- Email: [email protected]
Transurethral Resection of the Large Prostate: Review of 200 Cases in Which 25 Grams or More of Tissue Was Removed
TRANSURETHRAL RESECTION OF THE LARGE PROSTATE REVIEW OF 200 CASES IN WHICH 25 GRAMS OR MORE OF TISSUE WAS REMOVED GERSHOM
J. THOMPSON
Section on Urology, The Mayo Clinic AND
HENRY BUCHTEL
Fellow in Urology, The Mayo Foundation, Rochester, Minnesota
Urologists are in general agreement that it is possible to excise prostatic deformities by endoscopic methods; agreement as to the variety of deformity in which the operation is desirable, however, is conspicuously absent. Caulk, T. M. Davis, Alcock, Kretschmer, Folsom, and many others have said that practically all patients with obstruction of the vesical neck can be relieved of their symptoms by transurethral resection, while, on the other hand, Squier, Young, Randall, Beer, Hinman, Lowsley, and others were of the opinion that only a relatively small percentage of such patients are best treated with this method. It has been stated on various occasions that there must be middle ground on which the method will :finally come to rest; whether this apparently desirable solution of the problem will occur in the present decade is, however, debatable. The results obtained by any method of prostatectomy, whether suprapubic, perineal, or transurethral, should vary in direct proportion to the proficiency of the surgeon, and hence in proportion to his opportunity to achieve skill under the close supervision of someone more experienced. Those individuals who have mastered a certain technic of operation and are satisfied with the results obtained naturally will be influenced in their opinion of the relative worth of other methods of treatment. Very few men will have the patience and courage required to learn a new technic of operation carefully and give it a fair trial. It therefore seems unlikely that unanimity of opinion regarding either the worth of transurethral resection or its proper position in the category of surgical operations on the prostate will ever exist. At The Mayo Clinic during the past 4 years transurethral operations on the prostate gland have progressed to the point where practically all patients who have urinary obstruction can be relieved by the operation and very few indeed will require suprapubic or perinea! pros43
44
GERSHOM
J.
THOMPSON AND HENRY BUCHTEL
tatectomy. There has been a large increase in the number of patients subjected to operation, but this is only partially attributable to the application of the method to patients who were suffering from mild obstructive symptoms. This statement is borne out by the fact that, during the year 1935, 274 patients were suffering from complete urinary obstruction or overflow incontinence, at the time they registered at the clinic. This is a greater number of patients than elected to undergo total prostatectomy for the relief of all varieties of obstruction, complete or incomplete, at the clinic in any one year previously. It is a well known fact that prostatic atrophy coincident with contracture of the vesical neck may cause complete obstruction to urination, while, in contrast, extreme enlargement of the prostate gland may fail to produce even the slightest degree of urinary retention. In spite of these facts, it has been stated repeatedly that, if surgical treatment is deemed necessary in a case in which the prostate gland is rather large, the method of choice is suprapubic or perineal prostatectomy. It occurred to us that careful study of a series of cases in which a considerable amount of tissue had been removed by transurethral resection might help determine the validity of this assertion. Hence, we shall consider a series of 200 consecutive cases in which it was necessary to remove 25 gm. or more of tissue by transurethral resection, before adequate urinary function was restored. All of these patients had suffered from very definite obstruction to urination for from 1 to 20 years before they came to the clinic. In 140 (70 per cent) of the cases, complete retention had necessitated catheterization on one or many occasions during this interval. The patients in these cases were all operated on subsequent to June 1, 1932, and various data regarding them are presented in tables 1 to 8. Hess and others have, on various occasions, made the statement that the majority of patients who come to the clinic travel many hundreds of miles to come to Rochester, hence their physical condition must be better than that of the average patient encountered by other urologists. Hess said that it is unfair and unwise to draw any conclusions which might affect the treatment of patients elsewhere. Figure 1 represents the geographic distribution of the 200 patients. It can be seen that the large majority of the patients came from Minnesota and neighboring states, and that the trip required only a few hours' journey in a modern ambulance. We believe, therefore, that the series represents a fair cross section of patients who are suffering from prostatic hypertrophy.
TRANSURETHRAL RESECTION OF LARGE PROSTATE TABLE
45
1.-Age of patients*
AGE
PATIENTS
years
3t
Less than 50 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 to 84 85 to 89
3
13 43 50 48 32 6 2
* The median age was 69 years.
t These patients were 47, 48 and 49 years, respectively. TABLE
2.-Amount of residual urine when patients were admitted to hospital RESIDUAL URINE
NUMBER OF PATIENTS
cc.
Not recorded 0 to 49 50 to 149 150 to 299 300 to 599 600 to 999 1000 to 1999 2000 or more Not definitely known, bladder decompressed All urine residual, patient unable to void
TABLE
2
27 29 18 18
11 11 12 3
69
3.-Renal Junction on basis of blood urea CASES*
UREA PER 100 CC. OF BLOOD
On day of admission to hospital
On day of operation
mgm.
35 or less 35 to 39 40 to 49 50 to 69 70 to 99 100 to 199 200 or more
92 21 38 25 9 9
4
107 23 36 25 7 0 0
* In the 2 remaining cases the phenolsulphonphthalein test was used to estimate the renal function.
TABLE SYSTOLIC
4.- Blood pressure
PATIENTS
DIASTOLIC
PATIENTS
mm. mercury
mm. mercury
120 or Jess 120 to 129 130 to 139 140 to 149 150 to 159 160 to 179 180 to 199 200 or more
60 to 65 to 70 to 75 to 85 to 95 to 105 to 116 or
19 29 29 35 21 35 20 10
64 69 74 84 94 104 115 more
3 4 22 61 61 26 15 6*
* The highest value was 135; in 2 cases the blood pressure was not recorded. TABL E
5.- lncidence of extra-urinary disease* DISEASE
CASES
Severe arteriosclerosis ....... . . ... .... ...... . . . . . ........ . .. . .. . .... . Severe cardiac damage ... . .... . ..... . . . .... . .. . . ... .. . .. .. ......... . Complete bundle branch block ....... .. . .. . . .... . .. .. . . ..... . .. . . ... . Incomplete bundle branch block . . . ... . .. . .. ... .. . . .. . . . . .. . . .. . . . . . . Diabetes mellitus ............ . ..... . ...... . . . . . .. .. ..... . .. ... .... . Obesity ......... ' ...... . . . ........ ... ... . . . . . . ....... . ... . ....... . . Emaciation . . ............. . . . . . . . .. . ........ . .. . .. .. .. . ... . ..... . . . Severe anemia (value for hemoglobin Jess than 10 gm. per 100 cc. of blood) . . Severe bronchitis ... . ...... . ....... . ... . . ...... . . ... .. . . ... .. .. . .. . . Syphilis ...... .. . .. . . . ... .. ....... . .... . .... .. . . ........ . . . . . ... . . . Cerebrovascular accident. ... .. . .. . . . . ... . .. ... . ..... . ... ... . ...... . . Pulmonary tuberculosis .... .. . . . ..... . . . . .... . . . ..... . . . ... . . . . . .. . . Duodenal ulcer .. ..... .. .... . ......... . ..... . . . .. .. ... .. ..... . ..... . Parkinson's disease .. . .. .... .. . . . . ... . . . . .... . . . . .. . .. . .... .... . . . . . Arthritis deformans ........ . .. . . ............... . ................ . . . . Purpura hemorrhagica . . ... . . . . . . . . . ... .. . . .. . . . .... . . . ...... . ..... . Gout. ... . . .. . . .. . .. . . ... . . .. .. ... .. ...... . . . . ... . . . . . . . . .. . . . . . . . Severe hypotension .......... . .. . . ...... . . .... . .... . . .. . .. . .... . . . . . Chondromyxosarcoma sacrum .. . . ........ . ..... . . ... . .... . . .. . .. ... . .
19 30 5 2 4
11 9
12 3
5 3
2 2 1 1 1 1 1 1
* Extra-urinary disease was present in 101 cases in this series; this does not include moderate arteriosclerosis or arteriosclerotic hear t disease. TABLE
6.-Amount of prostatic tissue removed
TISSUE REMOVED
CASES
grams
25 to 29 30 to 39 40 to 49 SO to 59 60 to 69 70 to 79 80 or more
79 67 30 16 3 2 3*
* Ninety-two, 115, and 116 gm., respectively were removed in these cases. 46
47
TRANSURETHRAL RESECTION OF LARGE PROSTATE
Many of the patients were in extremis when they arrived at the clinic.
It is, of course, possible that natives of the Northwest survive greater TABLE
7.-Days spent in hospital PATIENTS
DAYS IN HOSPITAL
Before operation
After operation
96 34 19
* *
0 3 4 5 6
*
15
23 18 14 13 5 9 6 9 9
9 9 3 5 3 5 0 1 0 0 0 0 1 0
7 8 9 10
11
12 13 14 15 16
17 18 19 20 21 to 30 More than 30
9 9
5 11
0 0
5 5 3 33 15
200
200
0
Total. ....................
* None of the patients were dismissed from the hospital before the fifth postoperative day. TABLE
8.-Highest postoperative temperature
AFTER FIRST OPERATION
AFTER SECOND OPERATION
AFTER THIRD OPERATION
TEMPERATURE
Cases
Per cent
Cases
Per cent
Cases
Per cent
83 58 27 32
41.5 29.0 13.5 16.0
55 13 8
63.2 14.9 9.2 12.6
7 2 2 2
54.0 15.3 15.3 15.3
oF.
99 100 101 102 or more
11
stress and strain than do the inhabitants of certain other sections of the country, but this seems unlikely. Preoperative preparation. Patients who have had recurrent fever and
:..:..:J.! .J&.
48
GERSHOM
J.
THOMPSON AND HENRY BUCHTEL
chills and who are extremely weak must be treated, prior to prostatic operation, by drainage of the bladder until their general condition has greatly improved. This can be accomplished with safety in all except rare instances. Drainage can be secured with the urethral catheter or suprapubic tube. We prefer to use a catheter of moderate size (no. 14 to 16 French), which is made of soft rubber. The catheter should be fastened in the urethra with several strips of adhesive tape which are ¼inch (0.63 cm.) wide and which extend from the base of the penis along its length and for an inch (2.5 cm.) or more along the catheter. Reinforcement of the adhesive tape on the catheter by a piece of string,
tun
£:i?
z
t
SOOTH AMERICA 2
FIG. 1. Geographic distribution of 200 patients subjected to prostatic resection
rather than by an encircling strip of adhesive, will permit easy adjustment of the catheter if it is necessary, and also will promote cleanliness because the tip of the penis can be cleaned each day, thus preventing retention of pus in the urethra. The catheter is connected to a piece of sterile rubber tubing, which is connected with a large sterile bottle suspended from the bed rail. The importance of maintaining closed drainage and the avoidance of the introduction of foreign strains of bacteria cannot be over-emphasized. In addition to the usual general measures designed to better the patient's condition, blood transfusion should be liberally employed to combat the anemia which often is caused by long-standing renal insufficiency.
TRANSURETHRAL RESECTION OF LARGE PROSTATE
49
Preliminary cystostomy was performed in 17 of the 200 cases; in 14 other cases, such an operation had been done before the patients came to the clinic. It is difficult to make any definite rule of thumb by which cases can be chosen for preliminary cystostomy. In this series, the operation was performed when the prostate gland was extremely large or when the response to drainage by the urethral catheter for a few days was poor. In a small group of cases, the vesical wall was very flabby and atonic, and it sePmed best to perform cystostomy in order to rest the detrusor muscles completely. The presence of vesical calrnli is not in itself an indication for cystostomy, since in the majority of such cases litholapaxy and prostatic resection can be performed under the same anesthesia. This combined procedure was accomplished in 12 cases in this series; in 1 of these cases, 4 7 gm. of pros ta tic tissue was removed. It will be noted by reviewing table 7 that 96 patients did not enter the hospital until the day of operation, hence had no preliminary preparation which involved drainage of the bladder with a urethral catheter. It is also apparent that the majority of the 104 remaining patients, whose operation was deferred, were subjected to drainage with the catheter for only 3 or 4 days. Our experience early in the developmen L of transurethral resection established the belief that prolonged drainage with the urethral catheter often caused more harm than good; hence, it soon became our practice, in those cases in which renal function was found normal or only slightly impaired, to perform the operation immediately after completion of careful physical examination, the ordinary hematologic tests and roentgenograms of the thorax and abdomen. Whenever indicated, special examination, such as electrocardiographic study, extraordinary roentgenologic study, and consultation with other members of the staff in special fields, were obtained. In certain cases careful cooperation was required not only to improve the patient's general condition but also to anticipate and avoid postoperative complications. It will be noted by reference to table 3 that in 32 cases (16 per cent) the retention of urea on the day of operation exceeded 50 mg. per 100 cc. of blood. The low risk of transurethral resection in our opinion justifies the performance of the operation in cases in which the volume output of urine is good, without waiting for the blood urea to become stabilized. Because of this fact, a patient who has marked prostatic hypertrophy and who is intolerant of drainage by urethral catheter can, if renal function is fair, be subjected to early operation, and thus avoid urethral and
so
GERSHOM
J.
THOMPSON AND HENRY BUCHTEL
vesical spasms, epididymitis, pyelonephritis, chills and other distressing complications. Following removal of the offending enlargement of the prostate, these patients, in our experience, bear the catheter well. Operation. Spinal anesthesia induced by the injection of approximately 80 mg. of procaine, rarely more, and never more than 100 mg., seems definitely the ideal type of anesthetic agent for this operation, and it was used in the large majority of our cases. In our opinion, the instrument to be employed should be chosen according to the personal preference of the surgeon. There has been some discussion in the literature concerning the advantage of the punch type of instrument over instruments in which cutting is accomplished
FIG. 2. Thompson's resectoscope and multiple needle electrocie on which a piece of tissue has been impaled.
by an electrically activated wire loop. In our own experience postoperative morbidity was less when the knife punch was used, though this might be attributable to relative lack of skill with the loop instruments. Recently, one of us (Thompson) has developed a direct vision cold knife punch with which it is possible to visualize the field of operation constantly. Bleeding which results from excision of tissue can, at any moment, be controlled by an electrode which is always in position for advancement through a cannula constructed within the wall of the outer sheath. If one prefers the method, tissue can, after engagement in the fenestrum, be coagulated prior to excision with a multiple needle electrode; subsequently, closure of the knife, which is also an integral part of the instrument, will excise the piece of tissue and allow it to be withdrawn still impaled on the electrode (fig. 2). The improvements em-
TRANSURETHRAL RESECTION OF LARGE PROSTATE
51
bodied in the Thompson resectoscope have eliminated many steps in the technic of transurethral resection as performed with the BraaschBumpus resectoscope. This permits greater accuracy of excision of tissue and more rapid control of hemorrhage. Before the actual excision of tissue is begun, no matter which type of resectoscope is employed, the prostatic urethra should be thoroughly studied with the retrograde lens telescope. The contour of the various lobes, and, in particular, the extent of intravesical proliferation of the adenoma, must be carefully noted. Often a portion of lateral lobe will project anteriorly, push through the internal sphincter, and produce a cauliflower-like excrescence which overlies the internal urethral orifice and completely occludes it. In this series of cases failure to recognize such deformities has been chiefly responsible for the incomplete relief which was afforded by the primary operation. Attention has been called previously to the order of procedure in excising tissue with the knife punch. Excision of a lobe must be started on that portion which extends farthest into the bladder; by so doing, even the largest lobe can be morcellated and removed. If the middle lobe is unusually large it should be removed first, careful attention being paid to the ureteral ridge, ureteral orifices and posterior aspect of the trigone. Engagement of a huge lateral lobe practically always must begin at a point just lateral to the anterior commissure. As the excision of tissue in this region proceeds, it gradually becomes easier to engage tissue in the posterior half of the lateral lobe and, as the vesical aspect of the lobe is removed, it becomes increasingly easier to engage tissue situated out in the prostatic urethra. One should endeavor to eliminate all inverted V deformity in the anterior half of the vesical neck, and should continue the excision until the anterior half of the internal urethral orifice has a semicircular appearance. Elimination of the inverted V deformity as far out in the urethra as possible without endangering the external sphincter muscle is desirable. It is often surprising how much adenomatous tissue has extended up from the lateral lobes and has flattened or even encircled the urethra anteriorly. If removal of this tissue is neglected, an intermittent stream usually results, often with terminal dribbling and spasm, although the patient may be able by continued effort to empty his bladder. Such inferior functional results usually are the result of tissue in the anterior half of the lobe, dropping down or falling in and occluding the urethra after the bottom or dorsal half of the lateral lobe has been excised. It may be necessary
52
GERSHOM
J.
THOMPSON AND HENRY BUCHTEL
in certain cases to have an assistant insert a finger in the rectum and push up on the prostate to facilitate engagement of tissue in a very pocketed portion of the prostatic urethra. In the large majority of cases, however, such a maneuver is not required. Hemorrhage must be accurately controlled, preferably as the operation proceeds. The tendency of the surgeon to delay the control of spurting vessels until the majority of the prostate has been removed must be avoided. It is far better to control the larger arteries immediately after cutting them, for recent studies have demonstrated that, during the course of an operation which involves the removal of a large amount of tissue, a liter or more of blood may be lost. In our experience patients withstand two operations performed S or 6 days apart better than they do one operation which requires more than an hour for its completion. We observed early that postoperative reaction from the second operation is without exception less than that which follows the first operation, hence we firmly believe that mortality will be less if prolonged operations are assiduously avoided. One would think that, if hemorrhage is accurately controlled and the usual attention paid to the well-being of the patient, the operation might be continued, with safety, even as long as several hours, providing anesthesia is maintained. We are convinced, however, that the nervous strain, the lithotomy position for prolonged periods, and long continued instrumentation with resultant trauma of the perineum and pelvis have a very deleterious effect. In 87 (43.5 per cent) of the cases in this series, the patients were subjected to operations in two or more stages. Postoperative care. If the control of hemorrhage from spurting arteries has been fairly accurate, an inlying catheter, which is frequently irrigated, will usually take care of venous oozing, which generally persists for 5 or 6 hours after operation. As an alternative, if a skilled nurse is not available, it is wise to insert a hemostatic bag in the denuded prostatic urethra. Any tendency to rectal or urethral spasm or a desire to defecate should be overcome by generous use of opium suppositories. If this is not done bleeding will be increased. Free movement of the legs should be encouraged, intake of fluids should be forced, and unless marked nausea has resulted from the spinal anesthesia the patient should eat his evening meal. The following morning, except in unusual cases, we insist that he shall sit up in a chair an hour or so and take several steps around the room. This improves the circulatory mechanism, gives him courage, and makes him optimistic.
TRANSURETHRAL RESECTION OF LARGE PROSTATE
53
On the second or third morning after operation, it is our practice to remove the urethral catheter. The patient is instructed to continue the large intake of fluids, and 6 hours later a catheter is again passed to determine the presence or absence of residual urine. If there is none, or only an ounce or two, and if the patient says that he voids freely, catheterization is not repeated until the next day. On the other hand, if 5 ounces or more of residual urine is found, the catheter is taped in again and allowed to remain for another 48 hours. At the end of 5 to 7 days, if the functional result is still poor, a second operation is performed. If one adheres to the policy of early reoperation, much less reaction, morbidity and mortality will be encountered. In this series of 200 cases, febrile reaction was as noted in table 8. It is interesting to note that the incidence of temperatures greater than 99°F. was less after the second and third operations than it was after the first. Prevention of overdistention of the bladder and of undue straining at micturition will minimize febrile reaction. We purposely avoid administration of sedatives after the catheter has been removed and believe that a moderate nocturia for a week or so after operation is really a protective symptom. Following dismissal from the hospital, the patient reports for daily observation. Generally, this consists merely of gross inspection of the voided urine. If there is any suspicion that urine is being retained in the bladder, a catheter is passed for verification. Various urinary antiseptics are prescribed, if they seem indicated. In the majority of cases, however, forcing fluids will clear up the urinary infection rapidly. Many of the patients report complete abolishment of nocturia within a period of 2 weeks after operation. Approximately half of the patients will note an occasional tinge of blood in the urine in the convalescent period. Only a few, however, will have bleeding of particularly noticeable degree, and approximately 2 per cent will have sharp bleeding, which must be controlled by an inlying catheter or by fulguration of the bleeding point. In this series of 200 cases, 5 patients were returned to the operating room for the control of bleeding by these methods. In no instance was cystostomy required. Results. Sixteen patients have returned to the clinic 6 months or more after initial dismissal and have been subjected to reoperation because the functional result was deemed unsatisfactory. One patient had carcinoma of the prostate; therefore, recurring obstruction might be expected. Six of the 16 patients complained of recurrent hematuria
54
GERSHOM
J.
THOMPSON AND HENRY BUCHTEL
of varying degree. They said that the urinary stream was entirely satisfactory, and catheterization failed to disclose residual urine. In these cases, cystoscopic examination revealed that an inflamed, adenomatous nodule of tissue in the sphincteric region was the source of the bleeding, hence, reoperation was advised. In the remaining 9 of the 16 cases, the amount of residual urine was less than 60 cc., except in 2 cases, in one of which definite spinal changes, which were caused by syphilis, had been recognized prior to his first visit to the clinic. In spite of this fact, since a definite enlargement of the prostate was present, transurethral resection was advised; the second operation restored normal urinary function. The other patient was an elderly physician, who, in addition to an hypertrophy of the prostate, had a large vesical diverticulum. Transurethral resection of the prostate established a normal sized urinary stream, but 170 cc. of residual urine persisted. On his return visit, reoperation reduced the amount of residual urine to 50 cc. in spite of the large diverticulum. One of the 16 patients who returned complained that a suprapubic sinus failed to close permanently. In this case, at the initial visit to the clinic, transurethral resection of 33 gm. of tissue had been done subsequent to suprapubic cystostomy and lithotomy. Examination revealed only 15 cc. of residual urine and the urinary stream seemed excellent, but in view of the failure of the suprapubic sinus to stay closed, a complete prostatectomy was thought indicated. At operation an additional 91 gm. of prostatic tissue was enucleated. This is the only case of the series in which prostatectomy has been performed subsequent to transurethral resection. It was very definitely a fact that all but one of these 16 patients who returned would have been contented with the result obtained by the first transurethral resection if the only alternative to offer them involved suprapubic or perineal prostatectomy. Likewise, our opinion concerning the necessity of reoperation in these cases would have been altered should prostatectomy have been the only available method of relief. Every urologist has seen, in his past experience, patients who were not entirely satisfied after suprapubic or perineal prostatectomy, and in many of these cases cystoscopy has disclosed deformity in the prostatic urethra which might well have been remedied by additional surgical procedures. Rarely, however, was reoperation by perineal or suprapubic incision advised by the surgeon or relished by the patient. The simplicity and safety of transurethral operation, however, urges repeti-
TRANSURETHRAL RESECTION OF LARGE PROSTATE
55
tion of the procedure on both patient and physician, hence it is certain that neither patient nor physician will in the future be contented with functional results such as were often deemed satisfactory after so-called complete prostatectomy. Replies to letters of inquiry sent to the surviving patients in this series of 200 cases in our opinion denote for the most part a high degree of satisfaction with the result obtained by operation. These letters are certainly not an entirely reliable basis for scientific conclusions but they do strengthen our opinion that transurethral resection is the method of choice in the surgical treatment of urinary obstruction in all but exceptional cases. One patient reported that he is completely incontinent and 3 other patients, all more than 70 years of age, said that retention of urine has again developed to a degree requiring occasional catheterization. These patients have been asked to return for reexamination, but thus far have failed to do so. Mortality in this series of 200 consecutive cases, in which 25 gm. or more of prostatic tissue was removed has been 1.5 per cent. Three patients, aged 66, 77, and 81 years respectively, died of pulmonary embolism, septicemia, and acute pyelonephritis, in the order named. Thirteen other patients are known to be dead; 3 of the latter lived only 2½ months; the cause of death was uremia in one instance and in the other 2, who died suddenly, the family physician attributed the death to cardiac disease, and said that urinary function was entirely satisfactory. Of the other 10 patients known to have died at intervals of 6 months to 2½ years postoperatively 4 have died of cardiac disease; 3 of metastatic carcinoma; and 1 each of postoperative strangulated inguinal hernia, interstitial nephritis, and septicemia. SUMMARY
A series of 200 consecutive cases of prostatic hypertrophy in which treatment involved transurethral resection of 25 gm. or more of prostatic tissue has been discussed; 140 patients, or 70 per cent, had suffered from complete urinary retention. Eighty-eight patients, or 44 per cent, were aged 70 years or more. Various data concerning preoperative examination, postoperative course and the functional result obtained in these cases are presented. Thorough removal of all adenomatous tissue which encroaches on the vesical neck, particularly in the anterior half, so that all inverted V deformity is eliminated and careful hemostasis during the progress of
56
GERSHOM
J.
THOMPSON AND HENRY BUCHTEL
the operation are important points in technic. Operations must not be prolonged or shock may result; in our experience, patients withstand a two- or three-stage procedure, each of short duration, much better than they withstand a single operation which lasts more than one hour. The bladder must not be allowed to become overdistended at any time during operation or during the postoperative course, or fever may ensue. If the functional result is not good immediately after drainage by inlying catheter has been discontinued, judicious intermittent catheterization or early reoperation are very essential to an uncomplicated convalescence. Replies to letters of inquiry indicate a high degree of satisfaction among the patients. Sixteen patients (benign lesions in 15 and malignant lesion in 1) have returned to the clinic for reoperation 6 months or more after their dismissal. One of these patients was subjected to perineal prostatectomy, while the others preferred to undergo further transurethral resection. Mortality in the series was 1.5 per cent. REFERENCES HEss, ELMER: Discussion of C. H . Mayo's paper on "Treatment of the enlarged prostate gland by modern methods," read before the meeting of the Pan-American Medical Association, Rio de Janeiro, June 20 to August 2, 1935. THOMPSON, G. J.: A new direct vision resectoscope. Urol. and Cutan. Rev. 39: 545-546 . (Aug.) 1935. THOMPSON, G. J.: Prostatic resection: presentation of a case. Proc. Staff Meetings of Mayo Clinic, 7: 725-727 (Dec. 21) 1932. THOMPSON, G. J., SHEARD, CHARLES, AND PILCHER, FRED: Unpublished data.
J. THOMPSON
Section on Urology, The Mayo Clinic AND
HENRY BUCHTEL
Fellow in Urology, The Mayo Foundation, Rochester, Minnesota
Urologists are in general agreement that it is possible to excise prostatic deformities by endoscopic methods; agreement as to the variety of deformity in which the operation is desirable, however, is conspicuously absent. Caulk, T. M. Davis, Alcock, Kretschmer, Folsom, and many others have said that practically all patients with obstruction of the vesical neck can be relieved of their symptoms by transurethral resection, while, on the other hand, Squier, Young, Randall, Beer, Hinman, Lowsley, and others were of the opinion that only a relatively small percentage of such patients are best treated with this method. It has been stated on various occasions that there must be middle ground on which the method will :finally come to rest; whether this apparently desirable solution of the problem will occur in the present decade is, however, debatable. The results obtained by any method of prostatectomy, whether suprapubic, perineal, or transurethral, should vary in direct proportion to the proficiency of the surgeon, and hence in proportion to his opportunity to achieve skill under the close supervision of someone more experienced. Those individuals who have mastered a certain technic of operation and are satisfied with the results obtained naturally will be influenced in their opinion of the relative worth of other methods of treatment. Very few men will have the patience and courage required to learn a new technic of operation carefully and give it a fair trial. It therefore seems unlikely that unanimity of opinion regarding either the worth of transurethral resection or its proper position in the category of surgical operations on the prostate will ever exist. At The Mayo Clinic during the past 4 years transurethral operations on the prostate gland have progressed to the point where practically all patients who have urinary obstruction can be relieved by the operation and very few indeed will require suprapubic or perinea! pros43
44
GERSHOM
J.
THOMPSON AND HENRY BUCHTEL
tatectomy. There has been a large increase in the number of patients subjected to operation, but this is only partially attributable to the application of the method to patients who were suffering from mild obstructive symptoms. This statement is borne out by the fact that, during the year 1935, 274 patients were suffering from complete urinary obstruction or overflow incontinence, at the time they registered at the clinic. This is a greater number of patients than elected to undergo total prostatectomy for the relief of all varieties of obstruction, complete or incomplete, at the clinic in any one year previously. It is a well known fact that prostatic atrophy coincident with contracture of the vesical neck may cause complete obstruction to urination, while, in contrast, extreme enlargement of the prostate gland may fail to produce even the slightest degree of urinary retention. In spite of these facts, it has been stated repeatedly that, if surgical treatment is deemed necessary in a case in which the prostate gland is rather large, the method of choice is suprapubic or perineal prostatectomy. It occurred to us that careful study of a series of cases in which a considerable amount of tissue had been removed by transurethral resection might help determine the validity of this assertion. Hence, we shall consider a series of 200 consecutive cases in which it was necessary to remove 25 gm. or more of tissue by transurethral resection, before adequate urinary function was restored. All of these patients had suffered from very definite obstruction to urination for from 1 to 20 years before they came to the clinic. In 140 (70 per cent) of the cases, complete retention had necessitated catheterization on one or many occasions during this interval. The patients in these cases were all operated on subsequent to June 1, 1932, and various data regarding them are presented in tables 1 to 8. Hess and others have, on various occasions, made the statement that the majority of patients who come to the clinic travel many hundreds of miles to come to Rochester, hence their physical condition must be better than that of the average patient encountered by other urologists. Hess said that it is unfair and unwise to draw any conclusions which might affect the treatment of patients elsewhere. Figure 1 represents the geographic distribution of the 200 patients. It can be seen that the large majority of the patients came from Minnesota and neighboring states, and that the trip required only a few hours' journey in a modern ambulance. We believe, therefore, that the series represents a fair cross section of patients who are suffering from prostatic hypertrophy.
TRANSURETHRAL RESECTION OF LARGE PROSTATE TABLE
45
1.-Age of patients*
AGE
PATIENTS
years
3t
Less than 50 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 to 84 85 to 89
3
13 43 50 48 32 6 2
* The median age was 69 years.
t These patients were 47, 48 and 49 years, respectively. TABLE
2.-Amount of residual urine when patients were admitted to hospital RESIDUAL URINE
NUMBER OF PATIENTS
cc.
Not recorded 0 to 49 50 to 149 150 to 299 300 to 599 600 to 999 1000 to 1999 2000 or more Not definitely known, bladder decompressed All urine residual, patient unable to void
TABLE
2
27 29 18 18
11 11 12 3
69
3.-Renal Junction on basis of blood urea CASES*
UREA PER 100 CC. OF BLOOD
On day of admission to hospital
On day of operation
mgm.
35 or less 35 to 39 40 to 49 50 to 69 70 to 99 100 to 199 200 or more
92 21 38 25 9 9
4
107 23 36 25 7 0 0
* In the 2 remaining cases the phenolsulphonphthalein test was used to estimate the renal function.
TABLE SYSTOLIC
4.- Blood pressure
PATIENTS
DIASTOLIC
PATIENTS
mm. mercury
mm. mercury
120 or Jess 120 to 129 130 to 139 140 to 149 150 to 159 160 to 179 180 to 199 200 or more
60 to 65 to 70 to 75 to 85 to 95 to 105 to 116 or
19 29 29 35 21 35 20 10
64 69 74 84 94 104 115 more
3 4 22 61 61 26 15 6*
* The highest value was 135; in 2 cases the blood pressure was not recorded. TABL E
5.- lncidence of extra-urinary disease* DISEASE
CASES
Severe arteriosclerosis ....... . . ... .... ...... . . . . . ........ . .. . .. . .... . Severe cardiac damage ... . .... . ..... . . . .... . .. . . ... .. . .. .. ......... . Complete bundle branch block ....... .. . .. . . .... . .. .. . . ..... . .. . . ... . Incomplete bundle branch block . . . ... . .. . .. ... .. . . .. . . . . .. . . .. . . . . . . Diabetes mellitus ............ . ..... . ...... . . . . . .. .. ..... . .. ... .... . Obesity ......... ' ...... . . . ........ ... ... . . . . . . ....... . ... . ....... . . Emaciation . . ............. . . . . . . . .. . ........ . .. . .. .. .. . ... . ..... . . . Severe anemia (value for hemoglobin Jess than 10 gm. per 100 cc. of blood) . . Severe bronchitis ... . ...... . ....... . ... . . ...... . . ... .. . . ... .. .. . .. . . Syphilis ...... .. . .. . . . ... .. ....... . .... . .... .. . . ........ . . . . . ... . . . Cerebrovascular accident. ... .. . .. . . . . ... . .. ... . ..... . ... ... . ...... . . Pulmonary tuberculosis .... .. . . . ..... . . . . .... . . . ..... . . . ... . . . . . .. . . Duodenal ulcer .. ..... .. .... . ......... . ..... . . . .. .. ... .. ..... . ..... . Parkinson's disease .. . .. .... .. . . . . ... . . . . .... . . . . .. . .. . .... .... . . . . . Arthritis deformans ........ . .. . . ............... . ................ . . . . Purpura hemorrhagica . . ... . . . . . . . . . ... .. . . .. . . . .... . . . ...... . ..... . Gout. ... . . .. . . .. . .. . . ... . . .. .. ... .. ...... . . . . ... . . . . . . . . .. . . . . . . . Severe hypotension .......... . .. . . ...... . . .... . .... . . .. . .. . .... . . . . . Chondromyxosarcoma sacrum .. . . ........ . ..... . . ... . .... . . .. . .. ... . .
19 30 5 2 4
11 9
12 3
5 3
2 2 1 1 1 1 1 1
* Extra-urinary disease was present in 101 cases in this series; this does not include moderate arteriosclerosis or arteriosclerotic hear t disease. TABLE
6.-Amount of prostatic tissue removed
TISSUE REMOVED
CASES
grams
25 to 29 30 to 39 40 to 49 SO to 59 60 to 69 70 to 79 80 or more
79 67 30 16 3 2 3*
* Ninety-two, 115, and 116 gm., respectively were removed in these cases. 46
47
TRANSURETHRAL RESECTION OF LARGE PROSTATE
Many of the patients were in extremis when they arrived at the clinic.
It is, of course, possible that natives of the Northwest survive greater TABLE
7.-Days spent in hospital PATIENTS
DAYS IN HOSPITAL
Before operation
After operation
96 34 19
* *
0 3 4 5 6
*
15
23 18 14 13 5 9 6 9 9
9 9 3 5 3 5 0 1 0 0 0 0 1 0
7 8 9 10
11
12 13 14 15 16
17 18 19 20 21 to 30 More than 30
9 9
5 11
0 0
5 5 3 33 15
200
200
0
Total. ....................
* None of the patients were dismissed from the hospital before the fifth postoperative day. TABLE
8.-Highest postoperative temperature
AFTER FIRST OPERATION
AFTER SECOND OPERATION
AFTER THIRD OPERATION
TEMPERATURE
Cases
Per cent
Cases
Per cent
Cases
Per cent
83 58 27 32
41.5 29.0 13.5 16.0
55 13 8
63.2 14.9 9.2 12.6
7 2 2 2
54.0 15.3 15.3 15.3
oF.
99 100 101 102 or more
11
stress and strain than do the inhabitants of certain other sections of the country, but this seems unlikely. Preoperative preparation. Patients who have had recurrent fever and
:..:..:J.! .J&.
48
GERSHOM
J.
THOMPSON AND HENRY BUCHTEL
chills and who are extremely weak must be treated, prior to prostatic operation, by drainage of the bladder until their general condition has greatly improved. This can be accomplished with safety in all except rare instances. Drainage can be secured with the urethral catheter or suprapubic tube. We prefer to use a catheter of moderate size (no. 14 to 16 French), which is made of soft rubber. The catheter should be fastened in the urethra with several strips of adhesive tape which are ¼inch (0.63 cm.) wide and which extend from the base of the penis along its length and for an inch (2.5 cm.) or more along the catheter. Reinforcement of the adhesive tape on the catheter by a piece of string,
tun
£:i?
z
t
SOOTH AMERICA 2
FIG. 1. Geographic distribution of 200 patients subjected to prostatic resection
rather than by an encircling strip of adhesive, will permit easy adjustment of the catheter if it is necessary, and also will promote cleanliness because the tip of the penis can be cleaned each day, thus preventing retention of pus in the urethra. The catheter is connected to a piece of sterile rubber tubing, which is connected with a large sterile bottle suspended from the bed rail. The importance of maintaining closed drainage and the avoidance of the introduction of foreign strains of bacteria cannot be over-emphasized. In addition to the usual general measures designed to better the patient's condition, blood transfusion should be liberally employed to combat the anemia which often is caused by long-standing renal insufficiency.
TRANSURETHRAL RESECTION OF LARGE PROSTATE
49
Preliminary cystostomy was performed in 17 of the 200 cases; in 14 other cases, such an operation had been done before the patients came to the clinic. It is difficult to make any definite rule of thumb by which cases can be chosen for preliminary cystostomy. In this series, the operation was performed when the prostate gland was extremely large or when the response to drainage by the urethral catheter for a few days was poor. In a small group of cases, the vesical wall was very flabby and atonic, and it sePmed best to perform cystostomy in order to rest the detrusor muscles completely. The presence of vesical calrnli is not in itself an indication for cystostomy, since in the majority of such cases litholapaxy and prostatic resection can be performed under the same anesthesia. This combined procedure was accomplished in 12 cases in this series; in 1 of these cases, 4 7 gm. of pros ta tic tissue was removed. It will be noted by reviewing table 7 that 96 patients did not enter the hospital until the day of operation, hence had no preliminary preparation which involved drainage of the bladder with a urethral catheter. It is also apparent that the majority of the 104 remaining patients, whose operation was deferred, were subjected to drainage with the catheter for only 3 or 4 days. Our experience early in the developmen L of transurethral resection established the belief that prolonged drainage with the urethral catheter often caused more harm than good; hence, it soon became our practice, in those cases in which renal function was found normal or only slightly impaired, to perform the operation immediately after completion of careful physical examination, the ordinary hematologic tests and roentgenograms of the thorax and abdomen. Whenever indicated, special examination, such as electrocardiographic study, extraordinary roentgenologic study, and consultation with other members of the staff in special fields, were obtained. In certain cases careful cooperation was required not only to improve the patient's general condition but also to anticipate and avoid postoperative complications. It will be noted by reference to table 3 that in 32 cases (16 per cent) the retention of urea on the day of operation exceeded 50 mg. per 100 cc. of blood. The low risk of transurethral resection in our opinion justifies the performance of the operation in cases in which the volume output of urine is good, without waiting for the blood urea to become stabilized. Because of this fact, a patient who has marked prostatic hypertrophy and who is intolerant of drainage by urethral catheter can, if renal function is fair, be subjected to early operation, and thus avoid urethral and
so
GERSHOM
J.
THOMPSON AND HENRY BUCHTEL
vesical spasms, epididymitis, pyelonephritis, chills and other distressing complications. Following removal of the offending enlargement of the prostate, these patients, in our experience, bear the catheter well. Operation. Spinal anesthesia induced by the injection of approximately 80 mg. of procaine, rarely more, and never more than 100 mg., seems definitely the ideal type of anesthetic agent for this operation, and it was used in the large majority of our cases. In our opinion, the instrument to be employed should be chosen according to the personal preference of the surgeon. There has been some discussion in the literature concerning the advantage of the punch type of instrument over instruments in which cutting is accomplished
FIG. 2. Thompson's resectoscope and multiple needle electrocie on which a piece of tissue has been impaled.
by an electrically activated wire loop. In our own experience postoperative morbidity was less when the knife punch was used, though this might be attributable to relative lack of skill with the loop instruments. Recently, one of us (Thompson) has developed a direct vision cold knife punch with which it is possible to visualize the field of operation constantly. Bleeding which results from excision of tissue can, at any moment, be controlled by an electrode which is always in position for advancement through a cannula constructed within the wall of the outer sheath. If one prefers the method, tissue can, after engagement in the fenestrum, be coagulated prior to excision with a multiple needle electrode; subsequently, closure of the knife, which is also an integral part of the instrument, will excise the piece of tissue and allow it to be withdrawn still impaled on the electrode (fig. 2). The improvements em-
TRANSURETHRAL RESECTION OF LARGE PROSTATE
51
bodied in the Thompson resectoscope have eliminated many steps in the technic of transurethral resection as performed with the BraaschBumpus resectoscope. This permits greater accuracy of excision of tissue and more rapid control of hemorrhage. Before the actual excision of tissue is begun, no matter which type of resectoscope is employed, the prostatic urethra should be thoroughly studied with the retrograde lens telescope. The contour of the various lobes, and, in particular, the extent of intravesical proliferation of the adenoma, must be carefully noted. Often a portion of lateral lobe will project anteriorly, push through the internal sphincter, and produce a cauliflower-like excrescence which overlies the internal urethral orifice and completely occludes it. In this series of cases failure to recognize such deformities has been chiefly responsible for the incomplete relief which was afforded by the primary operation. Attention has been called previously to the order of procedure in excising tissue with the knife punch. Excision of a lobe must be started on that portion which extends farthest into the bladder; by so doing, even the largest lobe can be morcellated and removed. If the middle lobe is unusually large it should be removed first, careful attention being paid to the ureteral ridge, ureteral orifices and posterior aspect of the trigone. Engagement of a huge lateral lobe practically always must begin at a point just lateral to the anterior commissure. As the excision of tissue in this region proceeds, it gradually becomes easier to engage tissue in the posterior half of the lateral lobe and, as the vesical aspect of the lobe is removed, it becomes increasingly easier to engage tissue situated out in the prostatic urethra. One should endeavor to eliminate all inverted V deformity in the anterior half of the vesical neck, and should continue the excision until the anterior half of the internal urethral orifice has a semicircular appearance. Elimination of the inverted V deformity as far out in the urethra as possible without endangering the external sphincter muscle is desirable. It is often surprising how much adenomatous tissue has extended up from the lateral lobes and has flattened or even encircled the urethra anteriorly. If removal of this tissue is neglected, an intermittent stream usually results, often with terminal dribbling and spasm, although the patient may be able by continued effort to empty his bladder. Such inferior functional results usually are the result of tissue in the anterior half of the lobe, dropping down or falling in and occluding the urethra after the bottom or dorsal half of the lateral lobe has been excised. It may be necessary
52
GERSHOM
J.
THOMPSON AND HENRY BUCHTEL
in certain cases to have an assistant insert a finger in the rectum and push up on the prostate to facilitate engagement of tissue in a very pocketed portion of the prostatic urethra. In the large majority of cases, however, such a maneuver is not required. Hemorrhage must be accurately controlled, preferably as the operation proceeds. The tendency of the surgeon to delay the control of spurting vessels until the majority of the prostate has been removed must be avoided. It is far better to control the larger arteries immediately after cutting them, for recent studies have demonstrated that, during the course of an operation which involves the removal of a large amount of tissue, a liter or more of blood may be lost. In our experience patients withstand two operations performed S or 6 days apart better than they do one operation which requires more than an hour for its completion. We observed early that postoperative reaction from the second operation is without exception less than that which follows the first operation, hence we firmly believe that mortality will be less if prolonged operations are assiduously avoided. One would think that, if hemorrhage is accurately controlled and the usual attention paid to the well-being of the patient, the operation might be continued, with safety, even as long as several hours, providing anesthesia is maintained. We are convinced, however, that the nervous strain, the lithotomy position for prolonged periods, and long continued instrumentation with resultant trauma of the perineum and pelvis have a very deleterious effect. In 87 (43.5 per cent) of the cases in this series, the patients were subjected to operations in two or more stages. Postoperative care. If the control of hemorrhage from spurting arteries has been fairly accurate, an inlying catheter, which is frequently irrigated, will usually take care of venous oozing, which generally persists for 5 or 6 hours after operation. As an alternative, if a skilled nurse is not available, it is wise to insert a hemostatic bag in the denuded prostatic urethra. Any tendency to rectal or urethral spasm or a desire to defecate should be overcome by generous use of opium suppositories. If this is not done bleeding will be increased. Free movement of the legs should be encouraged, intake of fluids should be forced, and unless marked nausea has resulted from the spinal anesthesia the patient should eat his evening meal. The following morning, except in unusual cases, we insist that he shall sit up in a chair an hour or so and take several steps around the room. This improves the circulatory mechanism, gives him courage, and makes him optimistic.
TRANSURETHRAL RESECTION OF LARGE PROSTATE
53
On the second or third morning after operation, it is our practice to remove the urethral catheter. The patient is instructed to continue the large intake of fluids, and 6 hours later a catheter is again passed to determine the presence or absence of residual urine. If there is none, or only an ounce or two, and if the patient says that he voids freely, catheterization is not repeated until the next day. On the other hand, if 5 ounces or more of residual urine is found, the catheter is taped in again and allowed to remain for another 48 hours. At the end of 5 to 7 days, if the functional result is still poor, a second operation is performed. If one adheres to the policy of early reoperation, much less reaction, morbidity and mortality will be encountered. In this series of 200 cases, febrile reaction was as noted in table 8. It is interesting to note that the incidence of temperatures greater than 99°F. was less after the second and third operations than it was after the first. Prevention of overdistention of the bladder and of undue straining at micturition will minimize febrile reaction. We purposely avoid administration of sedatives after the catheter has been removed and believe that a moderate nocturia for a week or so after operation is really a protective symptom. Following dismissal from the hospital, the patient reports for daily observation. Generally, this consists merely of gross inspection of the voided urine. If there is any suspicion that urine is being retained in the bladder, a catheter is passed for verification. Various urinary antiseptics are prescribed, if they seem indicated. In the majority of cases, however, forcing fluids will clear up the urinary infection rapidly. Many of the patients report complete abolishment of nocturia within a period of 2 weeks after operation. Approximately half of the patients will note an occasional tinge of blood in the urine in the convalescent period. Only a few, however, will have bleeding of particularly noticeable degree, and approximately 2 per cent will have sharp bleeding, which must be controlled by an inlying catheter or by fulguration of the bleeding point. In this series of 200 cases, 5 patients were returned to the operating room for the control of bleeding by these methods. In no instance was cystostomy required. Results. Sixteen patients have returned to the clinic 6 months or more after initial dismissal and have been subjected to reoperation because the functional result was deemed unsatisfactory. One patient had carcinoma of the prostate; therefore, recurring obstruction might be expected. Six of the 16 patients complained of recurrent hematuria
54
GERSHOM
J.
THOMPSON AND HENRY BUCHTEL
of varying degree. They said that the urinary stream was entirely satisfactory, and catheterization failed to disclose residual urine. In these cases, cystoscopic examination revealed that an inflamed, adenomatous nodule of tissue in the sphincteric region was the source of the bleeding, hence, reoperation was advised. In the remaining 9 of the 16 cases, the amount of residual urine was less than 60 cc., except in 2 cases, in one of which definite spinal changes, which were caused by syphilis, had been recognized prior to his first visit to the clinic. In spite of this fact, since a definite enlargement of the prostate was present, transurethral resection was advised; the second operation restored normal urinary function. The other patient was an elderly physician, who, in addition to an hypertrophy of the prostate, had a large vesical diverticulum. Transurethral resection of the prostate established a normal sized urinary stream, but 170 cc. of residual urine persisted. On his return visit, reoperation reduced the amount of residual urine to 50 cc. in spite of the large diverticulum. One of the 16 patients who returned complained that a suprapubic sinus failed to close permanently. In this case, at the initial visit to the clinic, transurethral resection of 33 gm. of tissue had been done subsequent to suprapubic cystostomy and lithotomy. Examination revealed only 15 cc. of residual urine and the urinary stream seemed excellent, but in view of the failure of the suprapubic sinus to stay closed, a complete prostatectomy was thought indicated. At operation an additional 91 gm. of prostatic tissue was enucleated. This is the only case of the series in which prostatectomy has been performed subsequent to transurethral resection. It was very definitely a fact that all but one of these 16 patients who returned would have been contented with the result obtained by the first transurethral resection if the only alternative to offer them involved suprapubic or perineal prostatectomy. Likewise, our opinion concerning the necessity of reoperation in these cases would have been altered should prostatectomy have been the only available method of relief. Every urologist has seen, in his past experience, patients who were not entirely satisfied after suprapubic or perineal prostatectomy, and in many of these cases cystoscopy has disclosed deformity in the prostatic urethra which might well have been remedied by additional surgical procedures. Rarely, however, was reoperation by perineal or suprapubic incision advised by the surgeon or relished by the patient. The simplicity and safety of transurethral operation, however, urges repeti-
TRANSURETHRAL RESECTION OF LARGE PROSTATE
55
tion of the procedure on both patient and physician, hence it is certain that neither patient nor physician will in the future be contented with functional results such as were often deemed satisfactory after so-called complete prostatectomy. Replies to letters of inquiry sent to the surviving patients in this series of 200 cases in our opinion denote for the most part a high degree of satisfaction with the result obtained by operation. These letters are certainly not an entirely reliable basis for scientific conclusions but they do strengthen our opinion that transurethral resection is the method of choice in the surgical treatment of urinary obstruction in all but exceptional cases. One patient reported that he is completely incontinent and 3 other patients, all more than 70 years of age, said that retention of urine has again developed to a degree requiring occasional catheterization. These patients have been asked to return for reexamination, but thus far have failed to do so. Mortality in this series of 200 consecutive cases, in which 25 gm. or more of prostatic tissue was removed has been 1.5 per cent. Three patients, aged 66, 77, and 81 years respectively, died of pulmonary embolism, septicemia, and acute pyelonephritis, in the order named. Thirteen other patients are known to be dead; 3 of the latter lived only 2½ months; the cause of death was uremia in one instance and in the other 2, who died suddenly, the family physician attributed the death to cardiac disease, and said that urinary function was entirely satisfactory. Of the other 10 patients known to have died at intervals of 6 months to 2½ years postoperatively 4 have died of cardiac disease; 3 of metastatic carcinoma; and 1 each of postoperative strangulated inguinal hernia, interstitial nephritis, and septicemia. SUMMARY
A series of 200 consecutive cases of prostatic hypertrophy in which treatment involved transurethral resection of 25 gm. or more of prostatic tissue has been discussed; 140 patients, or 70 per cent, had suffered from complete urinary retention. Eighty-eight patients, or 44 per cent, were aged 70 years or more. Various data concerning preoperative examination, postoperative course and the functional result obtained in these cases are presented. Thorough removal of all adenomatous tissue which encroaches on the vesical neck, particularly in the anterior half, so that all inverted V deformity is eliminated and careful hemostasis during the progress of
56
GERSHOM
J.
THOMPSON AND HENRY BUCHTEL
the operation are important points in technic. Operations must not be prolonged or shock may result; in our experience, patients withstand a two- or three-stage procedure, each of short duration, much better than they withstand a single operation which lasts more than one hour. The bladder must not be allowed to become overdistended at any time during operation or during the postoperative course, or fever may ensue. If the functional result is not good immediately after drainage by inlying catheter has been discontinued, judicious intermittent catheterization or early reoperation are very essential to an uncomplicated convalescence. Replies to letters of inquiry indicate a high degree of satisfaction among the patients. Sixteen patients (benign lesions in 15 and malignant lesion in 1) have returned to the clinic for reoperation 6 months or more after their dismissal. One of these patients was subjected to perineal prostatectomy, while the others preferred to undergo further transurethral resection. Mortality in the series was 1.5 per cent. REFERENCES HEss, ELMER: Discussion of C. H . Mayo's paper on "Treatment of the enlarged prostate gland by modern methods," read before the meeting of the Pan-American Medical Association, Rio de Janeiro, June 20 to August 2, 1935. THOMPSON, G. J.: A new direct vision resectoscope. Urol. and Cutan. Rev. 39: 545-546 . (Aug.) 1935. THOMPSON, G. J.: Prostatic resection: presentation of a case. Proc. Staff Meetings of Mayo Clinic, 7: 725-727 (Dec. 21) 1932. THOMPSON, G. J., SHEARD, CHARLES, AND PILCHER, FRED: Unpublished data.