Medical Treatment of the Prostate Gland. Part 15
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.