Personal Experience in Modern Operations for the Relief of Prostatic Obstruction

1899 Boston Medical and Surgical Journal  
Surgeon to the Massachusetts General Hospital. In a paper written in 1896, at the request of tbe Executive Committee of the American Surgical Association, aud road before their meeting at Detroit, I stated that I thought the time then too early for tho formation of positivo opinions as to tho merits of the various operations for the relief of obstruction in cases of hypertrophiod prostate. At that time the recorded cases were few, and many of them had been under observation for but a short time
more » ... or but a short time since operation, and conclusions as to the final result were often impossible. It is this question as to the permanence of results which, next to the question of immediate mortality, has the greatest interest for us. To hasten the final correct solution of this question it is very desirable that surgeons dealing with this class of cases should put on record all observations coming within their opportunity, both of patients operated upon by them, and of those seen by them after operation by others. In this way only can we Bpeedily accumulate the data necessary for a correct judgment. This is my reason for presenting a short résume of my own experience iu this field of work. The present success that attends the use of our modern soft catheters iu cases of prostatic obstruction has reduced the number of cases in which I have had to resort to operation to the few which follow : SIX CASKS OF PltOSTATKCTOMY. Cask I. W. D. was seen by the writer in September, 1892, at which time he was sixty-five years of ago. He was first troubled with frequent urination thirteen years before. Three years later he was forced to begin the catheter life, which had thus lasted for ten years. Within the year before be was seen ho liad begun to have a good deal of pain in the rectum and glans penis. At the same time the frequency with which he had to use tho catheter increased so that for a short time before entrance he was drawing his water two or three times an hour. The urine was ammoniacal and contained much ropy pus. September 17, 1892, he was operated by suprapubic incision. The third lobe projected backward into the bladder, forming a tumor the size of a lien's egg, ulcerated on the surface This was cut off level with the proper bladder face of the prostate. One month later the suprapubic opening was sufficiently closed to enable the patient to pass urine normally (the first time in ten years). This patient has been seen at varying intervals since his recovery, the last time five years after operation. The urine has been passed completely by natural efforts, the frequency being from five to eight times in the twentyfour hours, and the urine has remained clear and acid. Cask II. C. E. L. began to be troubled with pain in urination and with increased frequency in 1888 or 1889, at which time he was forty-six years of age. In 1891 he had retention after a long march with the Grand Army of tho Republic. This was relieved by the catheter, but returned some days later and troubled him more and more until 1892, when he was obliged to establish the catheter life, after this time passing no water by tbe natural efforts. In 1895 he had symptoms of stone and litholapaxy was done on May 28d of that year. At this time rectal examination showed a prostate of moderate size. The litholapaxy afforded him some relief, but on May 4, 1896, he re-entered the hospital with pronounced symptoms of stone. He was advised now to have tbe stone removed by suprapubic incision in order that the prostate might be dealt with at the same time. Consenting to this, he was operated upon on May Cth. Four stones were removed and it was found that the obstruction at the orifice of the urethra was due to large projections into the bladder from both lateral lobes. These were cut off with rongeur forceps and were found to consist of prostatic tissue with dilated glands. Three weeks after operalion the suprapubic wound was sufficiently closed to enable him to begin to pass water without the use of a catheter and from that time on he passed the greater part of his urine in this way, using the catheter about once a day in order to ensure the thorough emptying of the bladder. In January, 1897 (nine months after operation), ho wrote that he was able to pass his water without the use of the catheter but could not wholly empty the bladder. Somo days he could very nearly do so, on other days he could not more than half empty the bladder naturally. He was then urinating about every two hours. In May, 1898, be was again much troubled by pain and frequent urination. He re-entered the hospital and a small stone was crushed and pumped out. After this ho was again comfortable and was able to pass water with ease. Cask III. H. T., seventy years old, was seen by tho writer in 1896. Ho had been troubled with difficulty of passing water for the past ten years. Since 1887 he had depended wholly on the catheter. In 1886 he began to have pain and more frequent need for catheterization. At the time the prostate was large, bard and irregular in shape. Examination under ether showed the presence of a stone, which was removed by litbolapaxy. After several months, however, tho pain began to return and a suprapubic operation was done, five stones removed, and a ring of projections around the bladder end of the urethra was cut away. After this his pain was decidedly relieved and he has had no recurrence of stone, but he still relies on the catheter to empty the bladder. In this case of an old and frail man it was not deemed advisable to do an extensive operation on the prostate, and only the portions that projected into tho bladder and were ulcerated were cut awaj\ It was not expected that the power of urination would be restored, but the case is reported here in order that mention should bo made of every operation of the nature of a prostatectomy done by the writer. Cask IV. W. T. 1)., sixty years of age at time of operation. Obstruction to urination and frequency began at fifty-five. The trouble was gradually progressive until at fifty-nine the patient suffered much with pain in the back and testes. A catheter was passed and drew about a pint of urine. For a year now he depended almost wholly on tbe catheter, passing practically no water by the natural efforts. At the end of this time, on July 6, 1897, he had a sudden hemorrhage into the bladder. The clots were removed, and under constant drainage the bleeding stopped and the urine became clear and acid. On July 18, 1897, a suprapubic cystotomy was done. The urethra was occluded by a third lobe, of considerable size, with projections also from both lateral lobes. All of these projecting masses were thoroughly removed with rongeur forceps. Hemorrhage was considerable but was controlled. The bladder was drained by two tubes through the suprapubic wound. Recovery was uninterrupted and satisfactory. As the suprapubic wound closed it was found that the patient had recovered the power of voluntary urination. Two months after operation be was urinating naturally every two to three and a half hours in the day and was not up in the night and the amount of residual urine was two ounces.
doi:10.1056/nejm189904271401701 fatcat:2m454z5l6feqfobxbcuw44izze