The principles and practice of modern surgery

by Roswell Park

Symptoms.

—When a man past the middle years of life, previously free from urinary difficulties, is aroused to urinate more frequently than usual, especially at night, while the desire to urinate and the natural feeling of relief at the conclusion of the act are more or less perverted, the beginning of prostatism may be suspected. If in addition to these features the urine shows fermentative changes, or the presence of mucus or pus, the more or less disastrous consequences of obstruction have begun. Symptoms similar to these may be caused by the presence of calculus. It is therefore necessary to differentiate between this and prostatic enlargement. This is first done by a careful digital examination of the empty rectum, the index finger being gently introduced and made to so completely palpate the prostate, through the anterior wall of the rectum, that an accurate estimate of its relative size, as well as of any marked irregularity, may be made. If the prostate be enlarged the explanation is at once afforded. If there be but little apparent change noted by this method the surgeon should introduce a stone searcher. Manipulation with this, in a bladder distended with fluid, should reveal the presence of a calculus, or should indicate a lengthening of the prostatic urethra, with such distortion, as might make the introduction of the instrument difficult, while by further manipulation, its beak being gently revolved, he learns whether behind the prostate there is a pocket in which residual urine may be retained. The question of calculus being settled the patient should now empty the bladder naturally and as usual, after which a catheter should be introduced, in order to withdraw such residual urine as may be retained, whose amount should then be noted. This is a measure of the size of the postprostatic pocket which the patient fails to empty, and in which decomposition and pathological changes are especially likely to occur. Should such a pocket be found in a case without noticeable other enlargement (as detected through the rectum) it will indicate intravesical growth and the formation of the so-called “third lobe” or “median bar,” as it was formerly called (i. e., an outgrowth at the posterior end of the prostatic urethra, projecting upward into the bladder, impeding alike the exit of urine and the introduction of an ordinary instrument). Those expert with its use may gain still further information of value by use of the cystoscope.

Treatment.

—The diagnosis thus established, the question of treatment is raised. Views concerning what is best have been largely modified by the operative methods recently introduced, and the advice given a few years ago is now frequently modified. So long as surgical treatment was unsatisfactory and incomplete it was to be postponed as long as possible. Under those circumstances patients were taught to use the catheter and established the “catheter habit.” Almost invariably they became careless, and the catheter habit led invariably to cystitis. Nevertheless circumstances may arise which make this good advice even today, as in the presence of other and serious disease, or of anything which makes radical operation inexpedient. Under such circumstances the patient must be impressed as profoundly as possible with the necessity for care and caution. If such a case has progressed to the stage of almost complete retention then the catheter should be used at regular intervals. If it be simply necessary to draw off residual urine once a day, then it may be used at night, at which time it would be well also to gently and carefully wash the bladder. It is possible in this way to temporize for a variable length of time, and until more serious conditions supervene.

When, however, the prostate has enlarged so conspicuously as to be not only a constant impediment but a constant menace to the comfort and even life of the patient, one is brought to seriously consider which of the various mechanical methods for relief should be instituted. The choice must now be governed by the physical condition and the surroundings of the patient, as age, degree and character of the obstruction, and the extent of septic infection. One has again to choose between the most radical and usually the most satisfactory method of extirpation (prostatectomy), or one of the less radical and palliative operations, such as the Bottini operation with the galvanocautery.

A few years ago White and others laid great stress on the fact that after removal of the testicles there was notable atrophy of the prostate, and suggested the expedient of double castration or orchidectomy for this purpose. The method proved disappointing, although doubtless more or less effective in some cases, and so objectionable to many patients, for obvious reasons, that it has been practically abandoned. The less mutilating substitute of division and exsection of a portion of each vas deferens (vasectomy) has for the same reason been discarded.

When radical measures become necessary the choice should be made between the galvanocautery (i. e., canalization of the base of the prostate and its median bar by means of the instrument devised by Bottini) and the bolder and more radical method of extirpation (prostatectomy). This prostatectomy is done by either the suprapubic or the perineal route. As between them there is often room for choice, for reasons mentioned below. Each method has its advocates and its opponents.[71]

[71] The question of credit and priority for these operations has been of late much discussed. To McGill, of Leeds, and Goodfellow, of San Francisco, should be given most of the credit for the earliest perineal operations, while Fuller, of New York, who first performed the suprapubic operation in 1894, should probably be given credit for the latter, although it has been evidently unjustly claimed for Freyer, of London. Belfield, of Chicago, was also one of the earliest advocates of extirpation of the enlarged prostate.

Suprapubic Prostatectomy.

—It is of assistance in this method to have the empty rectum somewhat distended, and held up by the introduction of a rubber bag, which may be later distended with water or with air. By this means the prostate and floor of the bladder are pushed upward toward the operator’s finger. This is, however, by no means necessary, but simply advantageous. The first part of the operation is essentially that described as suprapubic cystotomy. The bladder being thus opened and the prostate carried upward by a sound, which should have been inserted in the urethra, the finger first accurately notes its dimensions and the direction of its enlargement. Blunt scissors are now used, or the sharp finger-nail, for making an opening through the mucosa and prostatic covering, through the capsule of the latter, down upon that body. This opening is preferably made near the urethral entrance. The balance of the operation consists in blunt dissection by the end of the finger, i. e., enucleation of the prostate from within its enclosing capsule and surrounding tissues ([Fig. 661]). More or less disturbance of the basal structures is necessitated, but as the surgeon becomes expert the amount of this disturbance becomes relatively surprisingly small. In most instances it is possible also to practically strip off the prostatic tissue from the urethra, so that it is rarely necessary to tear or to cut across it in order to lift the prostate out of its bed. In the average case it is possible in this way to enucleate the prostate in a single piece, and to remove it as an entire organ. If, however, it should prove too large for the bladder opening which has permitted the procedure it would be better to morcellate it, or so far divide it with scissors as to permit its extraction piecemeal. Its removal leaves a bleeding cavity at the base of the bladder, with torn and separated tissues, and a pocket where the prostate used to lie, into which urine will be poured from above, while it cannot ordinarily be at first easily emptied from the more or less injured urethra connected with it. From this surface there will be at first considerable oozing, mostly venous. Should this be serious and prolonged a quantity of gauze may be packed into it through the opening, and pressure thus made. Such packing should only be retained for a few hours. Ordinarily it is sufficient to provide at once for drainage. My own preference is to make double provision for this by the passage of a catheter through the urethra, and by the insertion of a drainage tube from above, whose lower end rests within the pocket. It is a great desideratum to drain the urine as fast as it accumulates, and, at the same time, to keep the patient dry. This is best effected by a method described later, of complete bladder siphonage, which can be resorted to in either form of operation. It is again advisable to get the patient into the sitting posture, which should be done within a day or two, or as soon as his strength will permit, in order that gravity may assist in drainage. (See [p. 1003].)