COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD TRANSVESICAL PROSTATECTOMY IN TWO STAGES Paul Monroe Pilcher 4 PAUL MONROE PILCHER. ring wide open. That this frequently occurs is well shown by many specimens. However, it is hard to accept the theory that in some cases, or in many cases, the enlargement of the median lobe takes place in the direction of the lateral lobes, displacing them and causing atrophy of these lobes, compressing them out into a shell-like capsule ; to produce a lateral extension of an adenoma of the median lobe, the expansion must take place, not along the avenue of least resistance, but against a firm, well-developed structure. Judging from the anatomical relations as found on the operating table, Tandler's conclusions as to the part of the prostate involved in the obstruction are incorrect. Fig. I is an illustration taken from the work of Tandler and Zuckerkandl, showing a sagittal section through the pelvis in a case of prostatic hypertrophy. We agree that this repre- sents a typical case of median lobe enlargement.' A number of other illustrations which are shown in the work of Tandler and Zuckerkandl are unquestionably examples of median lobe enlargement, for in each the adenomatous mass is more or less symmetrical in the median line and is forced through the sphinc- ter dilating it. The same phenomenon has been plainly shown in many of our own specimens, for example, Figs. 2, 3, and 4, At the same time, the enlargement of the lateral lobes without the median lobe enlargement may take place, and in such cases the sphincter is greatly dilated and surrounds the hypertrophied mass. Such a case is seen in Fig. 5. In this case the lateral lobes have become enormously hypertrophied and have carried the median lobe, which is also enlarged, through the sphincter well into the bladder. It cannot be conceived that, after the enucleation which was accomplished in this case, any prostatic tissue was left behind unless it was the posterior lobe which is so nearly independent. Fig. 6, however, shows a different condition. This was a case of complete urinary obstruction, which had lasted for three years. B' , B' are the adenomatous lateral lobes. 5 is a greatly hypertrophied m^edian lobe. A is a crescent-shaped calculus, and the remaining pieces of tissue are compressed and atrophied bits of prostatic tissue which still TRANSVESICAL PROSTATECTOMY. remained imbedded in the capsule of the prostate after the adenoma had been enucleated. Fig. 7 is an example of sym- metrical enlargement of the median and both lateral lobes. Fig. 8 is an example of bilateral hypertrophy without any median lobe enlargement. The specimen is very distinct and convincing on this point. Fig. 9 is another example of irregu- lar hypertrophy of the lateral lobe with very little median lobe enlargement. Fig. 10 shows a specimen removed in one piece in which the median lobe is enlarged and has pushed forward into the bladder and distorts the urethra, lifting it up and mak- FlG. 4. Median Lobe r^ Eight Lobe Drawing showing tlie three lobes of the prostate separated. Same specimen as Fig. 3. ing it almost impossible to empty the bladder. The position of the sphincter is indicated by the arrows. Fig. ii shows still another type of development. The lateral lobes in this case had been previously removed by perineal operation. The symp- toms persisted and three years later this median lobe enlarge- ment, with a very freely movable ball valve attachment, was taken out by a transvesical operation. No remnants of the lateral lobes could be found. It is interesting to note the position o_f the internal sphincter as indicated by the arrows. KOi H Pm CalumWa 59nitJeri(ftp CoUege of S^f^^^itmna anb ^urgeong Hiijrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/transvesicalprosOOpilc TRANSVESICAL PROSTATECTOMY IN TWO STAGES WITH REMARKS UPON THE PATH- OLOGY AND CLINICAL PHASES OF PROSTATIC OBSTRUCTION BY PAUL MONROE PILCHER, A.M., M.D. PILCHER PRIVATE HOSPITAL OF BROOKLYN— NEW YORK J. B. LIPPINCOTT COMPANY PHILADELPHIA e' LONDON 1914 Reprinted From ANNALS OF SURGERY April 1914 TRANSVESICAL PROSTATECTOMY IN TWO STAGES. BY PAUL MONROE PILCHER, M.D., OF BROOKLYN, NEW YORK. I. THE PATHOLOGY OF CHRONIC PROSTATIC OBSTRUCTION. II. CONDITION IN- FLUENCING THE CHOICE OF TREATMENT-METHODS. III. THE THREE PHASES OF INTERRELATION BETWEEN OBSTRUCTION AT THE VESICAL OUTLET AND RENAL FUNCTION. TV. THE INDICATIONS FOR AND THE TECHNIC OF SUPRAPUBIC CYSTOSTOMY. V. TECHNIC OF TRANSVESICAL PROSTATECTOMY. INTRODUCTION. Since we have adopted the transvesical operation for the reHef of urinary obstruction due to changes in the prostate, we have been able more fully to study the so-called living pa- thology of the condition inasmuch as the vesical outlet can be studied with the prostate in situ, the nature of the obstructing mass determined and the resultant deformities of the bladder studied. The removal of prostates in one piece in many cases and the interurethral enucleation in others has provided us with new material for extending our observations concerning the gross pathology of the disease. Studying this last series of cases we are led to disagree with some of the more recently advanced theories concerning the pathology of the disease. In presenting this subject, therefore, we first offer our observations on the points in question. We do not reiterate much of the work which has already been pub- lished by Dr. Lewis S. Pilcher and myself.^ ^ Pilcher, Lewis S. : Choice of Operative Method for Removal of the Hypertrophied Prostate. Annals of Surgery, 1905, xli, 565. Observations Upon the Removal of the Prostate for the Cure of Pros- tatic Dysuria. New York State Journal of Medicine, June, 1906. Urinary Obstruction from Prostatic Hypertrophy. Year Book of the Pilcher Hospital, 191 1, i, p. 60. Pilcher, Paul M. : Pathology and Etiology of Obstructive Hypertrophy and Atrophy of the Prostate Gland. Annals of Surgery, 1905, xli, 481. Choice of Operation for the Relief of Prostatic Dysuria and the Pre- 2 PAUL iMONROE PILCHER. I. THE GROSS PATHOLOGY OF PROSTATIC HYPERTROPHY. Most of the recent articles dealing with prostatic hyper- trophy have presented evidence and theories concerning the gross pathology of the prostate. The work of Tandler and Zuckerkandl ( i ) tended to show that all of our previous ideas of the gross pathology of prostatic hypertrophy were wrong. Lowsley (2) presented his study of a series of sections of the human prostate in its early developmental period, which were distinctly in contrast to the series presented by the Austrian scientists. Wilson and McGrath (3) presented their studies of over 400 specimens and agreed to a certain extent with the theories of Tandler and Zuckerkandl. Henry Wade (4) gives the results of his exhaustive study of prostatism and deals with the surgical anatomy and pathology of the operative treatment. Our own observations have not satisfied us that these theories are absolutely demonstrated to the satisfaction of sur- gical pathologists. Lowsley agrees with the more advanced pathologists and recognizes five lobes in the prostatic mass. The middle lobe is quite independent of the others and its tubules are distinctly separated from the others. They are situated within the gland structure and are in relation with the floor of the urethra. The posterior lobe is situated furthest from the bladder and is almost an independent structure. It is further of interest to note that the tubules of the middle lobe lie side by side with those of the lateral lobes, but at no point do they intermingle. The lateral lobes are made up of a series of tubules on each side of the urethra and the acini of these lobes form the main mass of the gland. It is distinctly indi- cated that the lateral lobes are in direct relation with the urethra. The posterior lobe seems to be almost an independent structure and is seldom involved in hypertrophy of the gland. It, how- liminary Treatment Indicated. Journal of the Michigan State Medical Society, January, 1912. The Suprapubic Two-step Operation for the Removal of the Hyper- trophied Prostate. American Journal of Surgery, June, igi2. The Operative Relief of Obstructive Hypertrophy of the Prostate. Journal of the Michigan State Medical Society, September, 1913. „.,-.t^r'- L.a. B.u. Sagitta section through the pelvis, showing the prostate hypertrophied. B.u., bulbus urethralis; C.g., caput gallinaginis ; L.a., lobus anterior; L.m., lobus medius; R.r., recessus retrouretericus; V .s., vesicula seminalis. A short probe projects from the ejaculatory duct. (Tandler and Zuckerkandl, verlag von Dr. Werner Klinkhardt, Leipzig. Wilson and McGrath.) Fig. 2. Prostatic mass removed by transvesical operation, rubber tube showing direction of urethra. Beneath the rubber tube is a greatly hypertrophied middle lobe. The lateral lobes are seen forming the sides and roof of the urethra, but are not in any way obstructive Fig. 3. Anteviov Surface night Lohe Median Lobe Left Lobe Paul Pi h her. Enormous median lobe enlargement of the prostate with adenomatous changes in the lateral lobes. These lobes are smaller than normal and show no atrophy due to pressure. The specimen presents a view of the anterior face. The part above the rubber tube was entirely intravesical. The anterior face is covered by mucous membrane. TRANSVESICAL PROSTATECTOMY. -, ever, seems to be a starting point for malignant degeneration in many cases. The subvesical accessory glands of Albarran, which develop on the surface of the median lobe, are not of much chnical importance in the experience of the writer. As a result of our personal observations hereinafter de- tailed we believe ; 1. That Tandier and Zuckerkandl are mistaken in their conclusions that prostatic hypertrophy is always a hypertrophy of the anatomical middle lobe. 2. That Tandier and Zuckerkandl are incorrect in assum- ing that the so-called prostatectomy does not in a great majority of cases mean practically total removal of the prostate. We appreciate that in some cases of irregularly developed prostatic adenomata some prostatic tissue becomes atrophied and com- pressed and forms a shell around the adenomatous mass and is not entirely removed at operation. 3. We question that the surgical capsule is formed only by compressed peripheral parts of the prostate. 4. We agree that the anatomical relations of the hypertro- phied prostate to the sphincter vesicas, the bladder itself and the ductus deferentes recommend the transvesical route as the one to be chosen in removing an enlarged prostate. The first three of the conclusions advanced by the Austrians are so at variance with the accepted ideas of the pathology of the prostate in cases of obstructive hypertrophy, that the writer took occasion to visit Vienna and study the specimens which had been prepared by Professor Tandier and from which these conclusions were drawn. The writer spent some time in going over the question with Professor Tandier so that these observations are not based upon hearsay. Studying Tandler's specimens we accept his theory that the posterior lobe seldom hypertrophies. In other words, the enlargement takes place toward the bladder. However, in my mind the exhibits do not prove that the enlargement always involves the median lobe alone. If enlargement of the median lobe takes place, it must proceed along the avenue of least resistance, which is through the vesical outlet, gradually dilating it and forcing the sphincter 4 PAUL MONROE PILCHER. ring wide open. That this frequently occurs is well shown by many specimens. However, it is hard to accept the theory that in some cases, or in many cases, the enlargement of the median lobe takes place in the direction of the lateral lobes, displacing them and causing atrophy of these lobes, compressing them out into a shell-like capsule ; to produce a lateral extension of an adenoma of the median lobe, the expansion must take place, not along the avenue of least resistance, but against a firm, well-developed structure. Judging from the anatomical relations as found on the operating table, Tandler's conclusions as to the part of the prostate involved in the obstruction are incorrect. Fig. I is an illustration taken from the work of Tandler and Zuckerkandl, showing a sagittal section through the pelvis in a case of prostatic hypertrophy. We agree that this repre- sents a typical case of median lobe enlargement. A number of other illustrations which are shown in the work of Tandler and Zuckerkandl are unquestionably examples of median lobe enlargement, for in each the adenomatous mass is more or less symmetrical in the median line and is forced through the sphinc- ter dilating it. The same phenomenon has been plainly shown in many of our own specimens, for example, Figs. 2, 3, and 4. At the same time, the enlargement of the lateral lobes without the median lobe enlargement may take place, and in such cases the sphincter is greatly dilated and surrounds the hypertrophied mass. Such a case is seen in Fig. 5. In this case the lateral lobes have become enormously hypertrophied and have carried the median lobe, which is also enlarged, through the sphincter well into the bladder. It cannot be conceived that, after the enucleation which was accomplished in this case, any prostatic tissue was left behind unless it was the posterior lobe which is so nearly independent. Fig. 6, however, shows a different condition. This was a case of complete urinary obstruction, which had lasted for three years. B' , B' are the adenomatous lateral lobes. 5 is a greatly h3^pertrophied median lobe. A is a crescent-shaped calculus, and the remaining pieces of tissue are compressed and atrophied bits of prostatic tissue which still TRANSVESICAL PROSTATECTOMY. remained imbedded in the capsule of the prostate after the adenoma had been enucleated. Fig. 7 is an example of sym- metrical enlargement of the median and both lateral lobes. Fig. 8 is an example of bilateral hypertrophy without any median lobe enlargement. The specimen is very distinct and convincing on this point. Fig. 9 is another example of irregu- lar hypertrophy of the lateral lobe with very little median lobe enlargement. Fig. 10 shows a specimen removed in one piece in which the median lobe is enlarged and has pushed forward into the bladder and distorts the urethra, lifting it up and mak- FlG. 4. I^edian Lobe r- Eight Lobe Drawing showing the three lobes of the prostate separated. Same specimen as Fig. 3. ing it almost impossible to empty the bladder. The position of the sphincter is indicated by the arrows. Fig. ii shows still another type of development. The lateral lobes in this case had been previously removed by perineal operation. The symp- toms persisted and three years later this median lobe enlarge- ment, with a very freely movable ball valve attachment, was taken out by a transvesical operation. No remnants of the lateral lobes could be found. It is interesting to note the position o"f the internal sphincter as indicated by the arrows. 6 PAUL MONROE PILCHER. Ill this case we had the obstruction of the enlarged mass and in addition a ball valve action. Fig. 12 is the photograph of a specimen, actual size, re- moved in one piece. It is a perfect example of hypertrophy of both lateral lobes of the prostate. Fig. 13 shows a section through the centre of this mass and shows quite distinctly the three lobes, the two lateral lobes and the median lobe, and their position in relation to the urethra. The median lobe extends up like a wedge between the two lateral lobes and is only moder- ately enlarged. In this connection reference may be made to the series of photographs of specimens which were published in 1888 by Francis S. Watson, of Boston, in his treatise on the Operative Treatment of Hypertrophy of the Prostate, Plate 4 (reproduced here as Fig. 14) shows a very important feature; the lateral lobes are moderately enlarged, the median lobe is distinctly enlarged and is projecting into the bladder, forming the cause of the obstruction. Distal to the median lobe enlarge- ment is seen a raised-up portion, which is the colliculus or veru- montanum, at which point the vasa deferentia empty into the urethra. If the finger is introduced into the urethra by the transvesical route in enucleating the prostate, one can easily see from the specimen how the colliculus may be preserved. Fig. 15 is an undeniable example of hypertrophy of both the lateral and median lobes of the prostate. This specimen, which is a dissection not only of the prostate but of the bladder as well, shows exactly the relation which no drawing could so well express. Fig. 16 shows another phase which is a bilateral hypertrophy of the prostate with a slight median lobe develop- ment causing a distinct prostatic bar. The tortuous course of the urethra, the presence of the colliculus and its relative posi- tion are clearly shown. No one could argue that in these speci- mens such a hypertrophy originates from the median lobe alone. The floor of the urethra is very clearly shown and is seen to be free from all hypertrophied tissue. This portion of the urethra must invariably be involved, at least that portion between the colliculus and the sphincter, in all median lobe enlargements. Fig. 17 is a perfect example of median lobe enlargement alone. Fig. 5. B .^ Photograph of hypertrophied prostate removed by suprapubic route. Showing bi- lateral and median enlargement. At vesical pole, .4, the capsule and mucous membrane of the bladder are shown stripped back from the glandular portion of the gland. At B is seen the circular capsule which passes entirely around the gland. Fig. 6. Photograph of prostatic masses removed by transvesical route A i. a cresce^^^ shaped calculus; B. a large median lobe; B' B' the two f^«^?,l'°^es The other Pieces tissue shown in the specimen are atrophied prostatic tissue adherent .o the capsule. Fig. 7- Specimen removed by transvesical operation showing symmetrical enlargement of both median and lateral lobes. Fig. 8. Specimen removed by transvesical operation showing hypertrophy of lateral lobes without involvement of median lobe. Fig. 9. Specimen removed by transvesical operation showing irregular hypertrophy of the lateral lobes with very little median lobe enlargement. Fi<;. I. Specimen removed by transvesical operation showing marked median lobe enlargement with practically no lateral lobe enlargement. Fig. II. Median lobe enlargement with ball valve attachment. Fig. 12 <:„rfaor'^f^fi!!!"''"'^ °^ ^^^ prostate in which the two lateral lobes are involved The vesical within it/ol^ prostate appears at the top of the picture. This specimen was removed w thm Its capsule and is a perfect example of coincident hvpertrophy of both lateraUobes th^ fnnl''"^ '^'''^^'^ ^^^'""^ ^"^'^ enlargement. The section through this mass fs seen in ^.i^ Iffv,^^"'^ ,Yhich shows the narrow cleft occupied by the urithra The tvvo lateral masses and the small adenomatous median lobe are seen 'J ureinra. ine tv^o lateral Fig. 13. Cross section of specimen shown in Fig. 12 showing relation of median lobe and two lateral lobes to the urethra. Fig. 14. *^-5^ •.A i'V/ Bilateral and median lobe hypertrophy of prostate. Position of coUiculus. This photo- graph shows the exact relation of the urethra, hypertrophied prostate and bladder as an example of moderate bilateral hypertrophy of the prostate, with median lobe enlarged and projecting into the bladder, the median lobe forming the chief obstruction. Following the urethra upward from the bladder, it will be seen that the urethra inclines sharply downward due to the bulging of the median lobe, which forms the floor of the urethra as far forward as the colliculus. If the finger were introduced into the urethra through the bladder, it can be easily seen from this picture how the entire prostate could be removed without injury to the colliculus. (Reproduced from Francis S. Watson's work on The Operative Treatment of the Hypertrophied Prostate.) Fig. 15- Photograph of bladder and prostate which speaks for itself^ i^£;,-P?ophy%?bot"hfa"t! how anyone would deny that this P^'^^-'='=',PL^TheSoBraDh showing the distinct rela- ;kTrSSL??,r Praii-S': W^^-^n-^k^T^E 'StlSt.J-P-LlmSJ o. .h. Hyper- trophied Prostate.) Fig. i6. '^^^2 ' ■«--7fi' ' ^'-*T'j»* ^-1 ■.■at ■ -'^ Photograph of another specimen of obstructive hypertrophy of the prostate demon- strating another phase of hypertrophy of the lateral lobes. Position of the colliculus. In this case the two lateral lobes have developed unequally, that on the right side of the speci- men being much the larger and distorting the urethra very greatly. Both lateral lobes are hypertrophied and the median lobe is represented by a thickened area which becomes a bar because of its being raised up and forced bladderward by the enlarged lateral lobes. If these hypertrophied masses originated from the median lobe, the floor of the urethra would be raised up, whereas the specimen shows the floor of the urethra only distorted in a lateral . In „ n ■ "^"''^ %"" '^°°J '^ actually depressed. The position of the colliculus in this case is of\rHVp%"VoS?d1?rost1te':r "'■ "^"'""'^ ""^'^ °" ""'^ °P^^"''"^ Treatment Fig. 17. Photograph of a perfect example of a median lobe enlargement without hypertrophy of the lateral lobes. (Reproduced from Francis S. Watson's work on The Operative Treatment of the Hypertrophied Prostate.) TRANSVESICAL PROSTATECTOMY. 7 In this case the lateral lobes are distinct, but not hypertrophied. The specimen shown in Fig. 18 shows well the part taken by the lateral lobes in some cases of obstructive prostatic over- growth. The specimen was removed by the transvesical route, and the entire deformed portion of the prostate was removed in one piece. Fig. 18 shows the under surface of this pros- tatic mass. A rubber tube passing through the specimen indi- cates the position of the urethra. At the top of the specimen is seen a small collar which is the mucous membrane stripped up from the internal sphincter. This sphincter could be appre- ciated by a finger in the bladder. Fig. 19 is another photograph of this same specimen viewed from the anterior surface, show- ing, roughly, the course of the urethra, as exaggerated by the furrows produced by the presence of the rubber tube in the hardened specimen. The two lateral lobes which appear like the wings of a butterfly are joined together across the median line by a practically normal median lobe which is in no way hypertrophied. The collar of mucous membrane also appears at the top of this specimen and shows the lack of any bulging in the bladder. As far as could be appreciated by the finger, the entire prostate was removed in this case with the possible exception of the posterior lobe of the gland which was distal to the ducts, but the remains of which could not be appreciated by the finger. Examination of the cavity from which this pros- tate was removed, made immediately after the operation, demonstrated no tissue remaining which in any way resembled prostatic tissue. Fig. 20 is a photograph of a specimen re- moved the same day as the previous specimen and shows the prostatic mass as removed in one piece. The small drainage tube occupies the position of the urethra and shows it distorted and the presence of the greatly enlarged median lobe which extends into the bladder and lifts the urethra up. The bladder in this case is to the right of the specimen. As one views the specimen grossly, it would look as if the entire adenoma were one piece. When, however, the anterior commissure is divided, the specimen falls apart and forms three distinct portions ; the two lateral masses, which are the lateral lobes, are greatly hyper- 8 PAUL MONROE PILCHER. trophied and compress the urethra, the course of which is indi- cated by the furrow (Fig. 21). To the left in the upper quadrant of the picture is seen the median lobe which extends well down into the urethra, well past the first portion of the lateral lobes, in fact, forming a wedge-shaped lobe between the portions of the lateral lobes which extend into the bladder. However, the specimen clearly shows the relations of the two lateral lobes to the urethra. Fig. 22 shows another view of this same gland which indicates more clearly the exact position of the urethra and its relations to the lateral lobes and to the median lobe. In this specimen one lateral lobe has been re- moved and the furrow, as indicated in the specimen, shows the relation of the urethra to both the lateral and median lobes. The lateral lobe forms the side wall for over two inches, while the median lobe, passing beneath the urethra, extends along it for an inch and a quarter. Our own deductions are based primarily on an analytical study of our own cases, taking into account, first, the conforma- tion of the prostatic mass as presented to the cystoscopist and judged by the eye, and the mass as found in situ at the time of operation and appreciated by the finger; second, a careful determination of the adenomatous mass in relation to the open- ing of the urethra and the sphincter vesicas; and third, a thor- ough gross and sectional examination of all our specimens after removal by the transvesical route. Professor Tandler has not demonstrated conclusively that the lateral lobes of the prostate are compressed and atrophied by enlargement of the anatomical median lobe. If he could show us the various stages of the development of this phenom- enon by microscopical section, we would be convinced of his argument, but he has not presented any microscopical sections showing the transition from the adenoma Involving the median lobe and atrophy of the lateral lobes. Furthermore, before we could accept his theory of the enlargement being confined only to the median lobe, It would be necessary to show that the ducts leading from this lobe were entirely distinct from the ducts leading from the lateral lobes. Fig. i8. Specimen removed by transvesical operation, showing under surface in a case of enlarge- ment of both lateral lobes. Fig. 19. Same specimen as Fig. 18. The anterior commissure divided, showing two lateral hyper- trophied lobes and the normal sized median lobe joining the two enlarged lobes. Fig. 20. Specimen removed by transvesical operation showing the entire prostate removed in one piece. Fig. 21. Same specimen as Fig. 20. The anterior commissure divided allowing the hypertro- phied right lobe to drop down, showing the relation of the enlarged middle lobe and the left lateral lobe to the urethra. The middle lobe is seen to form the floor of the urethra for a distance of about one and one-half inches, but does not extend as far up on the urethra as the lateral lobe. Fig. 22. Same specimen. Shows this same condition more clearly. Fig. 23. A close view, through cystoscope, of a dilated ureter opening with lax walls. TRANSVESICAL PROSTATECTOMY. g II. THE CHOICE OF TREATMENT. Assuming the diagnosis to be correct, that is, that obstruc- tive prostatic disease exists, how shall we determine the course of treatment? And when the indication for prostatectomy is present, what is the safest procedure? I. Palliative Measures. — The establishment of a cathe- ter life, destroying an obstructing mass by using the cautery or punch, or the high frequency spark, are all but temporary ex- pedients. Any and all of these methods may be used to insure the patient's temporary relief, but invariably the patient con- tinues to become more enfeebled, is constantly the slave of his bladder, his mind is never at rest and finally, as a rule, he must face either an operation or death. Certainly this fact has been most forcibly demonstrated in the recent survey of our non-operated cases. These cases naturally fall into three classes, those in which the urinary obstruction is due to benign hypertrophy of the prostate, in other words, a chronic inter- stitial prostatitis; second, those cases in which the obstruction is due to carcinoma of the prostate ; and third, tubercular hyper- trophy of the prostate. In the first class, in those cases in whom the obstruction has developed to that stage where the use of a catheter, either at intervals or every day, has become necessary to insure their comfort, infection sooner or later takes place, followed by sepsis, uraemia, etc., and the average length of life is less than three years. This is a little longer than the average time found in Squier's recently tabulated cases. All of this time, however, the patient lives in filth and misery and is a burden to himself and a trial to his friends. In the second class of cases, the unoperated malignant growths of the prostate, no average can be stated which is of much value. The progress of cancer in the prostate is slow as a rule, but where there is much obstruction due to the growth, the combination of uraemia and the effects of the can- cer often terminate the life of the patient within a year. In the last 28 cases of benign hypertrophy of the prostate, which comprises all cases operated upon within the last two lO PAUL MONROE PILCHER. years, during which the new method hereinafter to be described has been followed, we have secured loo per cent, recovery. In the malignant growths covering the same period, consisting of six cases, there has been one death. In this case besides removing the prostate, the base of the bladder and the seminal vesicles were also resected. Results. — In the non-malignant cases above mentioned the average length of life is limited by old age and the various ills incident to its progress. All of the cases have had full control of their urine and they have returned to their normal health again. Of the malignant cases, one patient is living two years and two months since his operation and is now showing marked cachexia, but is still able to void his urine without the use of the catheter. A second patient is living, one year and two months since his operation, with marked symptoms of carcinoma involving the rectum, but is still able to empty his bladder. A third case died 12 hours after the operation. A fourth is still living, four months after operation, with no symptoms as yet referable to the bladder; complete control and voids normally. The fifth case was operated upon two months ago; still no symptoms of return and voids normally. The sixth case is still in hospital making a good recovery. One case of tuberculosis of the prostate was operated upon in which the prostate was removed by this method. The patient recov- ered and is to-day perfectly well, one year and four months since the operation. 2. Operative Considerations. — The chief indication. If practitioners and surgeons will hold in mind the fact that the chief indication is primarily to relieve the retention of urine rather than the removal of the prostate, the entire subject of obstructive prostatic disease will assume a different aspect. If we could dissuade surgeons, as a rule, from the course of immediately taking out a prostate which is known to be obstruc- tive, we would do much to help the cause of the prostatics. There are two methods of accomplishing the relief of the retention of urine, and one of these two methods should com- prise the first step in every operative encroachment upon the TRANSVESICAL PROSTATECTOMY. II bladder for this disease. First is the use of an indweUing catheter which systematically drains the bladder for a definite period of time until the kidney has reacted from the changed condition. This method may also be used to clear up the cystitis. The second method is a suprapubic cystostomy and the introduction of a permanent catheter occupying the cystos- tomy wound for the same purpose as an indwelling catheter. Before discussing the relative values of these two methods, one of which should always be employed before prostatectomy is considered, I wish to present a few facts which demonstrate that retention of urine in the bladder in prostatic disease has a very distinct and fundamental effect upon the general economy. The Kidney as Affected by Prostatic Hypertrophy. — First, clinical evidence: The clinician will observe, in cases of prostatic disease in which there is considerable retention of urine, that the most marked symptoms will be evidences of intestinal stasis, loss of appetite, loss of sleep, changes in tem- perament, mental degeneration, lack of personal pride, loss of weight and a general deterioration of the entire organism. Aside from this, further examination will show various phases of uraemic poisoning; in many cases a very marked increase in the secretion of urine with low specific gravity. Frequently the amount of urine will reach 150 ounces in 24 hours and its specific gravity be as low as 1002. In a recent case the 24-hour record was over 300 ounces. This, of course, is an index of functional derangement of the kidney. The rapid disappear- ance of all these clinical evidences of disturbed renal function, which follows draining of the bladder*, shows the direct relation of cause and effect. We have both acute and chronic, partial and complete forms of obstruction. In the cases of chronic partial obstruction it has been noted in general that the amount of urine secreted is increased, pro- viding the bladder is strong enough to regularly overcome the partial obstruction, and partially empty the bladder so that at no time the back pressure from the bladder is continually great. Where the musculature of the bladder is not so strong, 12 PAUL MONROE PILCHER. and there is a chronic retention of a considerable amount of urine with very Httle overflow, the amount of urine secreted will often average as high as 120 to 150 ounces in twenty-four hours with a low specific gravity. Where we have a contracted bladder with greatly thickened walls, in which there is only a small amount of retention, and the amount of retained urine almost entirely fills the contracted bladder, the urine is passed very frequently and in small amounts. Such a bladder may contain only two or three ounces and is almost continuously full. Under such conditions the kidney seems to diminish its secretions. The total amount secreted in twenty-four hours may be very little, finally result- ing in complete anuria. The other cases are those of acute retention of urine, in which the kidneys act freely until the bladder is filled to its capacity, at which time the kidneys stop acting entirely. It must be remembered that the bladder will never rupture from overdistention due to accumulation of urine. Aside from the clinical evidence of renal infection and renal insufficiency already presented, the most striking evidence of renal injury due to prostatic obstruction is presented in those cases dying from the disease. Autopsy shows a variety of conditions existing in the kidney, the lesion most common to all being a hydro-ureter beginning immediately above the bladder, resulting in various degrees of hydronephrosis and de- struction of the kidney parenchyma. This in turn is influenced by the degree and duration of the obstruction and in more advanced cases is accompanied by infection, the formation of renal calculi, and, in some cases, by actual infection and destruc- tion of the kidney parenchyma.^ To the mind of the writer those lesions are brought about by two mechanical conditions: i. The hypertrophy of the mus- cular walls of the bladder through which the lower end of the ureter passes and, 2, the constant presence of residual urine which helps to keep the muscles compressed and forming a " Wade : Prostatism, Fig. 40. March Annals of Surgery, p. 334. TPLANSVESICAL PROSTATECTOMY. I^ o chronic obstruction extending over that portion of the ureter which passes through the bladder wall. It is the exceptional case in which the infection is an ascending one, but usually, in my opinion, it is due to hematogenous and lymphatic infection of a tissue whose resistance has been greatly lowered by mechanical obstruction. Second J objective symptoms: The cystoscope shows that many changes have taken place in the bladder. First, we note that the muscular walls are markedly changed. They are hypertrophied and trabeculated, and false and true diverticula are formed, and occasionally calculi of various sizes and shapes are seen. Occasionally, also, the infection of the renal pelvis which follows retention of urine predisposes to the formation of renal stones which may be shown on the X-ray plate. The cystoscope, as a rule, shows the ureter opening raised up on a ridge with the interureteric fold quite distinct. The ureter opening in the majority of cases is normal with the exception that it is changed by the general muscular hypertrophy which surrounds it. Occasionally the ureter opening is dilated, as is seen in the accompanying illustration (Fig. 22,). Third, the operative proof: From a careful study of a series of cases in which a preliminary cystostomy was done, certain phenomena were repeatedly observed which seemed to justify us in dividing the sequelae to advanced prostatism into three phases. It has further emphasized in our minds the peajliar balance existing between the heart, kidney, secretion of urine, and the nervous control of these in the patient who has gradually become used to over-distention of the bladder. The pathology of this condition has already been referred to. We have learned not to rely upon any one clinical sign or symptom in judging the fitness of the patient for operation. We have learned that the balance between the various elements of the system are so adjusted that a disturbance of one element will bring to light weakness in some of the other elements which has not been suspected, for example, the phthalein test. This may be very deceptive. The patient may show 60 to 70 per cent, of excretion of phthalein in two hours before anything 14 PAUL MONROE PILCHER. has been done to relieve the retention of urine. But disturb the retained urine in the bladder and all of the other elements of the system are thrown into confusion. The back pressure is re- lieved; decompression of the kidney follows; swelling and con- gestion of the kidney takes place; and the functional capacity of the kidney immediately drops to a very low point. The out- ward signs of the derangement of this unbalanced kidney are very evident. This is the second phase. It is our belief that many of the cases which have died following operation are the result of a lack of appreciation of this second phase of a renal disturbance in prostatics. Many deaths have been reported on the third to the fifth day following a one-step prostatectomy, when the patient was seemingly doing well ; but when we add the phenomena of the second phase to the shock of the major operation with its loss of blood and the depressing effect of the general anaesthetic, it can be easily appreciated why these deaths take place, and many will agree that the overtaxed heart and the system overloaded with toxins which the kidneys should separate from the blood are the cause of death. Our extended observations have shown us that nearly every prostatic will present these three phases, and this fact has influenced us ver)^ greatly in favor of the two-stage operation in every case of benign hypertrophy. III. THE THREE PHASES, The results of our observations are graphically shown on the accompanying chart. Fig. 24, which shows the average condition which prevails in many advanced cases of obstructive hypertrophy of the prostate. The First Phase. — For the first day, the day on which the suprapubic cystostomy is done, the blood-pressure frequently registers from 200 to 220 mm. of mercury ; the urinary output for 24 hours will average from 70 to 120 ounces; the phenol- sulphone-phthalein test will frequently average above 60 per cent, in two hours and the urine will show only a trace of albu- min. If these conditions are considered by themselves, they will give us a false impression of the actual condition of the TRANSVESICAL PROSTATECTOMY. Fig. 24. 15 Btocd PrJjJary y^tpu Pitrialain t Al press ar e D&JB 98t ■huiuln 8 M M,M.- ■"N •^ \. s ■* ^ ^ ■ "** tea — » 1 70 - - A - / A LC 02 / 1 ^ \ ^ L V ^ 5 1 33 , \ ^ n^' ! 1 L / /*" 2( > < 3Z \ / *= ^j{ ■^ \ \ k J r f) '^ \ / > / \ /» J \ r V / V ifi io Tfi ^0 ut Z' »k n i" ' / >» s . /' \ / ■^ ./ '* "^ an ja. LI a lit . > i'r ac e ^ i ^ ;■? 4 ^ ^ r „ € y IO II la. i'i Ti t si ^c on a ^:hj re . ih£ ise th as B Phas e Chart showing the three phases following suprapubic cystostomy in an advanced case of obstruction due to prostatic hypertrophy. First phase: Includes the first and second day, the suprapubic cystostomy being done on the first day. If one would observe this chart excluding the following days, the conditions would seem to be favorable for any operative encroachment. See page 514. If taken alone, this surely would seem to indicate a safe surgical risk. Second phase: This phase extends over the third, fourth, fifth and sixth days after a suprapubic cystostomy. It shows a very marked decrease in urinary output during that time, (Legend continued on next page.) 1 6 PAUL MONROE PILCHER. patient. For example, if the patient's blood-pressure registered 200, was passing 90 ounces of urine in 24 hours with low specific gravity and with only a trace of albumin, we would be rather suspicious of the functional capacity of the kidneys. But when we make a phenol-sulphone-phthalein test, and find that the output in two hours is 60 per cent, or more, it rather leads us to believe that the actual functional capacity of the kidney is greater than the specific gravity of the given specimen would lead us to believe. The Second Phase. — A second glance at the chart will show a very different condition existing on the third or fourth day after the bladder has been opened and drained. Here we see a lowered blood-pressure, probably between 170 and 180. The urinary output has suddenly dropped to from 15 to 20 ounces in 24 hours ; the amount of albumin in the urine has increased enormously and often the urine itself boils almost solid. On the third to fourth day, the phenolphthalein test shows the actual functional capacity of the kidney at this most critical time to be only 75 per cent. This, then, is the change which has taken place simply following a suprapubic drainage of the bladder without any loss of blood or other surgical shock due to anaesthesia or prolonged manipulation. Add to this, then, the shock of a prostatectomy with its general anaesthesia, a very considerable loss of blood and the shock consequent to pain, and one does not wonder that so many cases have died on the third, fourth and fifth day from no apparent cause which could be demonstrated. The Third Phase. — Passing on then to the third phase of a large increase in the amount of albumin present, but most important of all the drop in functional capacity of the kidney from 60 to 15 per cent. Third phase: Showing the reaction and the recovery of the kidney after ten days. Blood-pressure 170, urinary output averaging 50, phthalein test 50 per cent., and a smaller amount of albumin present in the urine. Comparing this phase with the first phase we find a lower blood-pressure, a normal urinary secretion with an increased specific gravity, a lowered functional capacity of the kidne}^ as attested by the phenolphthalein test and a larger amount of albumin present in the urine than during the first phase. When, however, the reaction from this phase following enucleation of the prostate is considered, what a much better combination of circumstances exist in this phase than in the first phase. Follow- ing prostatectomy, the blood-pressure falls still lower, due to the loss of blood. The urinary output decreases most markedly during the first 24 hours, but recovers rapidly until, on the third day, it is practically normal. The phthalein test shows lessened reaction, but it never drops as low as was found in the second phase after suprapubic cystostomy, so that so per cent, according to the phthalein test in the third phase shows a very much greater relative functional capacity than 60 per cent, in the first phase. This we consider a point of very great importance. The amount of albumin following the operation is an unknown quantity. TRANSVESICAL PROSTATECTOMY. 17 the condition following drainage of the bladder, we find in the average case that on the seventh to tenth day the blood-pressure has decreased to from 160 to 170 mm., the urinary output has increased to from 40 to 50 ounces in 24 hours, the phenol- phthalein test shows a reaction of the kidney from an output of 15 per cent, to an output of 50 per cent., and the amount of albumin contained in the urine has decreased very markedly, but still shows a small amount present, more than was present before the cystostomy and very much less in amount than was found on the third or fourth day. Now if the prostatectomy is performed, the effect upon all these phenomena is quite different than was found after the preliminary cystostomy. The blood-pressure falls still lower, the urinary output decreases very little ; the functional capacity of the kidney does not fall more than ten points ; it is difficult to ascertain the amount of albumin present in the urine on account of the presence of the wound in the bladder, but at no time is it as great as was found on the third or fourth day after the cystostomy was performed. By following this method we entirely avoid the second phase after the prostatectomy. This conclusion is based upon the study of our last 28 suc- cessive cases, all of which have been operated upon after this method and all of which have recovered. It must be remem- bered that the second phase will last from a day or two to many weeks, and if the reaction to the third phase docs not take place within ten days to two weeks, the surgeon shotdd not under any circumstances be persuaded to remove the prostate, because if he does the chances are very much in favor of a fatal out- come. In one of our cases a gastric uraemia developed on the third or fourth day and it was impossible to remove the prostate for over five weeks. At the end of that time the third phase of the phenomenon appeared and the prostate was removed with- out any shock to the patient, followed by uncomplicated recovery. All clinical observers naturally realize that the different stages vary in many cases as to their extent and their duration. 1 8 PAUL MONROE PILCHER. This point may best be emphasized by the following illus- trative cases : Case I. — Diagnosis: Hypcrtrophied prostate; complete ob- struction; vesical calculus; mitral insufliciency ; chronic interstitial nephritis; double inguinal hernia. Condition on entrance to hospital July 14, 1913 : A large framed man, eigJity-tzuo years of age, who has led an active sea- faring life. For ten years has had increasing frequency of urina- tion and for two years has used catheter daily for the removal of residual urine ; nozv depends entirely upon a catheter zvhich he uses every four hours. The use of the catheter is becoming increas- ingly difficult and painful and has already provoked several attacks of double epididymitis. There is present a moderate cystitis. There are evidences of a generalized arteriosclerosis with some mitral insufficiency and a moderate degree of chronic interstitial nephritis. He has also a double inguinal hernia. Notwithstand- ing these many physical defects, he still presents evidences of con- siderable vital force and, in the opinion of the surgeons, is a rea- sonably fair operative risk in the face of the marked urinary crises which are developing. Blood-pressure, 220 mm. ; urinary output, 80 oz. ; phthalein test, 57 per cent. ; albumin, a trace. First Operation. — On July 15, 1913, a preliminary suprapubic cystostomy was done by Dr. L. S. Pilcher under local cocaine anaesthesia, using i per cent, solution of cocaine. The bladder was exposed in the usual manner without com- plaint from the patient. Upon opening the bladder a medium- sized uric acid calculus the size of a lima bean was detected and removed. A polypoid development of the middle lobe of the pros- tate perceived. A Pezzer catheter was secured in the bladder and the wound sutured. Patient sustained no shock from the opera- tion. During the following week he remained very comfortable. Urinary output dropped to 30 oz. ; phthalein test to 18 per cent., etc. (see Fig. 25). There was a gradual lessening in the blood- pressure and a notable improvement in his general well-being. A phenolphthalein test showed a steady increase in the renal activity. Consulting the accompanying chart. Fig. 25, it will be seen that the blood-pressure had been reduced to 170 and the functional activity of the kidneys had reacted from the first period of depres- sion. The patient's condition was very satisfactory, despite his TRANSVESICAL PROSTATECTOMY. Fig. 2S. 19 ]>lood Urlaa:'y ]'httia pres ej Lbiiml i£l-t n -.es 1 1 I 2( I M U- ■vl X V '•v s ^ ^ <^ r*^ 1 ?0 8C c z V y \ V / \ r \ ^ f^ >« ■«n 4 D )Z , 3( ) ( r^ , L. ^ 5\ fo ^ A. ^$ s f ■— ' J" s. f > s N \ y V / > /l Si L ax R^ s ml / % **ri / Nc X n( M 5d Sm al 1 an t / y 4 **' i-'i ra t s c Dn 1 Tt i] d PI a£ e p hR 3e PI PS e ». Day The Three Phase Cycle. Chart of Case I. Showing the three phases in a patient 82 years of age. Note the marked difference between the three phases — especially the drop from 57 per cent, to 18 per cent, in the renal efficiency and the large increase in amount of albumin. Prostate enucleated during third phase. Recovery. age of 82 years and his mitral insufficiency and chronic interstitial nephritis. It was, therefore, deemed proper to attempt enuclea- tion of his prostate. 20 PAUL MONROE PILCHER. Second Operation. — Transvesical prostatectomy. Under ether anaesthesia, the finger was passed through the suprapubic opening and without removing any of the sutures the prostate was enucle- ated in three minutes. Some packing of the prostatic pouch was necessary to control a moderate hemorrhage. There was no shock following the operation. Draining tube and packing re- moved in 24 hours and a Pezzer catheter introduced. The Pezzer catheter removed on the fourth day followed by uninterrupted healing of the wound and full restoration of function. Six months after the operation the patient is quite well and is urinating nor- mally. It seems quite evident to us that it w^as safer ten days after the primary operation to remove the prostate than it would have been at the time of the primary operation. With the blood-pressure of 170 instead of 220, with the kidneys re- lieved of the disorganization incident to retention of urine, and with a well-balanced functional activity, the prostatectomy could be undertaken without danger to the patient. In our series of cases the depression which occurs from the third to the sixth day has been so constant that it is a real factor to be reckoned with in all these cases, and it is our belief that no prostate should be removed until this period of reaction has been passed. In some cases the second stage lasts two, three, four or more weeks. During this period after the suprapubic cystostomy all of the clinical features of the case preclude the possibility of a prostatectomy and not until a fully developed third stage appears should the prostate be removed. The following case in which the patient developed a gastric uraemia, and massive oedema of the legs, will serve as an example. Case II. — Diagnosis: Obstructive hypertrophy of prostate; gastric urccmia. The patient was admitted May 9, 1913. General health good. Considerable obstruction. No symptoms of kidney trouble excepting a slight amount of albumin which was present. First Operation. — Suprapubic cystostomy; Pezzer catheter. May 10, 1913, operation quickly accomplished under local anaes- thesia. The day following operation passed 24 ounces of urine, clear, large amount of albumin present; 26 hours after operation TRANSVESICAL PROSTATECTOMY. 2 1 began to vomit ; 8 hours after operation hiccoughs began and con- tinued intermittently for 24 hours. Second 24 hours urinary out- put dropped to 2.^ ounces, still clear; vomiting continued; urine almost solid with albumin. Third 24 hours some nausea, no vomiting. Fourth 24 hours vomiting recommenced. Hiccoughs lasted for 14 hours, quite restless. Urine became bloody, almost solid with albumin — 29 ounces in 24 hours. Fourth day very sleepy, hiccoughs continuing, legs showed slight swelling, urine bloody. Fifth day slight hiccough, urine clearer, sat up. Patient showed a gradual improvement with the exception of the swelling in his legs, which increased so that both legs soon became very badly swollen. Coincident with this no phenolphthalein test was made on account of the large amount of blood and albumin present. June 2, phenolphthalein test showed 30 per cent, excretion the first two hours ; June 9, one week later, showed 22 per cent, excretion first two hours; June 15 showed 21 per cent.; July i, phenolphthalein test showed the excretion to be 48 per cent, in two hours. The patient's general condition showed a coincident improvement, swelling of the legs entirely disappeared, the amount of albumin in the urine very greatly decreased so a further operation was deemed advisable. Second Operation. — Transvesical prostatectomy. July 5, 1913. Suprapubic catheter removed and with the finger passed into the bladder through the suprapubic opening the prostate was easily removed. There was considerable hemorrhage which neces- sitated the introduction of packing. Reaction from the operation was very slight. Twenty-four hours after operation was sitting up in bed ; 48 hours after operation the drainage tube was re- moved from the wound and Pezzer catheter re-inserted ; 59 ounces were collected through this catheter during the 24 hours, with hardly any leakage. On the fifth, sixth and seventh days he evidenced some stomach irritability and vomited a little, but the attack passed off quickly. On the ninth day began to urinate a little. Wound healed promptly and the patient was discharged cured August 2. It is not only the kidney and its function which must be considered, but it may be that it is the heart that is the weak link in the chain, and in order to ensure a safe operation the 22 PAUL MONROE PII-CHER. Fig. 26. Ur Lnt ry Ph:haleLn o\it €0 £0 40 20 JO 6P te 3t 4D 3 20 ~A:.brmia IKiyt jLib In 01 n • I fi.1 gt f- mf )i) It R ) >z \ b ) >z V \ ^ ^ V >j K y •^ • - > ^ \ ^ \ / > V J c z \ / > ,1 V / \ t / >< / > / \ J 3 0: Af" % J 'f / ?in t / ,. .. . . ., ... .. w. .. •h / s / S . 3> _ The Three Phase Cycle. Prolonged Second Stage. First phase: Aside from the large amount of urine passed, the patient's condition was almost ideal. ,, 1 j Second phase : Which followed the suprapubic cystostomy was unusually severe. Marked diminution in the amount of urine. Urine boiled almost solid. Gastric uraemia supervened. Enormous swelling of the legs. Patient in desperate condition. At the end of 51 days, how- ever, all of the uraemia symptoms had disappeared. Amount of urine passed was normal. Third phase : At end of 50 days phthalein test showed 48 per cent. Urme showed very small amount of albumin. Patient's general condition satisfactory. Prostate enucleated with hardly any post-operative reaction. Patient made perfect recovery. TRANSVESICAL PROSTATECTOMY. '23 kidney must be in the best possible condition before the enuclea- tion is undertaken, for if, with a failing, dilating heart the renal function fails, there is little hope for the patient's recovery. The following case illustrates this point : Case III. — (Lynch.) Patient was a man whose actual age was sixty-five years although his appearance was that of a man of about eighty. For two years he had been struggling against the ravages of prostatic disease and had gradually become emaci- ated. Was rapidly losing his strength and had already lost his appetite. He had been catheterized frequently, but this had ceased to give relief and at the time of his examination was passing his water every 15 to 20 minutes day and night. As the result of a metal instrument being passed into the urethra he developed an acute retention with bleeding into the bladder. When seen by me he was in greatest distress and the bladder dilated up to the umbilicus. His pulse was small and weak. He was in consider- able shock. First Operation. — Suprapubic cystostomy. He was hastened to the hospital and immediately the bladder was opened under local anaesthesia, and a large amount of blood clot and urine were brought away and a Pezzer catheter sutured into the bladder and the wound closed around it. The patient reacted very well from the operation. The fol- lowing day his temperature reached 102°, his pulse 100, urinary output averaged 25 ounces. Renal sufficiency as shown on accom- panying chart, which was 69 per cent, of phenolphthalein excreted during the first two hours immediately after the operation, dropped on the third day to 20 per cent, in two hours under the same con- ditions. His pulse was weak and soft but not very rapid. His general condition was good. One week later the phenolphthalein test showed an elimination of 48 per cent, in two hours (Fig. 27). Two days after this, when examined, his condition was consid- ered proper for operation, and under ether anaesthesia this was accomplished. Second Operation. — Enucleation of prostate. Time of enuclea- tion i^ minutes. Control of hemorrhage, which was consider- able, by packing as above described. The day following the oper- ation patient's condition good. Packing and drainage tube re- moved. Pezzer catheter inserted. Urinary conditions good. On 24 PAUL MONROE PILCHER. third and fourth days very considerable cardiac insufficiency, pulse extremely weak, intermittent and general weakness (see chart. Fig, 28) ; temperature 101.8°, pulse 130, respirations 40. Under Fig. 27. — 1 1 1 1 h-t- OTlf a X egt ^ ' * « ... - u ft .0. 4J> ri 03 •H J \ 6 9? f (7 +3 — J >. 1 V P -. 1 1 i ■'O ^ ^ 1 \ / /^ y /" \ t / K J / \ k / r V / \ / 2C \io 1 2 3 A 5 6 7 9 Chart showing drop in renal function during second phase from 69 per cent, to 20 per cent. (Case III.) proper medication the conditions gradually returned to normal, which they reached on the fourth day. However, this chart will show the dangerous reaction following the operation which, if it had occurred coincident with the shock of the primary operation TRANSVESICAL PROSTATECTOMY. 25 > tn 3 5 6 z i z z g 2 -1 > s § ce g s -I ^ ■f 05 © a 1 00 i 1 5 © 00 9 i © c r © 4n c 0? ©;n - . 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As already referred to, in cases of enormous dilatation of the bladder with oedema of the legs, scrotum, etc., the three- phase cycle shows a remarkable curve when traced on the chart. The accompanying diagram, Fig. 29, shows the condition existing in a patient still under our care. During the first 24 hours the patient passed 249 ounces of urine, a catheter being used to withdraw the amount in small quantities and never emptying the bladder, that viscus being continuously dilated as high as the umbilicus. On the second day more urine was withdrawn at a time and the urinary output was 308 ounces, specific gravity 1002. Following the chart it will be seen that gradually the urinary amount decreased and that on the fourth day the bladder was completely emptied for the first time by catheter, the amount passed during the 24 hours being about 120 ounces. This modified second phase shows a preliminary rise and the enormous output of urine would unquestionably have overwhelmed the patient had a prostatectomy been done, or even a suprapubic cystostomy. Fig. 30 is the pulse chart of the same patient and shows the remarkable effect the condition had upon the action of the heart. On the twelfth day the phthalein test showed a 40 per cent, output, but the pulse was extremely unreliable. Five days after the suprapubic cystostomy the phthalein test showed an output of 67 per cent, and the pulse at that time would not permit a prostatectomy. In fact, with a heart so badly damaged and a kidney which had been exposed to so much pressure, the date of the prostatectomy must be put ofif for some weeks. ^ Other cases show only a mild degree of depression in the second phase and it would undoubtedly have been perfectly safe to remove the prostate at the first operation, but as yet I have not " Thirty-eight days after the cystostomy the prostate was removed and the patient has made a good recovery. TRANSVESICAL PROSTATECTOMY. Fig. 29. 27 - - - PILCHER PRIVATE HOSPITAL - — ^0 R- opt — / / 1 / ./ * * ^' .'[*f . - - - 5 ^ ;. i >.; ■< « 3 C _ JOO P- V ; ^ 1/ 190 L £ ^ i. 'j leo ■0 " i' ■: ■ ■ f> 5 I ,r 3 " / k /■ "l ^ J ^\ /■ ^ ■V ' (/I r f V > 4 -J - ""'■ ) L / V r s " - V L »^ ■> y -> , , N V * 90 '■' / 1UY_ ^ -/ :>:;ectoiiiy in two stages 2002434156