715-720, 1941. GUNDERSEN, A. H.: Transurethral prostatic resection for bladder neck obstruction. Wisconsin Med. J., 36: 824-82[), 1937. NESBIT, R. M. AND LYNN, J.M.: The influence of vasectomy upon the incidence of epididymitis following transurethral prostatectomy. ,J. Urol., 59: 72-75, 1948. SWAN, C. S. AND MINTZ, E. R.: The review of prostatectomies for benign prostatic hypertrophy at the Massachusetts General Hospital in the years 1926-1930, inclusive. J. Urol.. 26: 67-90, 1931.
JouRNAL OF U.aoi:.oc,y
VoL 63, No. l, January, 1950 Primed in U.S.A.
TRANSURETHRAL PROSTATIC RESECTION: A COMPARISON OF TWO SERIES OF CASES 1 MAXWELL A.•JOHNSON
AND
ALF H. GUNDERSEN
From the Departments of Urology of the LaCrosse Lutheran Hospital and the Gundersen Clinic, LaCrosse, Wis.
Almost twelve years ago, one of us (A. H. G.) presented an analysis of 100 consecutive transurethral resections on the prostate gland which he had performed during the preceding 1½ years. It is of interest to inquire as to the progress, or lack of it, which has been obtained in connection with this operation since that time. Therefore, a second series of 100 consecutive cases treated transurethrally was studied with view to making possible comparisons, This second series was operated upon during the period June 1, 1947 to January 1, 1948. AGE DISTRIBUTION
The average age of all patients operated on transurethally for prostatic obstruction remains at about. 70 years (table 1). It should be observed, however, that the age distribution has undergone a change. About twice as many patients are being resected in the 81 to 90 year age group and in the .51 to 60 year age group today as compared with the situation 12 years ago. There is, therefore, a spreading out of the ages at which resection is undertaken; produced on the one hand by a general increase in the old age population, and on the other hand by a tendency to have patients seek urological help at an earlier age. The largest number of cases are now found in the 61 to 70 age group as against the peak in the 71 to 80 age group previously. PREOPERATIVE CARE AND COMPLICATIONS
Apparently due to the tendency to have patients seek urological help sooner we are now seeing less complicated cases (table 2). While in the first series 31 patients were completely obstructed when first seen, only 16 in the second series had this complaint. Also, in the first series 24 cases had elevation of the nonprotein nitrogen while only 8 in the second series had this complication. Oddly enough, the incidence of large diverticula remains at 5 to 7 per cent. The resection of recurrent cases remains at 8 to 9 per cent. While the number of resections for recurrent benign growths decreases, the cases of prostatic carcinoma live longer on estrogenic therapy and more carcinornatous local .recurrences need resection. Preoperative hospitalization has decreased slightly (table 4). While the average preoperative stay was 3½ days 12 years ago, it is now 2½ days. Again, this reflects the fact that we are seeing less advanced and less complicated cases. 1 Read at annual meeting, Wisconsin Urological Society, Lacrosse, Wis., April 24, 1948, and also at first annual meeting of Southwestern Surgical Congress, Houston, Texas, September 27, 1949.
147
148
MAXWELL A. JOHNSON AND ALF H. GUNDERSEN TREATMENT
The introduction of the routine administration of sulfonamides as well as the invention of the bag catheter have brought about a change in our preoperative care. All patients except those with gross elevation of the nonprotein nitrogen TABLE
1.-Age groups
200 cases of prostatic obstruction AGE GROUPS
100 CONSECUTIVE CASES TREATED BY 100 CONSECUTIVE CASES TREATED BY TRANSURETHRAL RESECTION- JUNE 1, 1935 TRANSURETHRAL RESECTION- JUNE 1, 1947
TO AUGUST I, 1936
TO JANUARY I, 1948
Average age ............ .
69¾ years
70½ years
Eldest case .............. .
90 years
89 years
Youngest case ........... .
33 years (median bar)
42 years (median bar)
Age groups:
15 cases cases cases cases cases 0 cases
8 cases 44 cases 41 cases 6 cases 0 cases 1 case
81-90 .................. . 71-80 .................. . 61-70 .................. . 51-60 .................. . 41-50 .................. . 31-40 .................. . TABLF.
33 37 12 3
2.-Preoperative findings SEll!ES
1
SEIUES
2
Completely obstructed on admission ........ .
31 cases
Elevated N.P.N. (36 mg.% or higher): Without symptoms ........................ . With symptoms ........................... .
Not given 24 cases
Recurrent cases ............................ . Adenomata ................................ . Carcinoma. ............................... .
8 cases 6 cases 2 cases
4 cases*
Papillomata ................................. .
2 cases
1 case
Diverticula ................................. .
7 cases
5 cases
Urinary calculi: Ureter .................................... . Bladder .................................. .
2 cases 4 cases
0 cases
16 cases
4 cases 4 cases
9 cases 5 cases
6 cases
* One done elsewhere. One with alkaline incrustations.
are started on small doses of sulfadiazine on admission. At the same time those with large amounts of residual urine or acutely obstructed are placed on catheter drainage with a No. 16, 5 cc bag catheter. They may be carried along this way for several days while necessary preoperative studies are made. Penicillin or other antibiotics are not used except for some special consideration.
149
TRANSURETHRAL PROSTATIC RESECTION
Probably because of the ease and safety with which catheter drainage can now be carried out, the number of such cases has increased from 21 per cent to 28 per cent in spite of the above noted decreases in patients acutely obstructed or with high nonprotein nitrogen determinations (table 3). Of the 28 per cent, 3 cases had drainage instituted before admission to the hospital and 25 cases had catheters placed after admission. Only 1 patient in the current series had a suprapubic cystostomy; this was done to remove a large bladder calculus. Three suprapubic cystostomies were done in the series 12 years ago. TABLE
3 .-Treatment SERIES
1
SERIES
2
One resection ................................ . Two resections .............................. . Three resections ............................. . Four resections .............................. .
82 14 1 3
cases cases case cases
92 cases 6 cases
Cystostomy ................................. . Catheter drainage (preoperative) ............. . No drainage (preoperative) .................. .
3 cases 21 cases 76 cases
1 case 28 cases 71 cases
TABLE
2 cases 0 cases
4.-Hospitalization SERIES
1
SERIES
2
Hospitalization Preoperative: Average . . ................................ . Shortest ................................... . Longest .................................. .
3½ days 0 days 40 days
Postoperative: Average . . ................................ . Shortest .................................. . Longest . . ................................ .
10½ days 2 days 69 days
3 days 56 days
13¾ days
11 days
3 days 63 days
3½ days 60 days
Total hospitalization: Average .................................. . Shortest ................................... . Longest .................................. .
2½
days
0 days 20 days
8½ days
Ninety-two cases in this recent series had 1 resection, while 6 cases had 2 resections and 2 cases had 3 resections. This compares with 82 cases with 1 resection, 14 cases with 2 resections, 1 case with 3 resections, and 3 cases with 4 resections 12 years ago. POSTOPERATIVE CARE
In comparing the postoperative reactions in our two groups, one must consider that on one hand we now have the aid of the sulfonamides and penicillin, formerly not available, while on the other hand we now produce a much larger wound area for the absorption of bacteria and products of tissue destruction.
150
MAXWELL A. JOHNSON AND ALF H. GUNDERSEN
It may be said that temperature reactions up to 102 F (rectally) have been reduced while the more severe reactions remain about the same (table 5). Catheter drainage has remained at 2 days postoperatively, with an occasional case being drained for 3 days. A trend toward shorter postoperative hospitalization continues. The already low average postoperative hospitalization 12 years ago of 10½ days has now been reduced to 8½ days. Except in those cases where alkaline incrustations have been present and where their recurrence is feared, patients are not sent home on sulfa drug. An adequate resection with good "funnelization" insures a minimum of infection and also an absence of fever or constitutional symptoms. Annoying dysuria during the postoperative and post-hospitalization period is controlled with small doses of methylene blue. TABLE
5.-Posloperative temperatures SERIES
Highest postoperative temperature (rectal): 98.6-100 .................................. . 100 -101 .................................. . 101 -102 .................................. . 102 -103 .................................. . 103 -104 .................................. . 104 -105 .................................. . 105 -106 ................................. ..
1
SERIES
44 34 22
50 16 14
7
10
8 5 2
5
2
4 1
POSTOPERATIVE COMPLICATIONS
Hemorrhage, both of the immediate and of the delayed varieties, continues to be an occasionally troublesome complication of the transurethral resection (table 6). Immediate hemorrhage is most often noted on the afternoon of the operative day. While formerly about 3 per cent of these cases had to be returned to the operating room for evaculation of clots and fulguration of bleeding points, we almost never see bleeding of this severity now. We believe that this is due to a more adequate resection together with meticulous control of bleeding before closing the operative procedure. We do not believe continuous irrigation to be necessary or desirable; the vast majority of our resections are never irrigated. Further, transfusion of blood is seldom required unless the patient was previously anemic. However, it would appear that the number of patients returning in 15 to 25 days postoperatively with a bladder full of clots has not been decreased but remains at from 4 to 6 per cent. This type of secondary hemorrhage has been thought to be due to sloughing tissue which was inadequately resected. That this is not the entire answer is indicated by the fact that we now leave less avascularized tissue than ever before. During the past year we have discontinued the routine bilateral vasectomy formerly practiced. It has been our impression that the incidence of epididymitis
151
TRANSURETHRAL PROSTATJC RESECTION
is unchanged whether vasectomy is performed or not. However, comparison of our two groups indicates that 12 years ago 2 per cent of patients developed this complication, whereas today about 5 per cent of patients develop it. This latt.~c figure is close to that reported by Lynn and Nesbit for 300 consecutive transurcthral resections done without vasectomy. The complications of peri-urethral abscess, phlebitis, and incontinence were TABLE
6.-Complicalions SERIES 1
SERIES 2
I. Hemorrhage A. Immediate ....................... . Requiring re-operation ......... . Requiring irrigating catheter ... . B. Delayed .......................... . Requiring anesthesia and reoperation .................... . Requiring catheter drainage .... . II. Epididymitis .......................... .
8 3 5 4
cases cases cases cases
2 cases 2 cases
2 cases (vas tie)
8 cases 0 cases
8 cases 6 cases
4 cases 2 cases
5 cases (no vas tie)
III. Perforation of bladder (extravasation of urine) .......................... . Periurethral abscess ................... . Phlebitis .............................. . Embolus .............................. . Incontinence .......................... . Prolonged frequency and urgency ...... . Relieved after 60 days ............... . Unrelieved of frequency (carcinoma) .. IX. Inability to empty bladder ............ . Diverticula .......................... . Atony ............................... . Insufficient tissue removal ........... . X. Stricture following operation .......... . XL Pyuria continuous after 3 months ...... . Diverticula .......................... . Chronic pyelonephritis .............. . Carcinoma with recurring obstruction ............................... . Atony of bladder .................... . Cystitis (unrelieved) ................ .
IV. V. VI. VII. VIII.
0 cases
1 case
1 case 1 case 0 cases 1 case 8 cases 4 cases 4 cases 6 cases 4 cases 1 case 1 case 3 cases 18 cases 7 cases l. case
0 cases
6 cases
0 cases
1 case 0 cases
5 cases
1 case 4 cases
13 cases 4 cases 9 cases 0 cases 1 case 6 cases 2 cases 1 case
2 cases
3 cases 0 cases
2 cases
0 cases
avoided in the recent series whereas 12 years ago 3 per cent of the cases developed one of these. However, I case of bladder neek perforation and 1 case of pulmonary embolus occurred in the recent series while none were recorded 12 years ago. Fortunately, neither of these patients died. One postoperative stricture was encountered in the current series as against 3 cases previously. We believe the reduction in stricture formation to be due to an increased appreciation of the limit to which the urethra can be stretched without forming a stricture. We freely use meatotomy and occasionally a perinea! urethrotomy.
152
MAXWELL A. JOHNSON AND ALF H, GUNDERSEN PATHOLOGY
Twelve years ago the average amount of tissue removed was 13.72 gm. (table 7). Now the average weight is 30.95 gm. It is interesting that we now routinely remove an average weight of tissue which equals the average reported from a large series of suprapubic prostatectomies. Also, 41 per cent of our resections are in the class which Creevy has designated "the large prostate"; that is, those over 30 gm. Study of the statistics for the pathological diagnosis of the two series suggests that the viewpoint of the pathologists rather than the distribution of the disease 7.-Pathology
TABLE
SERIES
Average weight of tissue removed ............ . gm
100-150 .................................... . 90-100 ..................... 80- 90 ...... 70- 80 .... 0
0.
0
0
•••••••••
0.
0
••••
•••••
0
•••••
0.
60- 70 ... 50403020100-
0
0
0
0
••••
0
0.
0.
0
0
••
0.
0
••
0
0
0
••
0.
0
0
0
0.
0
0
•••
0
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0
••
0.
•••
0
0
0
••••
••
0
••
0.
0
0
••••••••
0
0
0
•••
1
SERIES
13.72 gm.
30.95 gm.
cases
cases
0 0
1
0
1
1
3
0
9 2 11
2
60 .. 50 .................................... . 40 .................................. 30 .................. ·............... 20 ................................... 10 ....
10 38 41
12 12 30 17
Benign hypertrophy ......................... .
74
77
Malignant ................................... . Grade I ................................... . Grade II .................................. .
26
23 1
0.
0.
0
0
••••
0
••••••••••••
0
•••••••••••
0
0
••
•••
0.
0
••••••••••••••••••••
0
•••••••••••
Grade III ................................. . Grade IV .................................. .
2
1 3 6
17 6
3 0
5
(Leukemia 1) 16 0
processes has changed. Apparently tissue which 12 years ago we called grade 1 carcinoma, today, with more experience, we would label as benign or as grade 2 or grade 3 carcinomas. In other words, our division of "grade 1 carcinoma" was too broad. In both series somewhere around 75 per cent of cases were benign and around 25 per cent were malignant. It is of passing interest that 2 of our recent patients had leukemia. One case showed leukemic infiltration in the prostatic tissue while the other did not. RESULTS
An insufficient amount of time has elapsed to completely evaluate our recent series. Since the more complete resection should show its superiority in a decrease in the number of resections for recurrent adenomata, the full evaluation of the second series cannot be made now. The situation today is summarized in table 8.
153
TRANSURETHRAL PROSTATIC RESECTION
It is to be noted that on a short term basis the change from 12 years ago is not so great as one might guess. Some 81 per cent of patients now obtain excellent results as against 74 per cent previously. The percentage of patients obtaining good results has decreased from 17 per cent to 12 per cent; this change has been reflected in the increase in the percentage of patients obtaining an excellent result. The percentage of patients with fair results remains unchanged at (i per cent. While the percentage of poor results fell to none in the recent series, it was only l per cent in the 12 year old series. The mortality rates for both series are shown in table 8 as well as a summary of the 1 death in the recent series. Included in the recent series are 3 patients TABLE
8.-Results and mortality
RESULTS
Excellent, grade 1 Free, easy, painless urinary stream. No residual. Nocturia 1-2 times. Infection absent. Good, grade 2 Free, easy, painless stream. No residual. N octuria 2-4 times. Infection or pyuria usually present. Fair, grade 3 Residual 1 to 4 ounces. Infected. Good control. Nocturia 4--6 times. Poor, grade 4 Incontinent. MORTALITY
SERIES
1
SERIES
2
per ce11I
Per cent
74
81
17
12
6 1 2
0
1
Death-Case 0.0. Age 80. Disoriented, hemiparesis. Blood pressure 210/140. 60 gm. resected. Died of sepsis and broncho-pneumonia-3 days.
who have died at home of various causes (heart disease, 2 cases; mental deterioration and cachexia, 1 case). These cruses are classified as to their prostatic conditions shortly before death. SUMMARY
It would seem that the changes and improvements in the transurethral resection during the past 1.2 years have not Leen so great as one might at first imagine. We believe that definite improvement in all phases has been made but this has not been so great as that seen in some other surgical fields. A general trend for resecting younger men with less complicated cases together with a more complete resection and a shorter hospitalization period can be noted. Febrile reactions and the majority of complications are slightly less frequent now but such complications as late secondary hemorrhage, epididymitis, and atony of the bladder continue to be troublesome problems. The ratio of benign
154
MAXWELL A. JOHNSON AND ALF H. GUNDERSEN
to malignant glands continues about the same through the years. While we are now resecting a greatly increased average weight of tissue, the results on a short term basis are not strikingly improved. It may, however, be that as fewer patients niturn with benign recurrences over a period of years the actual superiority of om present day operation will more dramatically be shown. 2020 S. Xanthus St., Tulsa, Okla. (M.A.J.) 1936 Smdh Ave., La Crosse, Wis. (A.H.G.) REFERENCES CREEVY, C. D.: Resection of the "large" prostate: technique and results. J. Urol., 45: 715-720, 1941. GUNDERSEN, A. H.: Transurethral prostatic resection for bladder neck obstruction. Wisconsin Med. J., 36: 824-82[), 1937. NESBIT, R. M. AND LYNN, J.M.: The influence of vasectomy upon the incidence of epididymitis following transurethral prostatectomy. ,J. Urol., 59: 72-75, 1948. SWAN, C. S. AND MINTZ, E. R.: The review of prostatectomies for benign prostatic hypertrophy at the Massachusetts General Hospital in the years 1926-1930, inclusive. J. Urol.. 26: 67-90, 1931.