Fig. 661
Suprapubic prostatectomy. Process of enucleation by finger-tip of one hand in the bladder, the other hand making pressure in the perineum. (Hartmann.)
When difficulty is met in enucleation assistance is derived by the introduction of one or two fingers of the disengaged hand into the rectum, by which certain manipulation can be effected from below that will be of material help. Pressure in the perineum or manipulation of a sound may also be of assistance.
So soon as satisfactory drainage through the urethra can be effected the suprapubic tube should be removed, and the wound thus encouraged to close.
Perineal Prostatectomy.
—Perineal prostatectomy constitutes a similar attempt at enucleation, effected from a different direction. The patient now being in the lithotomy position, with the rectum not only emptied but sterilized, the perineum is widely opened. While the removal may be accomplished through a median incision it is better to have ample room, therefore by a semilunar flap a sort of trap-door should be raised, its apex downward, through which easy access to the deep perineum is afforded. It is only necessary to divide the central tendon of the recto-urethral muscles before the operator arrives at the apex of the prostate and the membranous urethra. The latter, being exposed at this point, is usually divided upon a grooved staff. Here, at its junction, the capsule is usually divided by a free opening, through which the finger-tip is insinuated and made to strip the capsule from the prostate itself. By different operators instruments have been devised which facilitate much of the subsequent work. Perhaps the best of these is the double-blade retractor of Young, which, shaped like a sound, can be opened after introduction, and made to serve excellent purpose by traction upon its handles. If, now, the perineal route have been large enough, and retracted sufficiently, the prostate can be so pulled down into the wound as to be exposed to sight as well as to touch. The effort is sometimes made to enucleate the prostate entire and withdraw it whole, but usually to separate each lateral mass by itself. It is advisable to seize with strong tenaculum forceps and pull down the loosened portions of the organ, in order that it may be more easily separated at its upper part; but it has now been found unnecessary to either open the bladder above the pubis, or even to expose it by an opening through the skin so that it may be pressed down, traction from below taking the place of suprapubic pressure, whatever is needed in the latter direction being effected through the uninjured abdominal wall ([Figs. 662], [663] and [664]).
Fig. 662
First exposure of prostate after introduction of sound through opening just in front of it. (Proust.)