In men we are interested specifically in preserving fertility, erectile function, and ejaculation. We can preserve these functions by timely corrective surgery, by modifying surgical techniques to avoid unwanted sequelae, or by substituting surgery for some other form of therapy less likely to produce unwanted complications. This article reviews the changes that have occurred in urology that allow us to offer our male patients better preservation of their sexual function.

Table 1 lists urologic procedures that may be used to protect sexual function or that have the potential to interfere with sexual function. These procedures span the entire life of a male patient.

Innate threats to function

Some boys and men have conditions that do not cause immediate problems but may pose a future threat to fertility. The trend is to be more aggressive in diagnosing such conditions.

Undescended testicle. Undescended testicles (cryptorchism) occurs commonly in male neonates but often resolves during the first 6 months of life. Testicles that have not descended by the time the patient is 9 months of age are unlikely to do so.

These testicles have an increased incidence of infertility later in life, as well as an increased incidence of testicular malignancy. Cancer of the testicle can, in turn, impair fertility, not only by the loss of one gonad but also by the therapy that may be required afterward. Chemotherapy inhibits spermatogenesis for a prolonged time and occasionally permanently. Retroperitoneal node dissection can interfere with emission. Timely surgery to position the testicles in the scrotum (orchiopexy) can significantly reduce the incidence of both these conditions.

Furthermore, there is growing evidence that the use of gonadotropic stimulating hormone (GnRH) instead of or in conjunction with orchiopexy can further improve fertility in these boys. We recommend that the testicles be brought down to the scrotum during the first 2 years of life. Although this will not completely eliminate the risk of malignancy, it will make the testicles more amenable to examination and could provide for early detection of any abnormality.

Varicoceles. Varicocele is the abnormal distention of scrotal veins (pampiniform plexus) owing to the congenital absence of venous valves, which permits the retrograde flow of venous blood to the testicle and slowly dilates these veins. Varicocele occurs in more than 10% of normal men and in probably the same percentage of adolescents.

Only in a few of these subjects is it associated with subfertility. Young adolescents normally present with a visible scrotal mass, which can be symptomatic. There is growing evidence that the adolescent varicocele affects future fertility in some instances. Kass has proposed that adolescents with a varicocele and ipsilateral smaller than normal testes, as well as those with bilateral varicoceles or abnormal results of semen analysis, should be offered repair to preserve their fertility potential. An abnormal response to an infusion of GnRH has been found in some infertile men with varicoceles. Kass and others believe that such a test could help us decide which teenagers with varicoceles are at risk of future subfertility and should be repaired. Ongoing studies are continuing to define the role of varicocelectomy in the young adult and child, but it seems that early varicocelectomy in selected cases can preserve fertility.

Comparison of the gross anatomy of the human (left) and rat (right) prostate

PZ = peripheral zone; CZ = central zone; TZ = transition zone; fm = anterior fibromuscular stroma; UD = distal urethra; UP = proximal urethral segment; E = ejaculatory ducts; bn = bladder neck; s = preprostatic and distal striated urethral sphincters; C = coronal plane; OC = oblique coronal plane; BL = bladder; SV = seminal vesicles; CG = coagulating gland; V = ventral lobe of the prostate; L = lateral lobe of the prostate; D = distal lobe of the prostate; Bur G = bulbourethral gland; UR = urethra; PU = pubis; vas deferens; CE = cauda epididymis.

Reproduced from Price D. Comparative aspects of development and structure in the prostate. In: Vollmer EP, editor. Biology of the prostate and related tissues. Vol. XII. Bethesda (MD): Dept. of Health, Education, and Welfare (US); 1963.; and Jesik CJ, Holland JM, Lee C. An anatomic and his-tologic study of the rat prostate. Prostate 1982; 3.

Aspartate transport and citrate production in prostate luminal epithelial cells

The low affinity L-aspartate transporter Na⁺-K⁺ ATPase and a citrate transporter are represented at the apical membrane. The high affinity L-aspartate transporter and glucose transporters are represented in the basal membrane.

Reproduced from Lao L, Franklin R B, Costello L C. High-affinity L-aspartate transporter in prostate epithelial cells that is regulated by testosterone. Prostate 1993; 22.

Effects of tissue localization of the androgen receptor on differentiation of the urogenital sinus (UGS)

Epithelium and stroma from the urogenital sinuses of wild-type (androgen-receptor positive) or Tfm (androgen-receptor negative) mice were recombined and grafted under the renal capsule. Prostatic epithelium was obtained when wild-type or Tfm epithelium was recombined with wild-type stroma. Recombination of wild-type or Tfm epithelium with Tfm stroma resulted in development of a vaginal morphology.

Reproduced with permission from Cunha G R, Chung W K, Shannon J M, Reese B G. Stromal-epithelial interactions in sex differentiation. Biol Reprod 1980; 22.

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.

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.

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.

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.

Carcinoma of the Prostate Gland

Carcinoma of the prostate, because of its frequency and its essentially fatal nature, presents the urologist with his most baffling problem. Young’s statistics (1935) reveal that a fifth of the male patients who seek relief of obstruction of the vesical neck have carcinoma of the prostate.

Pathology. A striking morphologic peculiarity of carcinoma of the prostate gland, that has been emphasized by most authors, is the diversity of its forms. In the same case, in different portions, the carcino-matous proliferation may be found at one time as an adenocarcinoma and again as a scirrhous, a medullary, or a squamous-cell carcinoma.

A large percentage of prostatic carcinomas are associated with benign hypertrophy. In only 10 (13 per cent) of the 72 cases studied by Wilson and McGrath was there no evidence of associated hypertrophy.

Chart I

Incidence, By Age-Groups, of Carcinoma in Relation to Benign Enlargement in 280 Cases

In his very complete study of 280 prostates from men between the ages of 31 and 90 years, Robert A. Moore found the occurrence of carcinoma and benign enlargement to be as shown in Chart I. It is evident, therefore, that the possibility of carcinoma must be kept in mind in every case of prostatic hypertrophy.

Numerous careful studies show that in over 75 per cent of cases the carcinoma starts in the posterior lobe (the portion of the gland which does not participate in benign adenomatous hypertrophy).

Prostatic carcinoma is, as a rule, insidious and slow-growing, though highly malignant, and may remain confined to the prostate and periprostatic region for long periods. Only 10 to 20 per cent, according to Barringer, are radiosensitive.

In many cases, by the time the growth has become sufficiently advanced to be clinically diagnosed, it has extended beyond the posterior lobe into the lateral and median lobes and upward to the base of the prostate. There it may penetrate the capsule and involve the seminal vesicles. Through the prostate’s rich supply of lymphatics, the carcinoma may extend to the pelvic nodes, or, by the perirectal plexus, to the abdominal nodes. Dissemination through the blood stream may occur early, and distant metastases, particularly in the bones, are often detected before the occurrence of local symptoms. The small prostatic tumor often disseminates widely. The high frequency of skeletal metastases, and the predilection for the pelvis and lumbar vertebrae, have been noted by practically all observers.

Symptoms. The symptoms are not characteristic. Disturbances of urination are usually the first symptoms, but advanced carcinoma may be present without urinary symptoms. Pain — referred to the sacroiliac region, rectum, perineum, or suprapubic area — is often an early symptom, and may be due to metastases to the bones. Terminal hematuria, retention, loss of weight and strength, and constipation are significant, but late, symptoms.

Diagnosis. Carcinoma of the prostate has, unfortunately, usually existed for a long period by the time it is recognized. The diagnosis is based upon the findings of rectal palpation and microscopic examination of a biopsy specimen removed by means of an instrument, such as the Lowsley biopsy instrument. In well-advanced cases recognition is usually not difficult; but in early cases, in the soft (medullary) type of carcinoma, and in carcinoma superimposed upon a benign hypertrophy, diagnosis may be difficult. A single, small nodule may easily escape notice, especially when masked by edematous prostatic tissue or in the absence of symptoms. The entire gland may be irregularly enlarged, of a board-like hardness, and fixed; but usually the growth is in the form of a nodule or hardened area in the posterior lobe, where it is readily palpable by rectum. Evidence of the fixed gland may be seen on cystourethroscopic examination.

Prognosis and Treatment. The prognosis in the past has been cheerless in the extreme. Over 95 per cent of the cases are beyond cure when first seen. The high early incidence of pelvic lymphadenopathy, capsular infiltration and invasion of the contiguous structures, and skeletal metastases precludes the successful surgical treatment of the disease in most cases.

In cases in which the carcinoma is confined to the prostate and periprostatic region, total or subtotal perineal prostatectomy yields a fair percentage of cures estimated upon a 3 to 5 years’ basis, and prolongations of life for considerably longer periods are not uncommon. If seen too late for hope of radical removal, partial perineal prostatectomy, or transurethral resection of the obstruction, with implantation of radon seeds, is the method of choice.

Improvement in prognosis is dependent on an increase in the number of early diagnoses, with radical removal.

Sarcoma of the Prostate

Sarcoma of the prostate is relatively rare, and may occur at any age. A review of the literature by Lowsley and Kimball, in 1934, disclosed only 132 reported cases, 35 of which occurred in patients under 22 years of age. These tumors usually grow rapidly and attain large size, early infiltrating the bladder, seminal vesicles, and rectum. Growth of the tumor backward beneath the base of the bladder pushes the latter upward and forward, causing obstruction of the ureteral orifices, urethral orifice, and urethra, with resultant partial or complete retention. Growth of the tumor toward the perineum causes prolapse of the rectum, with obstruction to defecation and urination.

Diagnosis. Early diagnosis is essential. In early cases rectal examination may be negative, but usually reveals a palpable nodule. Occasionally the growth may be indurated and nodular, but usually it is of uniform consistency and has an elastic “balloon-like” feel; hence the condition may be erroneously diagnosed as abscess. The diagnosis can positively be made by needle biopsy.

Prognosis and Treatment. The prognosis is poor. The most favorable results have been achieved through the use of radium and Roentgen rays. In early cases, the skilled use of these agents may prove curative, and in late cases they may give relief and prolong life. Operative intervention should be limited to the relief of obstruction and the treatment of complications.