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PROSTATIC SURGERY by T Postgrad Med J: first published as 10.1136/pgmj.25.286.373 on 1 August 1949. Downloaded from 373 PROSTATIC SURGERY 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 prostate. 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, medicine, 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 urology 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 physician 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.
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