The organ once enucleated, there results a bleeding cavity, at the base of the bladder, which, however, is now opened below and should drain itself easily. If the surgeon’s finger and his instruments have been kept, as they should have been constantly, within the prostatic capsule there is no possibility of harm to the rectum, which, however, may be utilized for assistance in the manipulation should it be required. There remain, therefore, after enucleation the checking of hemorrhage, provision for drainage, and suitable narrowing of the wound. The first and second of these are usually combined by the insertion of a tube, of sufficient rigidity to permit a gauze packing to be placed around it. This should be connected exteriorly with a suitable drainage tube, and bladder siphonage be provided. The wound around the tube is closed by two or three deep sutures, usually of silkworm-gut, since it tends naturally to close by pressure and requires but little further attention.
The greatest harm likely to be done in this operation is injury to the seminal vesicles, above the prostate, between which and the prostate itself the surgeon may not distinguish, with unnecessary mutilation of the posterior urethra. Occasionally, in spite of great care, the rectum will be slightly lacerated. Injury or destruction of the vesicles might lead to impotence, while mutilation of the urethra would be followed by delay in repair, with uncertainty of subsequent bladder action and control.
Subsequent treatment consists in removing both gauze and tube at the earliest possible date, which should not be later than the fourth day; after this irrigation may be given once or twice a day, with the least possible use of instruments.
In either of these methods of prostatectomy the greatest reliance is to be placed upon natural processes of repair. In some way, which seems almost inscrutable, torn bladder and more or less mutilated urethra come naturally together and connection is reëstablished.
After this brief description of operative methods there remains only to contrast them. The especial advantages of the suprapubic method are the total avoidance of perineal fistula, of disturbance of the deep urethra, of the perineal structures, of the seminal vesicles, and a minimum of disturbance of the entire basal portion of the bladder, with a greater theoretical possibility of speedy restoration of its function. It is the method of choice with certain operators of large experience. It seems especially indicated in cases of pronounced intravesical enlargement, but may be made difficult in obese individuals.
In behalf of the perineal route must be alleged the advantage of seeing much of what one is doing, of being really nearer to the field of activity, and of more perfect control of the mass which is to be removed, as well as the fact that the prostate is not an intravesical organ.
Whichever method be adopted the patient should be encouraged to be up and about as soon as possible. Subsequent bladder control comes with varying rapidity to different patients. Urinary fistulas are not likely to persist in patients who have not worn drainage tubes too long. After two or three weeks it is advisable to pass a sound occasionally, in order to maintain proper direction of the urethral canal and prevent formation of stricture. Bladders in which there has been a serious complication of cystitis should be irrigated through the openings so long as they are maintained.
The operation of itself is not a very serious nor difficult measure. It is too often performed on feeble or septic patients, as a last resort, when it is too late.
The galvanocaustic operation is done with an instrument devised by Bottini, shaped like a lithotrite, with a movable platinum blade, which can be heated to the desired degree by the electric current. This instrument is introduced into the deep urethra until its beak enters the bladder, after which the latter is turned half around; then the electric current is turned on, the movable caustic blade gradually withdrawn by a screw mechanism in the handle, and made to traverse a distance of one inch to one inch and a half, previously measured, and in such a way as to burn a channel through the floor of the prostatic urethra, and through any median bar or obstruction which may exist. This is the principle of its use. At one time it was popular, although of late prostatectomy seems to have supplanted nearly every other method. Nevertheless in certain cases it will be found of advantage. I have preferred to combine it, in most cases, with a small perineal opening, introducing the instrument after opening the membranous urethra, and having it in this way much more completely under control. Through the opening thus made subsequent bladder drainage can be effected if desired. It permits also of more perfect exploration of the bladder with the finger.