Medical Treatment of the Prostate Gland. Part 14
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The Department of Urology of the New York Hospital
(Given January 31, 1941)
Benign Hypertrophy of the Prostate
Treatment. Many patients with benign hypertrophy of the prostate have no obstructive symptoms and do not require surgery. In benign hypertrophy without residual urine, palliative treatment is usually advisable; this consists of periodic prostatic massage, urethral dilatations, urethrovesical irrigations, the application of heat to the prostate, and hydrotherapy. Periodic check-up is essential.
Hormonal therapy affords symptomatic relief in some early cases of prostatism with slight or moderate urinary disturbances; but even its most enthusiastic advocates do not claim that it benefits all types of cases, or that it is to be considered a substitute for surgical relief in major prostatic obstruction.
Roentgen therapy of benign hypertrophy also is an accepted procedure, but opinions vary as to the effect of such treatment. The more conservative urologists and radiotherapists incline to the opinion that the only effects of irradiation are a definite alleviation of the associated congestion and edema, giving temporary relief in selected cases. It cannot, however, be regarded as a substitute for prostatectomy or resection.
Surgical treatment is usually required in cases with residual urine. Every patient presents an individual problem, and the type of operation selected should be the one best suited to the case in question. It has always been our contention that every well-trained urological surgeon should be psychologically and technically equipped to perform any operation in urology. To that end, we train our young men in the proper technique of perineal, suprapubic, and transurethral prostatectomy. Each of these has its place in urological surgery. By limiting his surgery to one of these methods only, the operator limits his usefulness to his patients.
Widespread interest has been manifested in the past two decades, by both the medical profession and the laity, in transurethral resection of the prostate. In 1913, Hugh Young developed a method of transurethral surgery for certain types of enlargement of the subcervical group of tubules. This operation, called the Young punch operation, did more efficiently and less dangerously what the Italian Bottini operation (performed through an external urethrotomy wound) was designed to do. Young’s operation was modified and improved, in 1920, by the late John Caulk, of St. Louis, who added a cauterizing element. In 1926, at The New York Academy of Medicine, Maximilian Stern presented a resection instrument made for him by the late Rheinold Wappler. This instrument was too small to be entirely effective, but it was soon improved by Bumpus, Collings, McCarthy, Foley, Kirwin, and others.
A tremendous wave of enthusiasm swept this country and extended abroad, and for a time claims were made to the effect that open surgery upon the prostate gland was doomed to oblivion. As the fanaticism subsided, there also died down the extravagant claims that transurethral surgery was an office procedure, and that any prostate of any size could be removed without the preliminary preparation of the patient which had reduced the mortality of the open operation from nearly 50 per cent to about 6 per cent. It soon became evident that this surgical maneuver was not as simple as it had at first seemed. One great harm done by its too ardent protagonists was that their claims gave every doctor who could manipulate a cystoscope the idea that he could perform the transurethral operation. Such, of course, was not the case, and the mortality of these amateur surgeons was tremendous.
Transurethral resection has a permanent and highly important place in surgery of the vesical neck, and with the passage of time its scope and limitations are being better defined. It is true that the method has a slightly geographic aspect; most of those who believe in transurethral prostatectomy to the exclusion of the open operation, it has been noted, live in the Midwest.
Before deciding which operation to perform in a given case, one must determine the type of enlargement present. In general, it is our practice to remove by means of transurethral resection all enlargements of the middle lobe and of the subcervical group of tubules, all fibrous bars, and certain obstructions due to malignancy of the prostate. We prefer to use the Kirwin rotary resectoscope as a rule.
If the enlargement of the gland is mainly intravesical, suprapubic prostatectomy is the method of choice. The operation employed is the so-called Fuller-Freyer technique. In this procedure, the capsule over the most prominently presenting part of the gland is incised, and from this point the enucleation is accomplished. Care is taken not to split the anterior commissure as by so doing one often tears into the plexus of Santorini on the anterior surface of the prostate, greatly increasing the bleeding.
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