Health and Prostate

The Department of Urology of the New York Hospital
(Given January 31, 1941)

Attention is called to the effect of disease of the prostate gland in the young as well as the old.

Young men are liable to acute and chronic inflammation of the prostate, sometimes producing abscess, requiring surgery, but more often causing low back pain, urinary disturbances, and sexual disturbances. Non-surgical treatment is indicated in the latter; this consists of massage, urethral dilatation, urethrovesical irrigations, chemotherapy, hydrotherapy, diathermy, and other forms of physiotherapy. Tuberculosis of the prostate occurs fairly frequently in young men, and is usually part of a progressive urogenital tuberculosis. Treatment, as a rule, is non-surgical. Sarcoma of the prostate, a rare disease that is almost invariably fatal, affects young men and even children relatively often.

Appropriate diet and medication are indicated in all prostatic conditions.

Older men are subject to prostatic calculosis, and all forms of obstructive prostatism, both benign and malignant. Appropriate surgical methods must be applied after careful investigation has revealed the exact conditions that prevail.

In less than 5 per cent of cases of carcinoma of the prostate gland is the malignancy discovered in time to effect a cure by total extirpation. This is because there are no symptoms in early stages of the disease. It is therefore an important duty of the general practitioner and the family doctor to do a rectal examination on every male patient over 50 years of age, and to investigate thoroughly every case in which the prostate is not perfectly normal.

The Department of Urology of the New York Hospital
(Given January 31, 1941)

Benign Hypertrophy of the Prostate

In all other cases, perineal prostatectomy is done. This includes enlargements which encroach on the posterior urethra. Prostatectomy for the removal of a malignant gland, or for long-standing chronic inflammation, is also accomplished through the perineum. A recent modification of the usual perineal prostatectomy, by the author, has reduced postoperative incontinence of urine to a minimum. This consists in plicating the membranous urethra just external to the apex of the prostate by the insertion of a mattress suture of ribbon gut.

Recently, patients suffering from enlargement of the prostate, who have passed the period of sexual activity, have been operated upon by means of a subtotal prostatectomy, which is accomplished as follows: The prostate gland is exposed by the perineal route in the usual manner. The lateral surfaces of the gland are exposed, which is usually easily accomplished as there are seldom any adhesions from these aspects of the organ. The apex is then cut across and the entire gland and capsule excised except for a small strip of the anterior commissure. The seminal vesicles and ampullae of the vasa deferentia are cut across. The neck of the bladder is brought in contact with the membranous urethra by means of a mattress suture which not only approximates these structures and plicates the urethra, but stops all bleeding as well, thus doing away with the necessity of packing.

Our results with this modified perineal operation are so good that we perform it by choice unless the patient is still active sexually. In the latter case, it is unwise to do this procedure as the seminal vesicles and ampullae of the vasa deferentia are cut across, and ejaculation is impossible.

Preliminary preparation of the patient is of the greatest importance irrespective of the type of operation selected. This consists primarily of properly managed drainage, which is accomplished either by (1) a suprapubic cystostomy, with suction drainage, or (2) an indwelling urethral catheter.

Complications in prostatectomy by any of the three techniques mentioned are approximately the same. The mortality rate is lower in trans-urethral prostatectomy than in the suprapubic and perineal procedures because the large majority of these operations are done on much younger men.

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.

The Department of Urology of the New York Hospital
(Given January 31, 1941)

Benign Hypertrophy of the Prostate

Benign hypertrophy of the prostate gland occurs in from one-third to one-fifth of all men over 50 years of age.

Etiology. Many theories have been advanced as to why the prostate tends to hypertrophy with age. The chief are: (i) that the hypertrophy is due to true tumor formation, which takes its origin, according to some, from the periurethral accessory glands, or, according to others, from any part of the prostate gland proper; (2) that it is a fibroepithelial growth akin to myoma of the uterus; (3) that the condition is a cystic glandular hyperplasia having its basis in infection of long standing; (4) that the hyperplasia is endocrinopathic, and due to an improper balance between the male and female hormones.

Pathology. Benign hypertrophy of the prostate most frequently occurs in the middle and lateral lobes — the anterior lobe being affected rarely, and the posterior lobe practically never. My studies show that the portion which enlarges most frequently is really a contiguous structure — the subcervical group of tubules. These may enlarge without hypertrophy of the prostate; but when the prostate proper is enlarged, the subcervical group will also be hypertrophied. If a portion of the gland protrudes into the bladder, it will usually be found to be the subcervical group of tubules.

Microscopically, four types of benign enlargement may be distinguished: glandular, cystic, fibroglandular, and fibrous. The much-discussed question as to whether adenomas or fibromyomas predominate in prostatic hypertrophy is of little practical importance as it is established that a pure formation of either type never occurs.

In prostatic hypertrophy there is a definite line of cleavage between the capsule and the prostatic tissue, making separation of the adenomatous prostate from the capsule an easy matter.

Symptoms. Enlargement of the prostate is usually an insidious disease, which develops slowly and is marked by gradually increasing frequency and nocturia. The patient notices that the character of the stream changes: it is often slow in starting, and lacks force. Men take this as evidence of advancing age and often pay little attention to it. The condition gradually gets worse, and is usually accompanied by urinary infection. Often microscopic blood is present, and occasionally macroscopic hematuria. In the rare case, complete obstruction of urination may occur without any premonitory symptoms.

The urine usually contains pus, blood, and albumin. If the disease is of long standing, casts are found, and the phenolsulphonphthalein test will show diminished renal function. The blood urea is increased, sometimes very greatly; but unless there is fever, the blood count is usually within normal limits.

Diagnosis. The patient should be given a careful general and special examination, including rectal palpation, an estimation of the amount of residual urine, determination of the renal function, and a cystoscopic examination to ascertain the exact nature of the enlargement. The size of the prostate as felt by rectum has nothing to do with its obstructiveness, and cystoscopy, or cysto-urethrography, is essential to determine the extent of the intravesical and intraurethral intrusion.