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Transurethral Prostatic Resection: Prevention and Treatment of Complications
Transurethral Prostatic Resection Prevention and Treatment of Com.plications C. D. CREEVY, M.D.*
IT
SEEMS to me that a thorough discussion of methods of avoiding (or more honestly, of trying to avoid) complications during and after transurethral prostatic resection requires a detailed presentation of technique. The first step in the successful performance of this operation is proper selection of the patient; i.e., the operation should be chosen to fit him and his disease, and not vice versa. It is assumed that the patient's general state and his renal function will be brought to their optimum levels before operation, and that complications unrelated to the prostatism will receive adequate attention. It is my conviction that symptoms must be severe enough so that the patient earnestly desires relief. Since no surgical operation yields uniformly satisfactory results, it is unwise to persuade a patient with only mild, premonitory symptoms of prostatism to submit to operation. The least complication or imperfection in result may leave him feeling cheated, and a postoperative urethral stricture will be worse than the original complaint. A preoperative roentgenogram of the urinary tract is routine; one is thus forewarned particularly of stones and metastases. Altered renal shadows prompt excretory urography. A preoperative urine culture is desirable; one will then know whether the urine is sterile or what antibacterial agent to use if it is contaminated, just in case of accident. Because of variations in individual preferences and judgment, I shall not discuss the relative merits of the various standard types of prostatic operations, nor specific reasons for selecting one rather than the others. Several local factors may hinder or contraindicate the transurethral
From the Urological Division of the Department of Surgery, Medical School of the University of Minnesota, M inneapolis. • Profe88or of Surgery and Director of the Urological Division of the Department of Surgery.
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operation. Among these are a narrow urethra, a thick perineum, a short suspensory ligament of the penis (all of which. will be discussed later), and an unusually large prostate as judged by repeated rectal palpation and, often, by urethrography. Each operator must decide for himself how large a gland he is able and willing to resect. From my point of view, a prostate as large as 150 grams may be resected'if all of the local conditions listed above are favorable and if the blood pressure is not too high. However, I have no quarrel with those who set the maximum much lower. Every urologist should be able to use all of the standard surgical approaches to the prostate, and each one will finally prefer one particular method for the average obstructing gland. Although I have in the distant past resected 190 grams from each of two patients in one session and 60 grams in a second, I do not now feel that the resection of such large glands is reasonable. CONTRAINDICATIONS
There are three absolute contraindications to transurethral resection: the presence in the bladder of a lesion requiring open operation, ankylosis of one or both hips so as to prevent placement of the patient in the proper position, and severe long strictures far back in the bulb or in the membranous urethra. A relative contraindication is high hypertension in the presence of a large gland, a combination tending to make for difficult hemostasis and excessive blood loss.
Fig. 261. The modified resectoscope and the injector for Pitressin.
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EQUIPMENT
It is futile to try to perform the operation without good equipment. Personal preference will dictate selection of the right resectoscope (Fig. 261). In my opinion, the plastic sheath should have a metal cover, which slides more freely than does plastic and therefore traumatizes the urethra less. The cover should end 1 cm. from the butt so that, if the insulating block fails, current cannot arc from butt to cover and burn the urethra. A modified Nesbit handle is used. I much prefer a short beak to a long one; the latter is in the way when one seeks to hollow out the fossa. Ordinarily, I use the Timberlake obturator. The spring on the lock is rewound in a direction opposite to standard so as to hold the working element in the sheath, thus preventing many a squirt in the face. Replacement of the inflow valve on the sheath with one having an inside diameter of 3/16 inch will improve vision during brisk bleeding. The small valve on the working element is removed and its opening plugged. Loops made of O.Q12\"inch rather than O.015-inch wire do· not last as long as the heavier ones, but they cut with a weaker current and leave less burned tissue. The instrument must work smootWy with one hand. Nesbit long ago emphasized that the lock on the working element must be loose, and
Fig. 262. The Foley table.
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Fig. 263. Alcock leg holders and the swinging, counterbalanced support for tubing and cords (viewed from head of table).
Fig. 264. Garske plastic drape partly covered by leggings;. O'Conor sheath in place.
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that the screws holding loop and telescope should be no tighter than absolutely necessary if movement is to be free. Loop and telescope must be straight (sight along them). The guide on which the working element moves may get out of line; this can be corrected by loosening the screw which holds it and finding the position which permits free motion. A paper shim above the guide (A in Fig. 261) may prevent binding. Lubricants are washed off so promptly that their use is futile. A binding working element may sometimes be freed by placing valve gr~ding compound on the guide and working the element in and out innumerable times (Nesbit). If it still fails to move with complete freedom, a new one should be obtained. I find that a strong spring on the working element is tiring to use.
Fig. 265. Modified O'Conor sheath.
It is essential to have two sheaths, two working elements, several telescopes and a half dozen loops sterile. When the instrument is cleaned after use, the same loop should be replaced in it; otherwise one will accumulate a number of used loops, all of which may burn out during one operation, occasioning much delay. A power-operated cystoscopic table such as the Foley (Fig. 262), which can be raised, lowered and tilted by pressure on foot pedals, saves a great deal of time and, properly used, minimizes the strain on the operator's back. Alcock leg holders (Fig. 263) minimize venous stasis and discourage phlebothrombosis. Use of the Garske plastic drape (Fig. 264) saves time in draping the patient, prevents contamination via soaked cloth drapes, and permits the use of a simplified and less cumbersome O'Conor sheath (Fig. 265), which is essential for aseptic, rectal palpation. I like a low, padded, adjustable stool with well
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oiled casters, and prefer to raise and lower the table rather than to adjust the stool. A free-swinging, counterbalanced arm on the table (Fig. 263) supports light and diathermy cords and water tube, which then do not become tangled. A nonelectrolytic, isotonic irrigating fluid (4 per cent glucose, 1.1 per cent glycine, 3 per cent mannitol [Cytal]) prevents intravesical and intravascular hemolysis, and, in the event of extravasation, probably injures tissue less than does plain water. A good, reliable electrosurgical unit of adequate power is essential. The best cutting current is generated by vacuum tubes, and the most effective coagulating current comes from a spark gap. My own preference is for the machine made by American Cystoscope Makers, Inc., but several other manufacturers make excellent ones. The proper setting for power output varies from one make to another; in general, one uses the lowest setting that gives the desired result. I cannot say that cutting with a Clblended" current reduces bleeding as compared to the undamped current from vacuum tubes. We give 0.5 gram of tetracycline orally the night before and early on the morning of operation, because experience has shown that this greatly reduces the incidence of bacteremia during and at the end of operation. Local variations in strains of organisms and their sensitivity to antibiotics may make other agents preferable. At least two units of cross-matched blood are at hand before operation is started. Either spinal or general anesthesia (no explosive agents) is used, the former being avoided in the presence of neurologic disease, backache or apprehension. Ligation and division of the vas is done just before instrumentation is started. The effectiveness of vasectomy in reducing the incidence of epididymitis cannot be denied. Its nature, purpose, and consequences are explained to the patient at least a day ahead of time and he signs a specific, simply worded, explanatory permit in the presence of a witness; a copy is retained for the hospital chart. This is medicolegal prophylaxis! TECHNIQUE
The urethra is lubricated by injecting gently a mixture of mineral oil and KY jelly, and sounds through size 30 French are passed. It has been alleged that the mineral oil may infiltrate tissues and cause granulomas; I doubt that this will follow gentle injection. (Incidentally, glove powder on the piston of a syringe makes it stick so that one cannot tell how forceful an injection is being made.) If the meatus is tight, it is cut until the sound moves freely. Occasionally a urethra which seems capacious at the start of operation begins later to grip the resectoscope sheath; the sheath is removed and the urethra is relubricated and redilated, rarely more than once. If this tightening occurs early or
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recurs frequently, other measures to reduce urethral trauma will be necessary. The same is true when there are strictures below the membranous urethra, a short suspensory ligament of the penis, or protrusion of the median or anterior lobe so located as to press the sheath against the urethra. Several measures are available. Smaller than standard resectoscopes may be used, but this prolongs the operation because the pieces which can be excised are smaller; larger glands cannot be resected with them. Emnlett makes an internal urethrotomy with the Otis urethrotome, but I have seen strictures follow its use. My own choice in all these situations is perineal urethrotomy. This maneuver is also helpful when the distance from external to internal meatus is so great as to hinder manipulation of the resectoscope, as with a large gland, a thick perineum or an erection. It is impossible to overemphasize the vital importance of developing a feeling for urethral trauma; one should never permit pride or haste to prevent using the prophylactic measures outlined above or, in extreme cases, abandoning resection in favor of open operation. Occasionally, even in the absence of reduction of urethral circumference, protruding lateral or median lobes will block the entrance of instruments. This situation can usually be circumvented in one of two ways: A perineal urethrotomy will permit passage of the resectoscope in a straight line, or one may insert a size 6 or 7 ureteral bougie into the bladder from the external meatus, after which the standard resectoscope with the tunneled obturator can usually be passed over it with ease. One may (infrequently) encounter a bladder too small to accept enough irrigating fluid to permit resection of any but the smallest gland because vision clouds with only a few ounces of fluid. This is usually due to spasm of the detrusor, which occurs when resection is undertaken after an inlying catheter has been present only for a day or two. One must not try resection; he can resort to open operation (preferably retropubic or perineal where a small bladder cannot interfere), or he can reinsert the catheter for 24 hours and then resort to intermittent catheterization while plying the patient with Banthine and antibiotics. In the latter event, one should measure capacity before undertaking anesthesia and operation again. In this connection one must remember that interstitial cystitis afflicts elderly men as well as women. Hence, if the residual urine and prostate are both small, the urine is sterile, and no inlying catheter has been used, one should measure the vesical capacity at cystoscopy; if it is well below normal, the bladder is emptied and then inspected for telltale petechiae of interstitial cystitis. No good will come of resecting or removing the prostate in these circumstances. The repeated distention of the bladder incident to resection may yield temporary relief, but recurrence of urgency and increased frequency are inevitable. Occasion-
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ally interstitial cystitis will accompany a really obstructive gland. It is better to find this out and to explain its consequences and the necessary after-treatment to the patient before operation. In case of doubt, it is desirable to await the effect of overdistention rather than to plunge ahead with operation. Many of the poor results reported years ago from
Fig. 266. The technique of attack.
Fig. 267. The objective of transurethral reHection.
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resection of the "small, obstructing prostate" were doubtless due to unrecognized interstitial cystitis. False passages made during insertion of the instruments are due to inexcusable roughness. Overlooking a large diverticulum of the bladder with a small orifice will usually lead to persisting infection and residual urine; in my opinion, all patients with large residual urines should have preoperative cystograms to avoid this error. Persistent late hematuria, although usually due to incomplete resection, may result from failure to notice a tumor of the bladder or to visualize the upper tract. Preoperative hematuria calls for excretory urography and painstaking inspection of the bladder. I have learne(~ to Iny mortification that, if a renal neoplasm complicates an obstructing prostate, it must be removed before the prostate is resected. I once deliberately reversed this order and had later to resect a hypernephroma of the prostate! Similarly, a coexisting bladder tumor is best removed before the prostate is attacked, in an effort to prevent recurrence in the prostatic fossa. Moreover, if the wall of the bladder is thin after resection of the tumor, it is unwise to distend it repeatedly during transurethral prostatic resection until some healing has occurred. The actual technique of resection (Figs. 266 and 267) is a slight modification of Nesbit's. The size and configuration of the gland are determined by careful inspection and palpation; the ureteral orifices and external urethral sphincter are carefully located so that they may be avoided, and the capacity of the bladder is estimated. The anterior cOlnmissure is then divided down close to the external sphincter by excising strips until circular fibers are seen except at the apex. Resection is now carried down between the surgical capsule and lateral lobe, again to a point short of the apex, and hemostasis is secured. This maneuver is repeated on the opposite side. The partly detached lateral lobes are next quickly excised, together with the median lobe. One must take great care during this part of the operation not to detach a large piece of prostate by undercutting it; if it is larger than the lumen of the resectoscope, it can be cut up and removed only with some risk of cutting the bladder and with a great waste of time. It is better to grasp the piece with special cystoscopic forceps (Fig. 268, A) and to remove sheath, forceps and fragment together. No attempt is made to remove all of the hypertrophied tissue until the whole fossa has been roughed out, because to do so will greatly increase the blood loss by opening large periprostatic veins early in the operation. The technique is modified when the middle lobe protrudes into the bladder sufficiently to interfere with evacuation of pieces. '"The intra-
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Fig. 268. A, Cystoscopic forceps for resectoscope. B, Power hoist for the percolator (cover removed, foot switch not shown). C, A simple evacuating syringe.
vesical median lobe is excised first, after which the routine just outlined is followed. It is important, in long glands, to learn to slide the sheath toward the operator while cutting; otherwise, too many cuts will have to be made to cover the distance from internal to external sphincter; this takes too long. Conspicuous spurters are electrocoagulated as they appear. A large one which clouds vision requires elevation of the irrigating pressure until the source of bleeding has been located and stopped, after which the pressure is reduced. A power-operated hoist for the percolator, operated by a double-pedal foot switch, is a time saver here (Fig. 268, B). A finger is kept in the rectum during most of the procedure both to' ascertain the thickness of tissue left behind, and to push it up into the path of the loop. When all of the abnormal tissue has been resected, one feels almost nothing except rectal wall between finger and resectoscope. Next, the apical tissue is excised down to a point just above the level of the superior margin of the verumontanum. Nesbit has described a wrinkle in the mucosa at the upper margin of the external sphincter. Although this is a useful landmark, it is very easy to overlook. Next, the resectoscope is withdrawn until the whole periphery of the lower limit of the resection can be seen. Any protruding tissue is excised.
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One then undertakes to smooth off the whole fossa so as to expose circular fibers except in the region of the external sphincter, where a very thin ledge of hypertrophied tissue is deliberately left to protect that important structure. After this has been completed, one again withdraws the resectoscope to inspect the lower limit of resection; ne,v tags will need excision. It is of the utmost importance not to judge completeness of resection with the bladder full; distention balloons out the fossa and gives a wholly false impression. The inexperienced operator can also be misled into overlooking tags by a thin film of clot which conceals irregularities in the fossa. The last step in the resection proper is inspection of the trigone. If it rises above the new posterior lip of the vesical orifice, the midtrigone is excised flush with the floor of the bladder, care being taken to avoid undermining and interference with the ureteral orifices. The importance of a careful search of the bladder for overlooked pieces of prostate (after all clots have been removed) requires emphasis. A thin film of clot may conceal detached fragments. A small piece may block the catheter. A large piece may turn up later inside a vesical calculus. Removal of fragments merits a few words. They are allowed to accumulate in the bladder until they interfere with vision, at which time many can be made to escape spontaneously if, with the bladder full, one places the beak of the sheath close to (but not touching) the floor of the bladder, removes the working element, and then slowly lowers and raises the ocular end of the sheath (Barnes). Remaining pieces are removed by directing the beak at the pieces and repeatedly injecting and aspirating the same fluid by means of the evacuating syringe (Fig. 268, C). Detached but adherent fragments are readily scraped off with the loop; those resisting removal may be attached to the loop by a brief burst of coagulating current and so withdrawn. COMPLICATIONS AND ACCIDENTS
Six major mishaps can occur during these maneuvers. 1. While advancing the sheath of the resectoscope for the next cut, one may catch the resected edge of the detrusor anteriorly and peel it off the prostate. This mishap is easily avoided by keeping the beak down (posterior) while entering the bladder gently. 2. One may poke the instrument through the prostate just below the detrusor laterally. Keep in the midline and be gentle; if there is any resistance whatever, stop and look. 3. One may undermine the trigone by cutting too deeply about the midline of the posterior lip of the vesical orifiee. The bladder wil~ then be elevated by an extravasation of irrigating fluid as resection progresses, making things needlessly difficult. Otherwise, extravasation here is not
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important if one uses antibiotics and isotonic fluid as already outlined. This extravasation is easily avoided by leaving a little tissue at the posterior lip to the very last, at which time a little undermining does no harm. 4. One may cut clear through the prostate. Anteriorly this opens the prevesical space so that fat may hang down; laterally it.exposes fat; posteriorly it may make a hole in the rectum, this being a catastrophe rather than a mishap. I make no attempt to avoid exposing fat laterally. The integrity of the anterior and posterior walls is protected by stopping when circular fibers are visible. Posteriorly, rectal palpation while resecting is imperative. 5. An intravesical explosion may follow ignition of hydrogen and oxygen liberated by electrolysis. l-'his is easily avoided by fairly frequent complete evacuation of the bla~der to the point of ejection of gas, which can also be aspirated with an evacuating syringe. I prefer the simple evacuator shown in Figure 268, C, to those commonly used. It is a modified 3-ounce Asepto syringe coupled by thick walled latex tubing to a metal adapter. A rigid connection between syringe and resectoscope will lead to frequent breakage. The inside diameter of adapter, tubing and tip of the syringe must be as great as that of the resectoscope sheath. It can be managed with one hand and without assistance. 6. One may cut a hole in the bladder. Since I have never done so during resection of the prostate, I regard this as absolutely inexcusable. It happens when the resectionist's attention wanders and he fails to take his foot completely off the pedal of the foot s,vitch while advancing the scope into the bladder. It also results from cutting in a clouded medium and mistaking trigone or lateral vesical wall for prostate. Don't cut if you can't see clearly. HEMOSTASIS AND REMOVAL OF" CL01"S
1'he danger of occurrence of most of these mishaps is increased by excessive bleeding. If bleeding cannot be controlled by electrocoagulation, three alternatives are available: injecting a vasoconstrictor into the prostate, lowering the blood pressure, or inflating the balloon of a Foley (Alcock) catheter in the fossa. I have found most helpful as a vasoconstrictor a solution containing Pitressin 1 m!., epinephrine 5 drops, and saline 30 m!. Six to 8 m!. are injected into each lateral lobe near the apex and also into the base of the middle lobe. 'rhe blood pressure will rise promptly but briefly. Bleeding is very much reduced, but one must not finish the operation until after the vasoconstriction has disappeared (about 45 minutes), or after-bleeding will occur. Lowering the blood pressure with the aid of a slow intravenous drip of 0.1 per cent Arfonad often spectacularly reduces bleeding. Ileal hypotensive anesthesia is unsafe for elderly patients, but it is rarely if
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ever dangerous to hold the systolic pressure at 100 to 110 mm. of mercury. In our hospital this usually involves some conflict with the anesthesiologists, who like to keep the blood pressure high. I insist upon being informed frequently concerning it, and also insist that no vasopressor agent be used without my prior knowledge. It is amazing how much a 20 mm. rise in systolic pressure can increase bleeding. Any attempt to raise the blood pressure above that which is normal for the patient should be firmly discouraged. Rarely it may be necessary to stop the operation and inflate a Foley balloon of appropriate size in the fossa, perhaps with traction, while steps are taken to control the blood pressure or to inject a vasoconstrictor. Removal of clots is occasionally a problem. lJsually the evacuator already described suffices. If it fails, one may place the beak of the resectoscope over the clots and aspirate them with a piston syringe; the inside diameter of its tip should equal that of the resectoscope sheath. The syringe should be unbreakable (metal or plastic). Evacuation of clots must leave the cut surface of the fossa bare, lest active bleeding or detached pie~es of prostate be concealed. Residual adherent clots may be picked off with cystoscopic forceps or cut off with the loop. CYSTOSTOMY
One can envision a situation requiring opening of the bladder, enucleation of the rest of the adenoma, and packing the fossa with gauze. A usef\ll trick is to take a deep bite of one side of the fossa with 0 plain catgut, then catch the gauze, then the other side of the fossa. Two or more such sutures tightly tied will usually stop the bleeding. Drainage is necessarily by suprapubic tube. Withdrawal of the packing will break the catgut and allow the fossa to open up. I have learned from experience that plain catgut strong enough to compress the fossa may fail to dissolve, hence the importance of catching the packing with it. Ligation of the hypogastric arteries has been recommended by several authors for bleeding uncontrollable by other means. It proved effective in the one instance of late secondary bleeding in which I used it. In deciding whether to open the bladder during transurethral resection it is important to know, from a preoperative culture, whether the urine is sterile. If it is, one can temporize in circumstances in which the presence of pathogens would require open operation. In general, I am complacent about holes in the lateral capsule and about small separations anteriorly and laterally between prostate and bladder. If one is in doubt, a cystogram will show the extent of the resulting leak and so aid in reaching a decision. A large rent anteriorly or laterally requires cystostomy and suture, but a small one requires no treatment if hemostasis is adequate. In case of doubt, it is well to make a short vertical incision through the linea
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alba in the midline above the symphysis pubis. A finger is inserted to the anterior aspect of the prostate and is replaced by a large· Penrose drain, which can usually be removed in two or three days.' . If a hole is made in the rectum, prudence dictates stopping the operation, performing cystostomy and gentle ;packing. of the fossa. I must admit that my only first-hand experience with this accident occurred while the bladder and fossa were distended. When the bladder was emptied, the openings in rectum and prostate did not coincide. I therefore used a Foley catheter, and the openings healed without prolongation of convalescence, but with some reduction of my own life expectancy. If a hole is made in the bladder, a cystogram will show whether it is intra- or extraperitoneal. Cystostomy and suture are imperative in the former event, and also in the latter if the urine is infected and the opening large. However, if the urine is sterile, the opening small and extraperitoneal, and the bleeding well controlled, I am inclined to rely upon a catheter, antibiotics and close observation. Although I have
Fig. 269. A Kreutzmann trocar.
not perforated the bladder itself during transurethral resection, I have had several extraperitoneal ruptures during overdistention for inter-stitial cystitis; all patients recovered with catheter drainage. The simple external drainage mentioned above may be used. An occasional patient will have a huge residual urine (700 m!. or more) without evidence of neurogenic dysfunction. A cystogram is made 'preoperatively to exclude diverticula. In such a situation without diverticula, I like to make a trocar cystostomy (Fig. 269} at the end of resection. The tube is clamped on the third' or fourth postoperative day. If satisfactory urination is impossible and cystoscopy discloses an adequate resection, the patient can be sent home on continuous suprapubic drainage, to be continued until he can empty his formerly hypotonic bladder. This saves an extra operation. If stones were found in the prostate in the preoperative roentgenograms, a film of the pelvis is made at the end of operation so that remaining stones may be found and removed. I have seen failure to do this result in postoperative vesical calculi.
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PERMISSIBLE LENGTH OF OPERATION
Much has been said about the maximum time which may be allowed for a single transurethral resection. If the patient is in good condition, if isotonic irrigating fluid is being used, and if bleeding is being replaced and is not so profuse as to require dangerous volumes of blood, the chief limiting factor is the state of the urethra. If it allows the resectoscope to move freely, there is no cause for concern. If it impedes movement, one must make an internal or perineal urethrotomy or one must discontinue the operation lest damage be done. The single exception is the urethra which becomes tight only a few minutes before the end of the operation; in this circumstance it is permissible to relubricate and redilate the urethra. Neglect of these precautions means strictures, which may cause more grief than the prostatic lesion did. Irrigation
POSTOPERATIVE CARE
In the immediate postoperative period in the uncomplicated procedure, I use a size 22 Foley-Alcock catheter with a 75 ml. balloon which
Fig. 270. A continuous irrigator.
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lies flat against the shaft of the catheter (C. R. Bard). If bleeding has been well controlled, the balloon is inflated to 30 ml. in the bladder; the catheter is attached to an irrigator containing normal saline (Fig. 270). The large limb goes via sterile rubber tubing (I have not yet encountered disposable plastic tubing which has enough flexibility and a large enough lumen) to a sterile bottle with a two-hole stopper. The irrigating fluid drips just fast enough to keep the outflow fairly clear. If, as is very often the case, venous bleeding cannot be well controlled, I put 10 m!. in the balloon, pull it down into the fossa and inflate it (up to 100 ro!. if need be) to stop the bleeding. In the meantime, the amount of blood in the irrigating fluid, which has been collected in a ID-gallon stainless steel can, is measured by Conger and Nesbit's method, and transfusion is started if indicated. If the operation is unusually bloody, or if there is trouble with hypotension, blood loss is measured and transfusion started early. Postoperative irrigating fluid is also saved for measurement of blood loss if desired. As soon as the irrigating fluid from the bladder is consistently clear, the inflow tube of the catheter is disconnected and occluded, and the patient is given a "Dispozabag" for diurnal use. Postoperative Bleeding
Occasionally a patient is sent to the recovery room with his blood pressure at the preoperative level and the return fluid from the bladder clear, only to have bleeding start afresh in an hour or so. If manipulation of the balloon, traction, and so forth do not bring the situation under control promptly, the patient is returned to the cystoscopic room for evacuation of clots and fulguration of bleeders. If the bleeding no,\! gets out of hand, one should never hesitate to open the bladder and pack the fossa as already described. 'fhe time to institute all of these measures is before the patient suffers a really large blood loss; the mere exchange of a large volume of blood by bleeding and transfusion may strain a defective cardiovascular apparatus, and the danger of a transfusion reaction increases in proportion to the number of units of blood given. I have taken a restrained view of the use of agents intended to liquefy clots since my experience with one which extravasated and caused extensive necrosis. The elnphasis upon these measures is based upon my determination to make resection just as complete as enucleation. This procedure opens large veins and makes hemostasis a problelll, but it leads to far more durable results. If all goes well, we give 500 milligrams of tetracycline orally on the evening of the second postoperative day (day of operation is 0), and the catheter is removed* after a second dose the following morning
* The balloon of a ]-'oley catheter which cOlnes out spontaneously should be inspected, lest a piece of latex be left in the bladder.
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unless the urine is bloody, in which case the catheter remains for another day. It seems important to irrigate the bladder for residual clots after deflating the balloon but before withdrawing it. Clots left in situ may later cause urinary retention, and the resultant straining may provoke a postoperative hemorrhage. Intravenous Fluids
In the average patient the fluid intake on the day of operation need not total more than 1000 m!. of 5 per cent glucose intravenously. Most patients will be able to drink as well. If there is a tendency to hypotension with cold, clammy skin and, perhaps, nausea in the immediate postoperative period despite adequate replacement of lost blood, the patient may have received a large inadvertent infusion through the open prostatic veins and so may be suffering from ·hyponatremia. Blood is drawn for an emergency serum sodium Ca hematocrit may be quicker) and, in addition to the standard measures for hypotension, a slow intravenous drip of 3 per cent saline is started; the total volume will be regulated by the value of the serum sodium, from which the deficit of sodium is easily calculated. No other intravenous solutions are given until the serum sodium is known, since their use will aggravate the hyponatremia. When such a situation has been successfully treated, urine output will exceed fluid intake for a day or two. Urinary Problems
The patient is cautioned not to try to void until he has the desire, because many cannot wait to find out how their bladders will work and will strain to get rid of a small volume. If micturition is reasonably comfortable, in good volume and without undue frequency, residual urine is not measured and no medication is given. If there is straining, frequency, unusual hematuria, or chills and fever, residual urine is measured; if it is high, the catheter is left in. Antibiotics are used for chills and fever, and a search is made for causes which need not be listed here. If substantial residual urines persist and one is confident that resection has been complete, the catheter is left in only at night and Urecholine, 50 milligrams four times daily, is given. If the residual persists after two days of this, or if there is straining with neither residual urine nor evidence of acute inflammation in the prostatic remnant, cystoscopy is repeated on the assumption that more tissue has to be removed. Informed pessimism should triumph over optimism here. A few patients will exhibit dysuria with increased frequency, sometimes with fever and impaired stream, after removal of the catheter. The prostate may feel larger than at the end of operation. This is probably acute prostatitis; it is treated with suitable antibacterial agents.
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Epididymitis is rare after vasectomy, but funiculitis down to the point of division of the vas is not uncommon. It ordinarily requires only reassurance. It may occur quite late. Urgency is common right after removal of the catheter but usually subsides in a day or two. True incontinence is rare in the absence of neurogenic dysfunction. Usually it will disappear with persistent sphincter exercises and elimination of infection, but occasionally it will defy all attempts at correction; this is seen chiefly in senile or dispirited patients who will not try to help themselves. Follow-up
After an uneventful recovery, the patient is discharged on the seventh or eighth postoperative day and is asked to stay in town for a few days to make sure that resumption of activity will not cause trouble. He receives an instruction sheet concerning limitation of activity, what to expect and when to call the doctor, as well as a return appointment. If he has had a meatotomy, or if the meatus is red and inflamed, he is given a plastic dilator and I{Y jelly and is sho,vn how to use them daily until he returns. Out of town patients are asked to return in six to eight weeks. A sound is passed then because experience has shown that a stricture must be rather tight before the patient notices anything amiss. Pyuria calls for culture and appropriate antibacterial agents. Persisting symptoms demand cystoscopy. If the amount resected was small (arbitrarily, 20 to 25 grams) the prostatic urethra is calibrated with the Rollman dilator and the patient is given an antibacterial agent to take for two days. Bitter experience has taught me that the scar of a small resection can be expected to cause contracture of the vesical neck so often that preventive measures should be employed in every instance. I try to have such patients come back for RoIlman dilatation at increasing intervals for two years. SUMMARY AND CONCLUSIONS
Essential to a safe and successful transurethral resection of the prostate are: (1) proper selection of the patient; (2) an efficient armamentarium; (3) a thorough understanding of the technique; and (4) an appreciation of the delicacy of the urethra. Avoidable complications of the operation include: (1) injuries to the urethra; (2) perforations of the prostate, the prostatovesical junction and the bladder; (3) hemorrhage during and after operation; (4) intravesical explosions; (5) cutting the external sphincter and ureteral orifices; (6) leaving detached pieces behind; (7) hemolysis with renal injury; (8) incomplete removal of obstructing tissue; (8) hyponatremia; and (10) epididymitis. Means of preventing or coping with most of these complications are discussed.
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REFERENCES 1. Barnes, R. W.: Endoscopic Prostatic Surgery. St. Louis, C. V. Mosby Co., 1943. 2. Campbell, M. F.: A New Fenestrated Trocar. J. Uro!. 65: 160, 1951. 3. Creevy, C. D.: The Intraprostatic Injection of Pitressin and Adrenalin in the Control of Bleeding during Transurethral Resection. J. Uro!. 50: 593, 1943. 4. Creevy, C. D. and Feeney, M. J.: Routine Use of Antibiotics in Transurethral Prostatic Resection. J. Uro!. 71: 615, 1954. 5. Creevy, C. D. and Webb, E. A.: A Fatal Hemolytic Reaction Following Transurethral Resection of the Prostate Gland. Surgery 21: 56, 1947. 6. Emmett, J. L.) Kirchheim, D. and Greene, L.: Prevention of Postoperative Stricture from Transurethral Resection by Preliminary Internal Urethrotomy. J. Uro!. 78: 456, 1957. 7. Garske, G. L.: New Drape for Transurethral Surgery and Cystoscopic Procedures. J. Urol. 69: 135, 1953. 8. Hoyt, H. S., Goebel, J. L., Lee, H. I. and Schoenbrod, J.: Types of Shocklike Reactions during Transurethral Resection, and Their Relationship to Acute Renal Failure. J. Uro!. 79: 500, 1958. 9. Kreutzmann, H. A. R.: An Improved Suprapubic Trocar. J. Uro!. 4-0: 341,1938. 10. Nesbit, R. M.: Transurethral Prostatectomy. Springfield, Ill., Charles C Thomas, 1943. 11. Nesbit, R. M.: Personal communication. 12. Nesbit, R. M.: Transurethral Prostatic Resection, In Campbell, M. F. (editor): Urology. Philadelphia, W. B. Saunders Co. 1954, vol. 3, p. 2015. 13. Nesbit, R. M. and Conger, K. B.: Studies of Blood Loss during Transurethral Prostatic Resection. t1. Uro!. 46: 713, 1941. 14. Taylor, R. O. and others: Volumetric, Gravimetric, and Radioisotope Determination of Fluid Transfer in Transurethral Prostatic Resection. J. Urol. 79: 490, 1958. 15. Wellner, C. E. and Hamm, R. S.: Radical Control of Post-Prostatectomy Haemorrhage. Arch. Surge 73: 790, 1956. 16. Weyrauch, H. M.: Surgery of the Prostate. Philadelphia, W. B. Saunders Co., 1959. 412 Union Street, S. E. Minneapolis 14, Minnesota
IT
SEEMS to me that a thorough discussion of methods of avoiding (or more honestly, of trying to avoid) complications during and after transurethral prostatic resection requires a detailed presentation of technique. The first step in the successful performance of this operation is proper selection of the patient; i.e., the operation should be chosen to fit him and his disease, and not vice versa. It is assumed that the patient's general state and his renal function will be brought to their optimum levels before operation, and that complications unrelated to the prostatism will receive adequate attention. It is my conviction that symptoms must be severe enough so that the patient earnestly desires relief. Since no surgical operation yields uniformly satisfactory results, it is unwise to persuade a patient with only mild, premonitory symptoms of prostatism to submit to operation. The least complication or imperfection in result may leave him feeling cheated, and a postoperative urethral stricture will be worse than the original complaint. A preoperative roentgenogram of the urinary tract is routine; one is thus forewarned particularly of stones and metastases. Altered renal shadows prompt excretory urography. A preoperative urine culture is desirable; one will then know whether the urine is sterile or what antibacterial agent to use if it is contaminated, just in case of accident. Because of variations in individual preferences and judgment, I shall not discuss the relative merits of the various standard types of prostatic operations, nor specific reasons for selecting one rather than the others. Several local factors may hinder or contraindicate the transurethral
From the Urological Division of the Department of Surgery, Medical School of the University of Minnesota, M inneapolis. • Profe88or of Surgery and Director of the Urological Division of the Department of Surgery.
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operation. Among these are a narrow urethra, a thick perineum, a short suspensory ligament of the penis (all of which. will be discussed later), and an unusually large prostate as judged by repeated rectal palpation and, often, by urethrography. Each operator must decide for himself how large a gland he is able and willing to resect. From my point of view, a prostate as large as 150 grams may be resected'if all of the local conditions listed above are favorable and if the blood pressure is not too high. However, I have no quarrel with those who set the maximum much lower. Every urologist should be able to use all of the standard surgical approaches to the prostate, and each one will finally prefer one particular method for the average obstructing gland. Although I have in the distant past resected 190 grams from each of two patients in one session and 60 grams in a second, I do not now feel that the resection of such large glands is reasonable. CONTRAINDICATIONS
There are three absolute contraindications to transurethral resection: the presence in the bladder of a lesion requiring open operation, ankylosis of one or both hips so as to prevent placement of the patient in the proper position, and severe long strictures far back in the bulb or in the membranous urethra. A relative contraindication is high hypertension in the presence of a large gland, a combination tending to make for difficult hemostasis and excessive blood loss.
Fig. 261. The modified resectoscope and the injector for Pitressin.
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EQUIPMENT
It is futile to try to perform the operation without good equipment. Personal preference will dictate selection of the right resectoscope (Fig. 261). In my opinion, the plastic sheath should have a metal cover, which slides more freely than does plastic and therefore traumatizes the urethra less. The cover should end 1 cm. from the butt so that, if the insulating block fails, current cannot arc from butt to cover and burn the urethra. A modified Nesbit handle is used. I much prefer a short beak to a long one; the latter is in the way when one seeks to hollow out the fossa. Ordinarily, I use the Timberlake obturator. The spring on the lock is rewound in a direction opposite to standard so as to hold the working element in the sheath, thus preventing many a squirt in the face. Replacement of the inflow valve on the sheath with one having an inside diameter of 3/16 inch will improve vision during brisk bleeding. The small valve on the working element is removed and its opening plugged. Loops made of O.Q12\"inch rather than O.015-inch wire do· not last as long as the heavier ones, but they cut with a weaker current and leave less burned tissue. The instrument must work smootWy with one hand. Nesbit long ago emphasized that the lock on the working element must be loose, and
Fig. 262. The Foley table.
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.C. D. Creevy
Fig. 263. Alcock leg holders and the swinging, counterbalanced support for tubing and cords (viewed from head of table).
Fig. 264. Garske plastic drape partly covered by leggings;. O'Conor sheath in place.
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that the screws holding loop and telescope should be no tighter than absolutely necessary if movement is to be free. Loop and telescope must be straight (sight along them). The guide on which the working element moves may get out of line; this can be corrected by loosening the screw which holds it and finding the position which permits free motion. A paper shim above the guide (A in Fig. 261) may prevent binding. Lubricants are washed off so promptly that their use is futile. A binding working element may sometimes be freed by placing valve gr~ding compound on the guide and working the element in and out innumerable times (Nesbit). If it still fails to move with complete freedom, a new one should be obtained. I find that a strong spring on the working element is tiring to use.
Fig. 265. Modified O'Conor sheath.
It is essential to have two sheaths, two working elements, several telescopes and a half dozen loops sterile. When the instrument is cleaned after use, the same loop should be replaced in it; otherwise one will accumulate a number of used loops, all of which may burn out during one operation, occasioning much delay. A power-operated cystoscopic table such as the Foley (Fig. 262), which can be raised, lowered and tilted by pressure on foot pedals, saves a great deal of time and, properly used, minimizes the strain on the operator's back. Alcock leg holders (Fig. 263) minimize venous stasis and discourage phlebothrombosis. Use of the Garske plastic drape (Fig. 264) saves time in draping the patient, prevents contamination via soaked cloth drapes, and permits the use of a simplified and less cumbersome O'Conor sheath (Fig. 265), which is essential for aseptic, rectal palpation. I like a low, padded, adjustable stool with well
c. D. Creevy
1754
oiled casters, and prefer to raise and lower the table rather than to adjust the stool. A free-swinging, counterbalanced arm on the table (Fig. 263) supports light and diathermy cords and water tube, which then do not become tangled. A nonelectrolytic, isotonic irrigating fluid (4 per cent glucose, 1.1 per cent glycine, 3 per cent mannitol [Cytal]) prevents intravesical and intravascular hemolysis, and, in the event of extravasation, probably injures tissue less than does plain water. A good, reliable electrosurgical unit of adequate power is essential. The best cutting current is generated by vacuum tubes, and the most effective coagulating current comes from a spark gap. My own preference is for the machine made by American Cystoscope Makers, Inc., but several other manufacturers make excellent ones. The proper setting for power output varies from one make to another; in general, one uses the lowest setting that gives the desired result. I cannot say that cutting with a Clblended" current reduces bleeding as compared to the undamped current from vacuum tubes. We give 0.5 gram of tetracycline orally the night before and early on the morning of operation, because experience has shown that this greatly reduces the incidence of bacteremia during and at the end of operation. Local variations in strains of organisms and their sensitivity to antibiotics may make other agents preferable. At least two units of cross-matched blood are at hand before operation is started. Either spinal or general anesthesia (no explosive agents) is used, the former being avoided in the presence of neurologic disease, backache or apprehension. Ligation and division of the vas is done just before instrumentation is started. The effectiveness of vasectomy in reducing the incidence of epididymitis cannot be denied. Its nature, purpose, and consequences are explained to the patient at least a day ahead of time and he signs a specific, simply worded, explanatory permit in the presence of a witness; a copy is retained for the hospital chart. This is medicolegal prophylaxis! TECHNIQUE
The urethra is lubricated by injecting gently a mixture of mineral oil and KY jelly, and sounds through size 30 French are passed. It has been alleged that the mineral oil may infiltrate tissues and cause granulomas; I doubt that this will follow gentle injection. (Incidentally, glove powder on the piston of a syringe makes it stick so that one cannot tell how forceful an injection is being made.) If the meatus is tight, it is cut until the sound moves freely. Occasionally a urethra which seems capacious at the start of operation begins later to grip the resectoscope sheath; the sheath is removed and the urethra is relubricated and redilated, rarely more than once. If this tightening occurs early or
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recurs frequently, other measures to reduce urethral trauma will be necessary. The same is true when there are strictures below the membranous urethra, a short suspensory ligament of the penis, or protrusion of the median or anterior lobe so located as to press the sheath against the urethra. Several measures are available. Smaller than standard resectoscopes may be used, but this prolongs the operation because the pieces which can be excised are smaller; larger glands cannot be resected with them. Emnlett makes an internal urethrotomy with the Otis urethrotome, but I have seen strictures follow its use. My own choice in all these situations is perineal urethrotomy. This maneuver is also helpful when the distance from external to internal meatus is so great as to hinder manipulation of the resectoscope, as with a large gland, a thick perineum or an erection. It is impossible to overemphasize the vital importance of developing a feeling for urethral trauma; one should never permit pride or haste to prevent using the prophylactic measures outlined above or, in extreme cases, abandoning resection in favor of open operation. Occasionally, even in the absence of reduction of urethral circumference, protruding lateral or median lobes will block the entrance of instruments. This situation can usually be circumvented in one of two ways: A perineal urethrotomy will permit passage of the resectoscope in a straight line, or one may insert a size 6 or 7 ureteral bougie into the bladder from the external meatus, after which the standard resectoscope with the tunneled obturator can usually be passed over it with ease. One may (infrequently) encounter a bladder too small to accept enough irrigating fluid to permit resection of any but the smallest gland because vision clouds with only a few ounces of fluid. This is usually due to spasm of the detrusor, which occurs when resection is undertaken after an inlying catheter has been present only for a day or two. One must not try resection; he can resort to open operation (preferably retropubic or perineal where a small bladder cannot interfere), or he can reinsert the catheter for 24 hours and then resort to intermittent catheterization while plying the patient with Banthine and antibiotics. In the latter event, one should measure capacity before undertaking anesthesia and operation again. In this connection one must remember that interstitial cystitis afflicts elderly men as well as women. Hence, if the residual urine and prostate are both small, the urine is sterile, and no inlying catheter has been used, one should measure the vesical capacity at cystoscopy; if it is well below normal, the bladder is emptied and then inspected for telltale petechiae of interstitial cystitis. No good will come of resecting or removing the prostate in these circumstances. The repeated distention of the bladder incident to resection may yield temporary relief, but recurrence of urgency and increased frequency are inevitable. Occasion-
c. D. Creevy
1756
ally interstitial cystitis will accompany a really obstructive gland. It is better to find this out and to explain its consequences and the necessary after-treatment to the patient before operation. In case of doubt, it is desirable to await the effect of overdistention rather than to plunge ahead with operation. Many of the poor results reported years ago from
Fig. 266. The technique of attack.
Fig. 267. The objective of transurethral reHection.
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resection of the "small, obstructing prostate" were doubtless due to unrecognized interstitial cystitis. False passages made during insertion of the instruments are due to inexcusable roughness. Overlooking a large diverticulum of the bladder with a small orifice will usually lead to persisting infection and residual urine; in my opinion, all patients with large residual urines should have preoperative cystograms to avoid this error. Persistent late hematuria, although usually due to incomplete resection, may result from failure to notice a tumor of the bladder or to visualize the upper tract. Preoperative hematuria calls for excretory urography and painstaking inspection of the bladder. I have learne(~ to Iny mortification that, if a renal neoplasm complicates an obstructing prostate, it must be removed before the prostate is resected. I once deliberately reversed this order and had later to resect a hypernephroma of the prostate! Similarly, a coexisting bladder tumor is best removed before the prostate is attacked, in an effort to prevent recurrence in the prostatic fossa. Moreover, if the wall of the bladder is thin after resection of the tumor, it is unwise to distend it repeatedly during transurethral prostatic resection until some healing has occurred. The actual technique of resection (Figs. 266 and 267) is a slight modification of Nesbit's. The size and configuration of the gland are determined by careful inspection and palpation; the ureteral orifices and external urethral sphincter are carefully located so that they may be avoided, and the capacity of the bladder is estimated. The anterior cOlnmissure is then divided down close to the external sphincter by excising strips until circular fibers are seen except at the apex. Resection is now carried down between the surgical capsule and lateral lobe, again to a point short of the apex, and hemostasis is secured. This maneuver is repeated on the opposite side. The partly detached lateral lobes are next quickly excised, together with the median lobe. One must take great care during this part of the operation not to detach a large piece of prostate by undercutting it; if it is larger than the lumen of the resectoscope, it can be cut up and removed only with some risk of cutting the bladder and with a great waste of time. It is better to grasp the piece with special cystoscopic forceps (Fig. 268, A) and to remove sheath, forceps and fragment together. No attempt is made to remove all of the hypertrophied tissue until the whole fossa has been roughed out, because to do so will greatly increase the blood loss by opening large periprostatic veins early in the operation. The technique is modified when the middle lobe protrudes into the bladder sufficiently to interfere with evacuation of pieces. '"The intra-
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C. D. Creevy
Fig. 268. A, Cystoscopic forceps for resectoscope. B, Power hoist for the percolator (cover removed, foot switch not shown). C, A simple evacuating syringe.
vesical median lobe is excised first, after which the routine just outlined is followed. It is important, in long glands, to learn to slide the sheath toward the operator while cutting; otherwise, too many cuts will have to be made to cover the distance from internal to external sphincter; this takes too long. Conspicuous spurters are electrocoagulated as they appear. A large one which clouds vision requires elevation of the irrigating pressure until the source of bleeding has been located and stopped, after which the pressure is reduced. A power-operated hoist for the percolator, operated by a double-pedal foot switch, is a time saver here (Fig. 268, B). A finger is kept in the rectum during most of the procedure both to' ascertain the thickness of tissue left behind, and to push it up into the path of the loop. When all of the abnormal tissue has been resected, one feels almost nothing except rectal wall between finger and resectoscope. Next, the apical tissue is excised down to a point just above the level of the superior margin of the verumontanum. Nesbit has described a wrinkle in the mucosa at the upper margin of the external sphincter. Although this is a useful landmark, it is very easy to overlook. Next, the resectoscope is withdrawn until the whole periphery of the lower limit of the resection can be seen. Any protruding tissue is excised.
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One then undertakes to smooth off the whole fossa so as to expose circular fibers except in the region of the external sphincter, where a very thin ledge of hypertrophied tissue is deliberately left to protect that important structure. After this has been completed, one again withdraws the resectoscope to inspect the lower limit of resection; ne,v tags will need excision. It is of the utmost importance not to judge completeness of resection with the bladder full; distention balloons out the fossa and gives a wholly false impression. The inexperienced operator can also be misled into overlooking tags by a thin film of clot which conceals irregularities in the fossa. The last step in the resection proper is inspection of the trigone. If it rises above the new posterior lip of the vesical orifice, the midtrigone is excised flush with the floor of the bladder, care being taken to avoid undermining and interference with the ureteral orifices. The importance of a careful search of the bladder for overlooked pieces of prostate (after all clots have been removed) requires emphasis. A thin film of clot may conceal detached fragments. A small piece may block the catheter. A large piece may turn up later inside a vesical calculus. Removal of fragments merits a few words. They are allowed to accumulate in the bladder until they interfere with vision, at which time many can be made to escape spontaneously if, with the bladder full, one places the beak of the sheath close to (but not touching) the floor of the bladder, removes the working element, and then slowly lowers and raises the ocular end of the sheath (Barnes). Remaining pieces are removed by directing the beak at the pieces and repeatedly injecting and aspirating the same fluid by means of the evacuating syringe (Fig. 268, C). Detached but adherent fragments are readily scraped off with the loop; those resisting removal may be attached to the loop by a brief burst of coagulating current and so withdrawn. COMPLICATIONS AND ACCIDENTS
Six major mishaps can occur during these maneuvers. 1. While advancing the sheath of the resectoscope for the next cut, one may catch the resected edge of the detrusor anteriorly and peel it off the prostate. This mishap is easily avoided by keeping the beak down (posterior) while entering the bladder gently. 2. One may poke the instrument through the prostate just below the detrusor laterally. Keep in the midline and be gentle; if there is any resistance whatever, stop and look. 3. One may undermine the trigone by cutting too deeply about the midline of the posterior lip of the vesical orifiee. The bladder wil~ then be elevated by an extravasation of irrigating fluid as resection progresses, making things needlessly difficult. Otherwise, extravasation here is not
C. D. Creevy
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important if one uses antibiotics and isotonic fluid as already outlined. This extravasation is easily avoided by leaving a little tissue at the posterior lip to the very last, at which time a little undermining does no harm. 4. One may cut clear through the prostate. Anteriorly this opens the prevesical space so that fat may hang down; laterally it.exposes fat; posteriorly it may make a hole in the rectum, this being a catastrophe rather than a mishap. I make no attempt to avoid exposing fat laterally. The integrity of the anterior and posterior walls is protected by stopping when circular fibers are visible. Posteriorly, rectal palpation while resecting is imperative. 5. An intravesical explosion may follow ignition of hydrogen and oxygen liberated by electrolysis. l-'his is easily avoided by fairly frequent complete evacuation of the bla~der to the point of ejection of gas, which can also be aspirated with an evacuating syringe. I prefer the simple evacuator shown in Figure 268, C, to those commonly used. It is a modified 3-ounce Asepto syringe coupled by thick walled latex tubing to a metal adapter. A rigid connection between syringe and resectoscope will lead to frequent breakage. The inside diameter of adapter, tubing and tip of the syringe must be as great as that of the resectoscope sheath. It can be managed with one hand and without assistance. 6. One may cut a hole in the bladder. Since I have never done so during resection of the prostate, I regard this as absolutely inexcusable. It happens when the resectionist's attention wanders and he fails to take his foot completely off the pedal of the foot s,vitch while advancing the scope into the bladder. It also results from cutting in a clouded medium and mistaking trigone or lateral vesical wall for prostate. Don't cut if you can't see clearly. HEMOSTASIS AND REMOVAL OF" CL01"S
1'he danger of occurrence of most of these mishaps is increased by excessive bleeding. If bleeding cannot be controlled by electrocoagulation, three alternatives are available: injecting a vasoconstrictor into the prostate, lowering the blood pressure, or inflating the balloon of a Foley (Alcock) catheter in the fossa. I have found most helpful as a vasoconstrictor a solution containing Pitressin 1 m!., epinephrine 5 drops, and saline 30 m!. Six to 8 m!. are injected into each lateral lobe near the apex and also into the base of the middle lobe. 'rhe blood pressure will rise promptly but briefly. Bleeding is very much reduced, but one must not finish the operation until after the vasoconstriction has disappeared (about 45 minutes), or after-bleeding will occur. Lowering the blood pressure with the aid of a slow intravenous drip of 0.1 per cent Arfonad often spectacularly reduces bleeding. Ileal hypotensive anesthesia is unsafe for elderly patients, but it is rarely if
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ever dangerous to hold the systolic pressure at 100 to 110 mm. of mercury. In our hospital this usually involves some conflict with the anesthesiologists, who like to keep the blood pressure high. I insist upon being informed frequently concerning it, and also insist that no vasopressor agent be used without my prior knowledge. It is amazing how much a 20 mm. rise in systolic pressure can increase bleeding. Any attempt to raise the blood pressure above that which is normal for the patient should be firmly discouraged. Rarely it may be necessary to stop the operation and inflate a Foley balloon of appropriate size in the fossa, perhaps with traction, while steps are taken to control the blood pressure or to inject a vasoconstrictor. Removal of clots is occasionally a problem. lJsually the evacuator already described suffices. If it fails, one may place the beak of the resectoscope over the clots and aspirate them with a piston syringe; the inside diameter of its tip should equal that of the resectoscope sheath. The syringe should be unbreakable (metal or plastic). Evacuation of clots must leave the cut surface of the fossa bare, lest active bleeding or detached pie~es of prostate be concealed. Residual adherent clots may be picked off with cystoscopic forceps or cut off with the loop. CYSTOSTOMY
One can envision a situation requiring opening of the bladder, enucleation of the rest of the adenoma, and packing the fossa with gauze. A usef\ll trick is to take a deep bite of one side of the fossa with 0 plain catgut, then catch the gauze, then the other side of the fossa. Two or more such sutures tightly tied will usually stop the bleeding. Drainage is necessarily by suprapubic tube. Withdrawal of the packing will break the catgut and allow the fossa to open up. I have learned from experience that plain catgut strong enough to compress the fossa may fail to dissolve, hence the importance of catching the packing with it. Ligation of the hypogastric arteries has been recommended by several authors for bleeding uncontrollable by other means. It proved effective in the one instance of late secondary bleeding in which I used it. In deciding whether to open the bladder during transurethral resection it is important to know, from a preoperative culture, whether the urine is sterile. If it is, one can temporize in circumstances in which the presence of pathogens would require open operation. In general, I am complacent about holes in the lateral capsule and about small separations anteriorly and laterally between prostate and bladder. If one is in doubt, a cystogram will show the extent of the resulting leak and so aid in reaching a decision. A large rent anteriorly or laterally requires cystostomy and suture, but a small one requires no treatment if hemostasis is adequate. In case of doubt, it is well to make a short vertical incision through the linea
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G. D. Greevy
alba in the midline above the symphysis pubis. A finger is inserted to the anterior aspect of the prostate and is replaced by a large· Penrose drain, which can usually be removed in two or three days.' . If a hole is made in the rectum, prudence dictates stopping the operation, performing cystostomy and gentle ;packing. of the fossa. I must admit that my only first-hand experience with this accident occurred while the bladder and fossa were distended. When the bladder was emptied, the openings in rectum and prostate did not coincide. I therefore used a Foley catheter, and the openings healed without prolongation of convalescence, but with some reduction of my own life expectancy. If a hole is made in the bladder, a cystogram will show whether it is intra- or extraperitoneal. Cystostomy and suture are imperative in the former event, and also in the latter if the urine is infected and the opening large. However, if the urine is sterile, the opening small and extraperitoneal, and the bleeding well controlled, I am inclined to rely upon a catheter, antibiotics and close observation. Although I have
Fig. 269. A Kreutzmann trocar.
not perforated the bladder itself during transurethral resection, I have had several extraperitoneal ruptures during overdistention for inter-stitial cystitis; all patients recovered with catheter drainage. The simple external drainage mentioned above may be used. An occasional patient will have a huge residual urine (700 m!. or more) without evidence of neurogenic dysfunction. A cystogram is made 'preoperatively to exclude diverticula. In such a situation without diverticula, I like to make a trocar cystostomy (Fig. 269} at the end of resection. The tube is clamped on the third' or fourth postoperative day. If satisfactory urination is impossible and cystoscopy discloses an adequate resection, the patient can be sent home on continuous suprapubic drainage, to be continued until he can empty his formerly hypotonic bladder. This saves an extra operation. If stones were found in the prostate in the preoperative roentgenograms, a film of the pelvis is made at the end of operation so that remaining stones may be found and removed. I have seen failure to do this result in postoperative vesical calculi.
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PERMISSIBLE LENGTH OF OPERATION
Much has been said about the maximum time which may be allowed for a single transurethral resection. If the patient is in good condition, if isotonic irrigating fluid is being used, and if bleeding is being replaced and is not so profuse as to require dangerous volumes of blood, the chief limiting factor is the state of the urethra. If it allows the resectoscope to move freely, there is no cause for concern. If it impedes movement, one must make an internal or perineal urethrotomy or one must discontinue the operation lest damage be done. The single exception is the urethra which becomes tight only a few minutes before the end of the operation; in this circumstance it is permissible to relubricate and redilate the urethra. Neglect of these precautions means strictures, which may cause more grief than the prostatic lesion did. Irrigation
POSTOPERATIVE CARE
In the immediate postoperative period in the uncomplicated procedure, I use a size 22 Foley-Alcock catheter with a 75 ml. balloon which
Fig. 270. A continuous irrigator.
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C. D. Creevy
lies flat against the shaft of the catheter (C. R. Bard). If bleeding has been well controlled, the balloon is inflated to 30 ml. in the bladder; the catheter is attached to an irrigator containing normal saline (Fig. 270). The large limb goes via sterile rubber tubing (I have not yet encountered disposable plastic tubing which has enough flexibility and a large enough lumen) to a sterile bottle with a two-hole stopper. The irrigating fluid drips just fast enough to keep the outflow fairly clear. If, as is very often the case, venous bleeding cannot be well controlled, I put 10 m!. in the balloon, pull it down into the fossa and inflate it (up to 100 ro!. if need be) to stop the bleeding. In the meantime, the amount of blood in the irrigating fluid, which has been collected in a ID-gallon stainless steel can, is measured by Conger and Nesbit's method, and transfusion is started if indicated. If the operation is unusually bloody, or if there is trouble with hypotension, blood loss is measured and transfusion started early. Postoperative irrigating fluid is also saved for measurement of blood loss if desired. As soon as the irrigating fluid from the bladder is consistently clear, the inflow tube of the catheter is disconnected and occluded, and the patient is given a "Dispozabag" for diurnal use. Postoperative Bleeding
Occasionally a patient is sent to the recovery room with his blood pressure at the preoperative level and the return fluid from the bladder clear, only to have bleeding start afresh in an hour or so. If manipulation of the balloon, traction, and so forth do not bring the situation under control promptly, the patient is returned to the cystoscopic room for evacuation of clots and fulguration of bleeders. If the bleeding no,\! gets out of hand, one should never hesitate to open the bladder and pack the fossa as already described. 'fhe time to institute all of these measures is before the patient suffers a really large blood loss; the mere exchange of a large volume of blood by bleeding and transfusion may strain a defective cardiovascular apparatus, and the danger of a transfusion reaction increases in proportion to the number of units of blood given. I have taken a restrained view of the use of agents intended to liquefy clots since my experience with one which extravasated and caused extensive necrosis. The elnphasis upon these measures is based upon my determination to make resection just as complete as enucleation. This procedure opens large veins and makes hemostasis a problelll, but it leads to far more durable results. If all goes well, we give 500 milligrams of tetracycline orally on the evening of the second postoperative day (day of operation is 0), and the catheter is removed* after a second dose the following morning
* The balloon of a ]-'oley catheter which cOlnes out spontaneously should be inspected, lest a piece of latex be left in the bladder.
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unless the urine is bloody, in which case the catheter remains for another day. It seems important to irrigate the bladder for residual clots after deflating the balloon but before withdrawing it. Clots left in situ may later cause urinary retention, and the resultant straining may provoke a postoperative hemorrhage. Intravenous Fluids
In the average patient the fluid intake on the day of operation need not total more than 1000 m!. of 5 per cent glucose intravenously. Most patients will be able to drink as well. If there is a tendency to hypotension with cold, clammy skin and, perhaps, nausea in the immediate postoperative period despite adequate replacement of lost blood, the patient may have received a large inadvertent infusion through the open prostatic veins and so may be suffering from ·hyponatremia. Blood is drawn for an emergency serum sodium Ca hematocrit may be quicker) and, in addition to the standard measures for hypotension, a slow intravenous drip of 3 per cent saline is started; the total volume will be regulated by the value of the serum sodium, from which the deficit of sodium is easily calculated. No other intravenous solutions are given until the serum sodium is known, since their use will aggravate the hyponatremia. When such a situation has been successfully treated, urine output will exceed fluid intake for a day or two. Urinary Problems
The patient is cautioned not to try to void until he has the desire, because many cannot wait to find out how their bladders will work and will strain to get rid of a small volume. If micturition is reasonably comfortable, in good volume and without undue frequency, residual urine is not measured and no medication is given. If there is straining, frequency, unusual hematuria, or chills and fever, residual urine is measured; if it is high, the catheter is left in. Antibiotics are used for chills and fever, and a search is made for causes which need not be listed here. If substantial residual urines persist and one is confident that resection has been complete, the catheter is left in only at night and Urecholine, 50 milligrams four times daily, is given. If the residual persists after two days of this, or if there is straining with neither residual urine nor evidence of acute inflammation in the prostatic remnant, cystoscopy is repeated on the assumption that more tissue has to be removed. Informed pessimism should triumph over optimism here. A few patients will exhibit dysuria with increased frequency, sometimes with fever and impaired stream, after removal of the catheter. The prostate may feel larger than at the end of operation. This is probably acute prostatitis; it is treated with suitable antibacterial agents.
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Epididymitis is rare after vasectomy, but funiculitis down to the point of division of the vas is not uncommon. It ordinarily requires only reassurance. It may occur quite late. Urgency is common right after removal of the catheter but usually subsides in a day or two. True incontinence is rare in the absence of neurogenic dysfunction. Usually it will disappear with persistent sphincter exercises and elimination of infection, but occasionally it will defy all attempts at correction; this is seen chiefly in senile or dispirited patients who will not try to help themselves. Follow-up
After an uneventful recovery, the patient is discharged on the seventh or eighth postoperative day and is asked to stay in town for a few days to make sure that resumption of activity will not cause trouble. He receives an instruction sheet concerning limitation of activity, what to expect and when to call the doctor, as well as a return appointment. If he has had a meatotomy, or if the meatus is red and inflamed, he is given a plastic dilator and I{Y jelly and is sho,vn how to use them daily until he returns. Out of town patients are asked to return in six to eight weeks. A sound is passed then because experience has shown that a stricture must be rather tight before the patient notices anything amiss. Pyuria calls for culture and appropriate antibacterial agents. Persisting symptoms demand cystoscopy. If the amount resected was small (arbitrarily, 20 to 25 grams) the prostatic urethra is calibrated with the Rollman dilator and the patient is given an antibacterial agent to take for two days. Bitter experience has taught me that the scar of a small resection can be expected to cause contracture of the vesical neck so often that preventive measures should be employed in every instance. I try to have such patients come back for RoIlman dilatation at increasing intervals for two years. SUMMARY AND CONCLUSIONS
Essential to a safe and successful transurethral resection of the prostate are: (1) proper selection of the patient; (2) an efficient armamentarium; (3) a thorough understanding of the technique; and (4) an appreciation of the delicacy of the urethra. Avoidable complications of the operation include: (1) injuries to the urethra; (2) perforations of the prostate, the prostatovesical junction and the bladder; (3) hemorrhage during and after operation; (4) intravesical explosions; (5) cutting the external sphincter and ureteral orifices; (6) leaving detached pieces behind; (7) hemolysis with renal injury; (8) incomplete removal of obstructing tissue; (8) hyponatremia; and (10) epididymitis. Means of preventing or coping with most of these complications are discussed.
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REFERENCES 1. Barnes, R. W.: Endoscopic Prostatic Surgery. St. Louis, C. V. Mosby Co., 1943. 2. Campbell, M. F.: A New Fenestrated Trocar. J. Uro!. 65: 160, 1951. 3. Creevy, C. D.: The Intraprostatic Injection of Pitressin and Adrenalin in the Control of Bleeding during Transurethral Resection. J. Uro!. 50: 593, 1943. 4. Creevy, C. D. and Feeney, M. J.: Routine Use of Antibiotics in Transurethral Prostatic Resection. J. Uro!. 71: 615, 1954. 5. Creevy, C. D. and Webb, E. A.: A Fatal Hemolytic Reaction Following Transurethral Resection of the Prostate Gland. Surgery 21: 56, 1947. 6. Emmett, J. L.) Kirchheim, D. and Greene, L.: Prevention of Postoperative Stricture from Transurethral Resection by Preliminary Internal Urethrotomy. J. Uro!. 78: 456, 1957. 7. Garske, G. L.: New Drape for Transurethral Surgery and Cystoscopic Procedures. J. Urol. 69: 135, 1953. 8. Hoyt, H. S., Goebel, J. L., Lee, H. I. and Schoenbrod, J.: Types of Shocklike Reactions during Transurethral Resection, and Their Relationship to Acute Renal Failure. J. Uro!. 79: 500, 1958. 9. Kreutzmann, H. A. R.: An Improved Suprapubic Trocar. J. Uro!. 4-0: 341,1938. 10. Nesbit, R. M.: Transurethral Prostatectomy. Springfield, Ill., Charles C Thomas, 1943. 11. Nesbit, R. M.: Personal communication. 12. Nesbit, R. M.: Transurethral Prostatic Resection, In Campbell, M. F. (editor): Urology. Philadelphia, W. B. Saunders Co. 1954, vol. 3, p. 2015. 13. Nesbit, R. M. and Conger, K. B.: Studies of Blood Loss during Transurethral Prostatic Resection. t1. Uro!. 46: 713, 1941. 14. Taylor, R. O. and others: Volumetric, Gravimetric, and Radioisotope Determination of Fluid Transfer in Transurethral Prostatic Resection. J. Urol. 79: 490, 1958. 15. Wellner, C. E. and Hamm, R. S.: Radical Control of Post-Prostatectomy Haemorrhage. Arch. Surge 73: 790, 1956. 16. Weyrauch, H. M.: Surgery of the Prostate. Philadelphia, W. B. Saunders Co., 1959. 412 Union Street, S. E. Minneapolis 14, Minnesota