Postgrad Med J: first published as 10.1136/pgmj.25.286.373 on 1 August 1949. Downloaded from 373

PROSTATIC By T. J. D. LANE, M.D. Surgeon to Meath Hospital, Dublin

This communication presents a critical survey There is no place for radiation or the use of the of the developtments in the treatment of prostatic sex hormones in the treatment of the adeno- obstruction since they were last reviewed by matous or fibrous . Because of the Clifford Morson (I935) in 1935. The opportunity possibility of latent cancer, the administration of is also taken to give a fairly detailed account of testosterone may not be free from risk and I have our present practice at the Urological Department never seen it do any objective good. On the of the Meath Hospital. other hand the control of such coincidental lesions While the last 14 years have indeed been vintage as diabetes mellitus or urinary infection may years for the urologist, unfortunately they have not greatly benefit the patient. brought us nearer the discovery of the cause of The questions which arise regarding the various bladder neck obstruction, whether this be aspects of surgical intervention in prostatic adenomatous,* fibrous, or malignant. But when obstruction will be discussed in the following Huggins (194I) showed the dependence of the order : Protected by copyright. prostatic cancer cell on male sex hormone, i. Who should operate ? although he did not find the cause of these 2. What are the indications for operation ? tumours, he certainly transformed our outlook on the disease and brought hope to the hopeless. 3. What pre-operative treatment is required ? While the theory of hormone imbalance is an 4. What is the treatment of choice for (a) Acute attractive way of explaining the development of retention ? (b) Chronic retention ? the adenomatous gland, it remains a hypothesis 5. What operation should be performed ? without. the possibility of reasonable practical 6. What post-operative care should be pro- application. When we really know the cause of vided ? this lesion, , both preventive and thera- 7. What special conditions arise in the case of peutic, may well achieve a resounding triumph. carcinoma ? Until this happens the only method of treating established prostatic obstruction due to adeno- 1. Who Should Operate ? http://pmj.bmj.com/ matous or fibrous disease, and still in some cases to cancer, is by operation. The answer to this question involves the im- becomes portant decision as to whether the operation of Until operation necessary we can prostatectomy should be carried out by a general usually only help the patient by advice; we council surgeon or should be reserved for the urologist. caution in conviviality, the avoidance of delay in Doyen (1917) declared:--' It requires but little emptying the bladder, the importance of warmth, knowledge to perform a surgical operation.' There and so forth. Undoubtedly the greatest service is, however, a vast difference we can offer is to review the patient's progress between the mere on September 29, 2021 by guest. every six or twelve months and thereby safeguard operator and the skilled and experienced surgeon. him against serious chronic obstruction developing In the first flush of success, Millin (1947a) and without symptorns. While in some cases symp- Wilson Hay (1948) allowed enthusiasm tem- toms and obstruction remain minimal for years porarily to overcloud their habitual clear-sighted- and death eventually is due to some other cause, in ness and claimed that their operations opened up others the lesion may be quietly progressive. prostatic surgery for the general surgeon. Unless, Because prediction of the future is uncertain, without any reason at all, I am to follow them in observation is obviously essential. their short-lived lapse into heresy, the question must at once be amended to who should TREAT these patients ? My answer is that they should be *In default of any other adequate word, ' adeno- treated by urological surgeons, and I believe that matous ' is used throughout this article to describe the in the future more and more of these cases will condition of benign prostatic hypertrophy. Its use in no way implies that the condition is considered to be be so treated. Much of the safety and success of neoplastic. relieving prostatic obstruction depends on team Postgrad Med J: first published as 10.1136/pgmj.25.286.373 on 1 August 1949. Downloaded from 374 POST GRADUATE MEDICAL JOURNAL August I949 work and efficient organization; these can only be 5. Even in the presence of established prostatic obtained in a unit where several cases are dealt obstruction with an obviously overdistended with week in and week out, throughout the year. bladder, operation is inadvisable in the patient with a serious or potentially serious vascular or 2. What are the Indications for Opera- cardiac lesion, provided there is no pyelo- tion ? ureterectasis. The important question of the proper time and No attempt will be made to give a full list of reasons for surgical intervention in prostatic the reasons for and against prostatectomy in obstruction has lately been brought to the forefront different circumstances., Established prostatic by Millin, McAllister and Kelly (1949). I com- obstruction is a useful term, and Millin would not pletely agree with Millin and his associates that have been attacked by Vernon (I949) and Chap- in general ' operation should be advised in estab- man (I949) for suggesting its earlier treatment by lished prostatic obstruction.' I further agree that surgery if prostatectomy was limited in practice to the residual urine test as a diagnostic test is urologists. In actual fact this is far from the case, obsolete. Observation of the urinary stream, with results that are common knowledge. In palpation including bimanual palpation of the spite of this knowledge is still fighting for bladder and, above all, intravenous pyelo-cysto- recognition as a speciality in these islands. graphy together render this test unnecessary, out-of-date, and dangerous in all but expert hands. 3. What Pre-Operative Treatment is Re- While Millin and his colleagues have not defined quired ? exactly what they mean by ' established prostatic Apart from measures directly concerning the obstruction,' I have little doubt that they would urinary tract, which will be dealt with in the next not differ with me on the following points: section, the high average age of prostatic patients Protected by copyright. i. In established prostatic obstruction *the makes a thorough investigation of their general decision to operate and the choice and timing of clinical condition of the utmost importance. The the operation should be reached only after a full co-operation of a specially experienced and thorough examination of the patient. is invaluable. We have found medical grading of 2. Established prostatic obstruction includes the patient very helpful, and my medical col- all patients who are still able to empty their league, Brian Mayne, has kindly contributed this bladders but (a) whose social life is made difficult note. by ' encores,' frequency or difficulty during the 'In order the more accurately to assess a day, or whose nights are made sleepless by the patient's condition pre-operatively, and to enable number of times they have to rise, especially if, comparisons to be made between one patient and in these same cases, difficulty has become serious; another as to fitness for operation, it was decided (b) whose urinary streams, observed under favour- to introduce a grading system. Patients about to able conditions, are seriously impaired; (c) who undergo operation are therefore placed in one of are subject to frequent attacks of retention ; (d) four grades. In determining the grade, the con- http://pmj.bmj.com/ who are unable to take a drink without getting dition demanding operation is not taken into acute retention, yet are not prepared to abstain consideration, but any other disabilities are care- from alcohol. fully assessed. 3. In many cases the existence of prostatic 'The grade in which a patient is placed does not obstruction can be established only by intravenous necessarily indicate that patient's long-term prog- urography. The findings of a cystographic nosis. A patient may be put in the lowest grade shadow of normal proportions after the patient as a result of a severe infection from which re- on September 29, 2021 by guest. has been given a fair opportunity of voiding, covery is possible, for example, bilateral lobar especially if associated with diverticula or, more pneumonia, or as a result of a condition from important, with dilatation of the lower end of one which recovery is impossible, for example, gastric or both ureters, is diagnostic. Inability to empty carcinoma with widespread secondaries. Thus it the bladder may quite often be detected in a is necessary when stating the grade of a patient to straight film, but urography is essential for a full give the reason for which the grade was chosen, and proper study. and also a note as to whether improvement can be 4. In a patient who, in addition to any obviously expected within a reasonably short time, as a overdistended bladder due to marked prostatic result of which the patient could be re-assessed obstruction, is also suffering from an extra-urinary and might be placed in a higher grade. A state- lesion which is certain to destroy his life in a few ment as to treatment should immediately follow months, then, if interference is compelled by pain the grade. For example or discomfort, the choice lies between endoscopic 'Med. Grade 4. Auricular fibrillation and resection, repeated catheterization or cystostomy. severe congestive heart failure. Improvement ex- August I949 LANE: Prostatic Surgery 375 Postgrad Med J: first published as 10.1136/pgmj.25.286.373 on 1 August 1949. Downloaded from pected in two weeks. Treatment: Digitalis; 4. What is the Treatment of Choice for salt free diet; fluid restriction, etc. (a) Acute Retention ? (b) Chronic Re- 'The four grades are distinguished as follows: tention ? 'Grade i. A patient having no disability other (a) Acute Retention than the operable disability. Some patients reach the urologist with the 'Grade 2. A patient having some disability urethra damaged by the general practitioner's other than the operable disability, but one which efforts to give relief with the catheter. While the is not likely to increase the operative risk appreci- urethra may be badly injured at a single attempt, ably. it is particularly prone to such injury if unskilful catheterization has been repeated over some days. 'Grade 3. A patient having some disability in This trouble can only be rectified, and the in- addition to the operable disability, which is likely cidence of strictures lessened, by insistence on to increase the operative risk appreciably, or which gentleness and the use of rubber catheters onlv. carries in itself a grave p;rognosis. Further, if catheterization is not immediately 'Grade 4. A patient having, in addition to the successful, the bladder should be emptied by the operable disability, some disability which carries suprapubic insertion of a trocar and cannula or such a grave prognosis at the present as to make spinal needle. In practice a cannula is much more operation unjustifiable, or which carries such a convenient, because it will empty the bladder so grave ultimate prognosis as to make operation much faster. It is interesting to recall that most unnecessary. authorities when describing tapping of the bladder 'On receiving the medical grading statement, the recommend complete emptying before withdraw- surgeon can add it to what he already knows about ing the instrument. Tapping can be repeated three or four times if necessary. A penicillin the patient's operable disability, and can decide Protected by copyright. the immediate fitness for operation, the advisability cover is advisable. Chloromycetin, which has of postponing operation, and the necessity for any just become available, promises to be a most useful special treatment or precautions to be undertaken and convenient drug. concurrently with the operative treatment.' (b) Chronic Retention Clifford Morson's reminder that Freyer's mor- Pre-Operative Treatment. With very few excep- tality rate was 4.7 per cent. was a salutary and an tions the treatment of chronic retention will be inspiring challenge. In spite of greatly improved surgical. If the retention is moderate in degree anaesthesia, the antibiotics and refinement in (a residual estimated to be about a pint or less), if technique few today do much better and many renal efficiency is not seriously not so well. I am convinced that only ceaseless impaired, if the care and attention to detail will effect material blood urea is below ioo mgm. per cent., if the improvements in our returns. This applies not urinary tract is uninfected and if the patient has a only to factors directly affecting the operation or good urinary output (three or more pints per day), even directly concerning the urinary system, but no pre-operative treatment is necessary. http://pmj.bmj.com/ also to the general clinical condition of the patient. If the degree of retention is gross (30 oz. or For example, as a result of recent preliminary more), it is my practice to drain the bladder. If investigations carried out by Professor W. E. J. such drainage is necessary for only a few days, as Jessop of the Department of Physiology, Royal is usually the case where renal efficiency is not College of Surgeons in Ireland,* it would appear seriously impaired (blood urea below I50 mgm. ' that 3 per cent. of prostatic cases may have per cent.), we tie in a No. I5 or No. i8 Ch.

diabetes of a sub-clinical grade.' Obviously such Tieman catheter. It is general knowledge that on September 29, 2021 by guest. cases, if undetected, may develop serious, even while some patients tolerate the catheter (in- fatal, post-operative complications. dwelling or intermittent) perfectly well for weeks or even months, others develop a urethritis in a A really thorough examination of the patient few days. There is no way of forecasting a will take, even with good organization, two or particular patient's reaction. Because of this, and three days. Holding such an examination to be because all modern operative techniques require essential, I have not given Wilson Hey's (I945) the indwelling catheter for at least three or four policy of immediate prostatectomy a crial. days, I think it best to ration its pre-operative employment. Accordingly, where for any reason more prolonged drainage is essential, we insert * Mr. Lane and Professor W. E. J. Jessop have a kindly provided full details of these investigations, Malecot catheter through a trocar and cannula which will be sent tp anyone interested on application 4I in. or so above the symphysis and a little to one to the Editor. side of the midline. For some months past we 376 POST GRADUATE MEDICAL JOURNAL August 1949 Postgrad Med J: first published as 10.1136/pgmj.25.286.373 on 1 August 1949. Downloaded from have used an i 8 French Malecot catheter passed gained by its employment, and since then de- through a 28 French cannula. Mothersill and compression, as we know it, has not been used by. Morson used an essentially similar technique as them. In a letter dated May 31, 1949, Dr. long ago as 1921. In 1943, Riches described an Edward Cook wrote :-' As- regards the subject of ingenious and practical method of suprapubic decompression, we still do not practise it here at catheterization. It is very interesting to note that this clinic. For almost 20 years now we have not both Mothersill and Morson (1921) and also worried about the necessity for gradual decom- Riches ( 943) incise the skin and rectus sheath. pression in any of these cases. In those patients The use of a large cannula and small catheter with a large retention, the catheter is inserted and makes for a little extra simplicity, in that it is up to i,ooo or I,500 cc. may be drawn off im- necessary to incise only the skin. The perform- mediately. If the retention is over this we have ance of this little operation has been deliberately on occasions, if the patient's general condition limited to the most junior members of the staff seemed rather poor, removed an additional 500 cc. of the Urological Department of the Meath every hour until the bladder is completely emptied. Hospital, and they employ it only when they are We have experienced no ill results because of this absolutely certain that they can feel an over- program.' distended bladder. Though stab cystostomy has Since I938 no patient has been ' decompressed' been condemned by Swift Joly (personal com- in my department and my experience tallies with munication) and Millin (I947b), our experience that of the workers at the Mayo Clinic. The case agrees with that of Morson and Riches regarding against decompression may be based on the follow- its safety, even in relatively inexperienced hands. ing considerations. 'No urologist has seen the It leaves the anterior surfaces of both bladder and need to decompress the hydronephrotic kidney; prostate usually in perfect, and always in good, every urologist has seen the hydronephrotic kid-

condition for the major attack. ney submitted to a plastic operation plus nephros- Protected by copyright. No discussion of cystostomy, however short, tomy in the morning functioning well, and drain- could be ended without condemning the all too ing freely in the afternoon of the same day. There prevalent practice of doing the ' open' operation might be more sense in advocating decompression through a low vertical midline incision, with the if as the result of vesical over-distension the tube inserted immediately above the symphysis ureteric orifices were patent and gaping, and the pubis. If done as a permanent measure this pelvis of the ureter in free communication with horrid practice adds greatly to the patient's dis- the bladder. Daily cystoscopic and operative comfort. If performed as a prelude to prostatec- experience teaches us that this is not so. Such free tomy it may render even cystoscopy all but im- communication is a rare terminal phenomenon. possible, by causing fibrosis of the suspensory Ordinary everyday pyelographic studies show, in ligament of the penis and thus preventing the case after case, the obstruction to be in either the downward deflection necessary to pass the instru- juxtavesical or intramural part of the ureter. The ment into the bladder. Worse still, this cowardly exact site is a subject that Professor R. A. Q. and slovenly bit of ' surgery ' too often makes a O'Meara has commenced to study. http://pmj.bmj.com/ retropubic prostatectomy impossible and hampers We adopt the Mayo Clinic method of closed the proper performance of a Freyer. We have drainage, using a modification of the bottle not so far tried Sandrey's perineal drainage. described by Emmett (I937) and made for us by Slow decompression of the bladder was origin- the Genito-Urinary Co., of London (Fig. i). ally described in a rather emotional article by There is a prevalent British superstition that these Von Zwalenberg (I920) of America. It was taken bottles are apt to become air-locked. We have

up at once by Verne Hunt (1923) and his associates used them for over ten years without meeting this on September 29, 2021 by guest. at the Mayo Clinic. In I927 Frank Kidd (I927) trouble. By changing the bottles, which hold two praised and. developed it. In 1931I Hamilton pints, at standard times a glance at them will tell Bailey (1934) extolled it and devised a special the patient's output at any intervening moment. instrument for practising it. The danger of im- The bottles, their fittings and the connecting tubes mediate emptying of the chronically overdis- are cleaned by a special orderly; they are sterilized tended bladder has been stressed more than once by boiling-an operation carried out by the nurses, by Riches (i944, 1949). Von Zwalenberg's who use strict aseptic and antiseptic care in dis- principle is still in vogue throughout Great connecting and reconnecting them to the catheters. Britain today. Viscocaps are convenient for sealing off the bottles Almost 20 years ago the workers at the Mayo after boiling. Clinic tried out a larger series of cases side by side, In a patient with marked uraemia, it is very with and without decompression. The results of important that an estimation of the alkali reserve their experiment showed that nothing was to be should be done when drainage is established, if it LANE: Prostatic Surgery August I949 377 Postgrad Med J: first published as 10.1136/pgmj.25.286.373 on 1 August 1949. Downloaded from manent cystostomy. In my experience permanent cystostomy inflicts much suffering and misery on only too many; if done at all, it should be reserved for the phlegmatic and well-to-do. The urologist worthy of the name must attack the obstruction itself. In cases of adenomatous enlargement I have performed in my time Freyer's operation in one and two stages, Thomson Walker's operation with and without immediate closure, Wilson Hey's excellent operation, and Millin's retropubic approach, to complete the list of ' open' opera- tions. I have no practical experience of Young's perineal prostatectomy. Last March Mr. Ogier Ward kindly demonstrated his vesiculo-capsular method to me at St. Peter's Hospital. As Ward points out, the indications for this procedure are limited, and I have not yet had an opportunity of trying it myself. In the transurethral fields I began by using the Stem-Davis McCarthy re- sectoscope, but since visiting the Mayo Clinic in 1938 have employed only Gershom Thompson's 'cold punch.'

My present practice is to use Freyer's operation Protected by copyright. for the patient with a large gland and a low cystostomy. All other cases are dealt with either by the cold punch or retropubically. Counting for the moment the fibrous and carcinomatous obstructions as well as the adenomatous, I use both FIG. i.-Modified Mayo Clinic urine collecting bottle. methods roughly to an equal extent. It is im- The inset shows a viscocap. 4 portant to distribute the material so that both operations are performed sufficiently often to has not been done already, and prompt corrective enable efficiency to be not only maintained but, if measures taken if necessary. Vasectomy is often possible, increased. This is a great change from done at this stage if the patient is over 70. the procedure of some years ago, when I resected Free administration of fluids is highly desirable IOO gm. at a sitting and performed endoscopic re- in uraemic cases, but the urologist must be guided section on 8o per cent. or so of all cases. At in this most important matter by his medical present I am endeavouring to limit the use of the http://pmj.bmj.com/ associates; for instance, forcing fluids into a punch in adenomatous cases to those only needing patient with congested lung bases can only harm 20-30 gm. resections. Altho6gh I still, and will both lungs and kidneys. Uraemia is often always, prize the punch, my change over from it associated with anaemia of sufficient significance to is based on reasons already given elsewhere. Be- need blood transfusion for its rapid correction. cause of the difficulty of assessing the size of the The patient needing pre-operative medical enlarged prostate, the operator who follows a treatment is prepared for operation as rapidly as similar policy must keep well within his maximum on September 29, 2021 by guest. possible, and my medical associate, Dr. Mayne, resecting ability, unless he is prepared to face the notifies me when maximum improvement has been prospect of many multiple 45-minute resections. effected. In dealing with the uraemic patient we It is well known that it is not safe to prolong trans- follow Thompson (1939) and do not wait till the urethral resection much beyond 45 minutes. blood urea is normal, but operate when it starts to Cysto-urethroscopy is not only a valuable fall, which almost always coincides with diuresis. method of excluding coincidental vesical path- Unless the patient's kidneys have been irreparably ology, but is also a splendid means of determining damaged, the blood urea will begin to fall within the size and configuration of the gland. It is often a week or two, though in some cases it may never the only way of discovering the ' middle lobe.' again reach a normal level. With the cysto-urethroscope the length of the prostatic urethra and the increase, if any, in the 5. What Operation Should be Performed ? internal urinary orifice in the sagittal plane can be I would like straight away to condemn per- accurately measured. The instrument will not, 378 POST GRADUATE MEDICAL JOURNAL August I949 Postgrad Med J: first published as 10.1136/pgmj.25.286.373 on 1 August 1949. Downloaded from however, completely disclose expansions of the surgeon should think of himself. No surgical prostate in either the coronal or sagittal planes. procedure is more exhausting both mentally and Bimanual rectal examination alone can do this. physically than the resection of a large prostate; Unfortunately bimanual palpation is quite often at one and the same time it is both exacting and impossible, hence, when resecting, the surgeon boring. must be prepared for a wide margin of error in I now only do resections requiring the removal his assessment of the size of the adenomatous of more than 30-40 gm. in really bad cases, and gland. Lastly, in this connection, I agree with even in them do Millin's operation if the mass Millin (x947)-that the time for cysto-urethroscopy exceeds 60-70 gm. This occasional extension of is immediately before operation. the use of the punch is a tribute to my faith in its A proper appreciation of the indications for, greater safety. and skill in the performance of all the modem operations can only be developed if a large amount ANALYSIS OF TOTAL NUMBER OF PROSTATIC CASES of clinical material is available. If I were a general OPERATED ON FROM OCTOBER, 1946-AUGUST, I948 surgeon obliged to do an occasional prostatectomy, I would be a two-stage Freyer addict. I would Per begin my attack on the large gland obstruction Type of Operation Cases Deaths Cent. with a stab cystostomy and maintain drainage for a Punch Resection .. 324 9 2.8 week or two. Suprapubic drainage has a mar- Suprapubic Prostatectomy vellous effect in reducing prostatic congestion, and with closure (modified Thomson-Walker) .. 26 I 3.8 the subsequent enucleation is so relatively blood- Retropubic Prostatectomy 133 8 6 less that packing and the use of such contraptions Wilson Hey Prostatectomy.. 21 I 4.8 as the Foley bag are rarely needed. As for the Freyer Prostatectomy .. 5

smaller , I should search hard and Protected by copyright. earnestly for urological assistance, for the sake of Total . .. 509 I9 3.7 the patient and my conscience. The more skilled urologist, though occasionally Deaths from all causes included. compelled to fall back on Freyer's operation, will N.B.-Permanent cystostomy was done on less than choose one of the modern methods because of o.5 per cent. of total admissions. their obvious advantages, in particular better haemostasis and speedier convalescence. It is It is only fair to point out that the I33 retro- clear that he must be able to use a resectoscope as pubic operations are my first I33 such operations. well. Obviously, each man will use the methods The 324 punch resections have behind them the that suit him and his circumstances. If the choice experience of well over i,ooo of these operations. is wisely made I feel sure that good men backed by During 1946-47 bad risk cases, almost regardless good organization, using any of the modern of the size of the prostate, were treated by endo- techniques, open or transurethral, will get com- scopic resection. parable results. http://pmj.bmj.com/ For my part I discarded the Harris and Wilson Notes on Technique Hey techniques in favour of the Millin because the Second-Stage Freyer retropubic suited me better. For one thing I We (my assistants and myself) excise the original could do it in about half the time needed by me for wound and fistula, and free the bladder from the either of the other two. Similarly, having given abdominal wall. A short incision is made in the diathermic resection a trial, I now use only bladder wall downwards from the lower edge of it gives me better the of Thompson's punch, because fistula; this, course, safeguards the peri- on September 29, 2021 by guest. differentiation between adenomatous tissue and the toneum. The adenomatous tissue, nearly always capsule, better haemostasis and faster cutting. I considerable in amount, is enucleated with the believe a properly performed punch (or, for that help of rectal counter-pressure given by the matter, diathermic) resection is as efficient and as second assistant. A pair of von Lichtenberg's permanent as any other' prostatectomy ' and also retractors are then inserted and the adenomatous safer. ' Prostatectomy ' is put in inverted commas mass, as it lies free in the bladder, is visualized. because it is a misnomer; in adenomatous disease, It is then extracted with Hobday's bitch forceps, adenomatous tissue only and not the prostate itself a veterinary instrument used in canine midwifery is removed. The present plan of limiting punch practice (Fig. 2). If both lateral lobes are markedly resections to 20-30 gm. glands was decided on enlarged, each is enucleated in turn. When these only after much thought and consideration, and the are grossly enlarged, the proximal part of each is decision was undoubtedly influenced by Millin's enucleated and then seized with Hobday's forceps, argument that even for the patient's sake the traction on which makes enucleation of the distal August 1949 LANE: Prostatic Surgery 379 Postgrad Med J: first published as 10.1136/pgmj.25.286.373 on 1 August 1949. Downloaded from encapsulated adenomatous 'seeds' adhering to the capsule after the removal of the main' tumour,' also for putting traction on tags prior to their scissors' resection, and occasionally for guiding t *' i"."' t. ..' :'"; ...... t, il ' * '' " the catheter into the bladder. We always palpate the interior of the bladder and realize the need for careful inspection of the prostatic cavity to ensure complete removal of all tissue needing removal. In dealing with the bladder neck, we base our work on Millin's practice. The closure of the FIG. 2.-Hobday's forceps. They are more curved on capsular incision is commenced by inserting a the flat than shown in this sketch. It may be an stitch at its extreme left-hand end. This stitch is advantage to provide the handles with a ratchet. useful both as a guide and as a tractor. The standard continuous stitch is then carried from part easier. Enucleation completed, the patient is right to left until the stay stitch in the middle is put in the Trendelenberg position, von Lichten- reached. The boomerang needle is used to thread berg's and Morson's retractors put in position, this through the upper edge of the incision and it and with the aid of a spotlight and scissors, tags is then tied and cut off. The long stitch is then and remnants visualized and cut away. In our continued in the usual way until the left hand of experience the second-stage Freyer is relatively the capsular wound is reached. While recognizing bloodless and we use neither packing nor the the importance of firm and accurate stitching, we Foley bag. A No. 20 or No. 22 Harris, or believe that too tight a closure is prejudicial to McCarthy electrotome catheter is passed per primary healing. We usually remove the urethral urethram and stitched in by Wilson Hey's method. catheter permanently in four or five days. Protected by copyright. The bladder is closed round a No. 30 or No. 35 Malecot, which is removed usually in two or Punch Resection three days. The urethral catheter with luck may In addition to the smaller adenomatous lesions, be dispensed with in a week or so. this is the only operation used by me for the fibrous gland and for the carcinomatous obstruc- Retropubic Prostatectomy tion which does not yield to hormone treatment. It is remarkable how satisfactory this operation We often use Thompson's (1934) modification of is in the obese. We occasionally use the trans- his operation for the smaller stone-bearing verse, but more often than not the low short prostate. Except when the perineal approach is vertical incision. If, in suturing the latter, two used, we work exclusively with the 27 French or three figure of eight silkworm tension sutures instrument. are placed, subsequent ventral herniation is very Two important developments must be reported. exceptional. We follow Millin's technique with a The first of these, the use of isotonic solutions few minor exceptions. Like him we coagulate instead of water, is applicable to the diathermic http://pmj.bmj.com/ large veins in the pre-prostatic fat; subsequent method also. Based on observations by Creevy section of these vessels greatly facilitates dis- (1947), Foley, Emmett, McLaughlin and others, it placement of the fat. In easy cases we dispense has, in my experience, transformed the con- with the lateral packs. Instead of a stay stitch to valescence of patients and completely removed the steady the capsule, we use a bullet forceps inserted risk of oliguria, which once or twice in a year's a millimeter or so from the line of the capsular work might end in a fatal, untreatable anuria. The of trouble is ' the incision. The capsular incision is conveniently underlying cause the haemolysis on September 29, 2021 by guest. made with a long-handled knife. When the of the patient's blood by the entrance into the capsular incision is completed a stay stitch is venous system of the sterile water used as an placed through the middle of its lower edge or irrigating fluid during operation.' We use 4 per flap and the bullet forceps and rongeur removed. cent. glucose solution which is sterilized in a We have given up the use of the T clamps, and suitable I2-gal. sterilizer, mounted 3 ft. 8 in. use long Spencer Wells to control bleeding points. above the top of the operating table. The solution They are by no means always needed. We is replenished daily as required, but at the end of occasionally succeed in sectioning the urethra each week the tank must be emptied completely. under vision. We find Hobday's forceps helpful The operator accustomed to water will find in extracting moderate-sized and large masses; glucose enhances his difficulties for a while, but Jacob's uterine vulsellum is also useful, par- with a little practice these troubles disappear as ticularly in the smaller cases; Luc's septum completely as the risk of oliguria. Jessop and I forceps are amazingly helpful in removing small, (1948) have confirmed Creevy's observation that 38o POST GRADUATE MEDICAL JOURNAL August I949 Postgrad Med J: first published as 10.1136/pgmj.25.286.373 on 1 August 1949. Downloaded from 6. What Post-Operative Care Should be Provided ? The nurses are taught to realize that modem prostatectomy is not really painful, and that if 'ijYi"+ 9 + - E .i..d7.q ; complaint is made of pain the catheter is probably obstructed. They are instructed to see that the a"*. j ka catheters keep dripping and in resection cases to palpate the hypogastrium. Codein in i gr. doses usually controls post-operative pain ; morphia is ri i reserved for the sensitive or highly-strung subject. t u1*S ***x The patient is given fluids freely by mouth or, if .tv.4 4:,gt3~ #>$~[X ffi s necessary, intravenously. Bladder washouts and i*.. W t* v5

alternate week. This plan has possible theoretical still living.' on September 29, 2021 by guest. and obvious economic advantages, and in most I have not reviewed my own cases yet, but have cases is just as efficient as continuous administra- no doubt at all of the general value of hormone tion. It is particularly helpful to the patient who treatment, though admitting that disappointing develops sore or painful breasts, as it materially relapses and occasional total failures must be reduces the severity and continuity of this trouble. faced. I have not followed Reed Nesbit (I944) in with- A recent review of 23 cases treated by orchidec- holding treatment until 'the onset of symptoms tomy in the first eight months of 1942, and arising from advanced or metastatic lesions.' As described in the Lancet in February, 1943, shows is now well known, dienoestrol is much less that the results in Dublin tally closely with those efficient than stilboestrol. obtained 'by Huggins (1946) in Chicago. Exclud- ing two in whom the lesion was almost certainly 2. Radiation vesical carcinoma, four of the remaining 2i are In my experience an occasional case that fails still alive, and three of them in good health. The 382 POST GRADUATE MEDICAL JOURNAL August I949 Postgrad Med J: first published as 10.1136/pgmj.25.286.373 on 1 August 1949. Downloaded from

JESSOP, W. E. J., and LANE, T. J. D. (I948), Irish J. Med. Sci., fourth case, examined recently, was found to have Nov., 1948. good urinary function, mild anaemia and no X-ray KIDD, F. (I927), cit. BAILEY, H. (I934), Brit. J7. Surg., 6, 225 MAYO, C. H. (1932), cit., BUMPUS, H. C., 'Minor Surg. of evidence in the bony pelvis, vertebrae or lungs of Urinary Tract,' p. 55. metastases, though secondaries must be present MILLIN, T. (1947a), Irish J. Med. Sci., May, 1947. because his serum acid phosphatase is 17 units. MILLIN, T. (1947b), 'Retropubic Urinary Surgery,' Edinburgh, E. & S. Livingstone Ltd., p. 65. Of the cases that did not survive, death in many MILLIN, T., McALLISTER, C. L. O., KELLY, P. M. (I949), was not due to prostatic cancer. Lancet, I, 38I. MOORE, R. (I935), 7. Urol., 33, 224. MORSON, C. (193S), Post Grad. Med. J., II, 437. MORSON, C. (1946), Brit. Med. J., I, 888. BIBLIOGRAPHY MOTHERSILL, G. S., and MORSON, C. (I921), I, 418. NESBIT, R., and CUMMINGS, R. H. (I944), J. Am. Med. BAILEY, H. (I934), Brit. Y. Surg., 6, 225. Assoc., 124,- I8o. BUMPUS, H. C. (I926), Surg. Gyn. & Obst., 43, 150. RICHES, E. W. (I943), Brit. J. Surg., 31, 135. CHAPMAN, T. L. (I949) Lancet, I, 502. RICHES, E. W. (1944), Proc. Roy. Soc. Med., 37, 226. CREEVY, C. D. (I947), Y. Urol., s8, I 25. RICHES, E. W. (I949), Brit. Med. J., I, 888. CREEVY, C. D. (I948), Y. Am. Med. Assoc., 138, 4l2. THOMPSON, G. (I934), Collected Papers, Mayo Clin., 26, 34I. DOYEN, E. (1917), 'Surgery, Therapeutics and Operative Tech- THOMPSON, G. (I939), Proc. Staff. Meet. Mayo Clin., 401. nique,' Eng. Ed., I, x6. VERNON, H. K. (I949), Lancet, I, 547. EMMETT, J. (I943), Y. Urol., 49, 815. WILSON HEY, H. (I945), Brit. J'. Surg., 33, 41. HUGGINS, C., and HODGES, C. V. (I941), Cancer Research, I, WILSON HEY, H. (I948), 'Textbook of Genito-Urinary Surgery,' 293. ed. H. P. Winsbury-White. Edinburgh, E. & S. Livingstone HUGGINS, C. (1946), Y. Am. Med. Assoc., I3I, 576. Ltd., p. 477. - HUNT, V. C. (1923), Collected Papers, Mayo Clin., p. 505. VON ZWALENBERG, C. (I920), J. Am. Med. Assoc., 75, 1711. Protected by copyright. http://pmj.bmj.com/ on September 29, 2021 by guest.