Finally comes the question of extirpation or a complete cystectomy. This radical and difficult measure has been added to the list of possible surgical procedures. In a case of general papillomatous disease it might be successful, but it is questionable whether any case of cancer which would call for such a measure can be cured by it. The operation has been done much oftener in women than in men, and usually by a combined procedure of suprapubic opening, which may be vertical or transverse, with attack from the vagina. If the vaginal wall be involved it may also be cut away. The ureters should be isolated and preserved, when, the affected tissues being removed, it becomes a question of what to do with them. They may either be left to drain into the vagina, which is thus utilized simply as a conduit, and which may be closed later and the urethra thus utilized, a urinal being worn, or they may be immediately or by a secondary operation turned into the rectum. The latter procedure introduces fresh complications, though, if successful, it would minimize the unpleasant features of such a case.[69]
[69] Symphysiotomy may, when required, be combined with suprapubic operation as in the case of young children, for removal of very large stones or tumors, as has been recently demonstrated by Palmer, of Persia.
It is thus possible to successfully extirpate the entire bladder proper, conserving the ureteral orifices or not, as well as the urethra, although the resultant condition can hardly be considered brilliantly satisfactory.[70]
[70] In a recent case I have been able to more easily effect this procedure by raising a flap, including the tissues of the mons, exsecting a portion of the symphysis containing the insertion of the recti, by oblique division, in such a way that when replaced the bone could not be easily displaced, and in this way uncovering the space of Retzius so that, by combined manipulation, it was easier to detach the bladder wall from its surroundings.
THE PROSTATE.
The prostate, with the duct extremities of the seminal vesicles, are enclosed in a fibrous sheath or capsule, of more or less density, which has been called by Belfield the broad ligament of the male. In structure this body is composed of a mixture of adenomatous and muscular (involuntary) fibers, with considerable connective tissue, so that in many respects it is the homologue of the uterus. It not only serves as the portal of the bladder, but through it pass the prostatic urethra and the seminal ducts. Infection proceeding from either direction may, therefore, travel along either one of several paths, spreading disaster and causing a variety of troubles. Such infection may be tuberculous, gonorrheal, or of the ordinary septic type. There will ensue in consequence various forms of prostatitis: the acute, which may lead to abscess, and the chronic, which will always lead to hypertrophy.
ACUTE PROSTATITIS.
Acute prostatitis is generally the result of gonorrheal infection, the consequence of extension from the urethra into the mucous follicles and the prostatic structure. Primary tuberculous disease in this location is rare. Septic infection comes either from the use of unclean instruments, from the presence of infected urine, or from the extension of cellulitis from some adjacent structure. It is not infrequently seen in connection with deep and tight strictures and accompanying cystitis, or in connection with the presence of small concretions, i. e., prostatic calculi.
Acute prostatitis is an exceedingly painful affection, made so particularly by inelasticity of the capsule, which affords no accommodation for the swelling due to the inflammation. In addition to the inevitable pain and tenderness the swelling will sometimes practically close the urethra in such a manner that urination becomes almost impossible. To nearly every case will be added some of the symptoms of acute cystitis, which may have preceded the prostatitis. Prostatic inflammation can be made known by the exquisite tenderness of the organ, discoverable by digital examination through the rectum. This feature, with tenderness in the deep perineum, and the above symptoms make diagnosis easy.
According to the intensity of the lesion will be the liability to suppuration. Prostatic abscess is a frequent result, and its presence is evidenced by accentuated pain and tenderness, with perhaps considerable febrile disturbance. In some cases fluctuation can be detected through the rectum. Such cases sometimes evacuate themselves spontaneously, although often in an undesirable way, when left untreated, or unrecognized, discharge taking place usually into the rectum, but perhaps into the bladder or into the urethra. Should pus burrow into the pelvis there will arise a deep pelvic cellulitis, with probable disastrous consequences.