R. Theodore Bergman

Urethroscopy and miscellaneous endoscopic procedures

Urethroscopic instruments are described in Chapter I. The irrigating urethroscope with a direct vision lens such as the Lowsley instrument provides a good view of the urethra. Instruments can be passed through it for treatment of urethral lesions. Air distention of the urethra through the Swift Joly aero urethroscope and others of similar construction exposes a wide field of vision and provides good visualization (**Harkness). Air embolism, however, is a hazard of this method of urethroscopy. Open tube urethroscopes are selected for the good visualization they provide of areas to be treated by endoscopic application of medicaments.

Miscellaneous endoscopic surgical procedures and treatments

Ureteral dilation for the treatment of ureteritis and of stenosis of the ureteral lumen is practiced extensively by many urologists and is condemned by others. A middle road between the two extremes is the preferable course Hunner; Millin. When definite dilatation of the ureter and/or renal pelvis exists above a ureteral stenosis, progressive dilation of the ureter is indicated. Many patients present symptoms characteristic of obstruction to the flow of urine through the ureters, although there is no evidence of ureteral obstruction or of renal pelvic back pressure. A few will be helped by ureteral dilation, but it is difficult to predetermine which individuals these are. Reproduction of the pain by a catheter passed up the ureter or by distention of the renal pelvis with fluid injected through the catheter is believed by some to be an indication for treatment by ureteral dilation. Such treatments are best spaced at intervals of ten days to two weeks. More frequent application is likely to cause edema and excessive trauma. Large cystoscopes are available for use by urologists who practice dilation of the ureters to a large size (Chap. 1, p. 21). Braasch bulb catheters cause less trauma than dilating instruments which are a uniform diameter all along the shaft. The calibre is increased one or two sizes at each treatment; when the ureter does not dilate easily, it is necessary to repeat the same size for several treatments. Many urologists lavage the renal pelvis with 1:500 silver nitrate or other antiseptic solution injected through the catheter which is used to dilate the ureter.

Examination, preoperative care and selection of the anesthetic

This is similar to the examination required for open prostatic surgery (Vol.XIII). Examinations to determine the indications for endoscopic surgery are given in Chapter XVII.

Abnormalities of the bladder neck and posterior urethra in the male

The vesical orifice may be contracted due to fibromuscular hyperplasia, to muscular hypertonia or to fibrosis. Each of these conditions may be either congenital or acquired, and may occur in either male or female children or adults. When the contracture is acquired it is usually a fibrous contracture, and is due to infection or is a sequela of operative procedures on the bladder neck.

Results and sequelae

The results obtained from any surgical operation, or from any type of treatment for that matter, are the most impelling factor in the scale of values determining whether or not that method should be continued. In fact, at the end of a sufficient adjustment period either contention will have automatically subsided or the force of consistently poor results will have doomed the procedure to ultimate abandon. It is undeniable that the wave of enthusiasm upon which a new operation rides into popularity may carry it farther than its merit would justify, but the tide soon recedes leaving the procedure to find its true level.

Technique with the Stern-McCarthy electrotome

The purpose of setting forth in detail the technique of endoscopic prostatic surgery is not to teach the embryo urologist or the occasional urologist how to perform this operation; nor is it to displace or replace any hospital training of the urologic surgeon. Instead, it is offered to supplement such instruction, and to give the house surgeon a didactic knowledge of the procedure before he starts using it — as well as to save some of the time and energy of the attending urologist who patiently or otherwise endeavors to explain and demonstrate the fine points. The portion dealing with the more advanced technique might also help those who have had their basic training, and who are trying to perfect and adapt themselves to the more difficult operation of removing larger prostates by the endoscopic method. If, perchance, one of the many urologic surgeons who are expert resectoscopists should read this volume, he will undoubtedly find that the details of technique given here do not correspond with those used by him. It is hoped he will understand that the author makes no claim that his is the one and only method in use, and that the following expose is not intended to convey the impression that this is the last word in technical knowledge. It is merely the description of a procedure which in our hands has proved workable, and is presented as such and no more. It should be pointed out that the basic principles which apply to endoscopic prostatic surgery also apply to other types of endoscopic surgery.

Bladder contour abnormalities associated with normal mucosa

The normal bladder may be irregular in contour (Chap. IV). The lateral recesses are sometimes deep, or the trigone may be elevated in one individual more than in others. When the bladder is incompletely distended, the folds of its wall in the fundus and dome are irregular in contour; these flatten out as the bladder is filled. During the latter months of pregnancy the dome and fundus protrude inward. These contour irregularities due to normal conditions may at times be more noticeable than those arising from abnormal ones.

Endoscopic surgery—a specialty within a specialty

The introduction of a new surgical procedure or technique is always hailed by a volley of conflicting opinions regarding its application, and considerable time must elapse before its acceptance becomes general and its indications standardized. Factional disparity has been particularly rife in the history of endoscopic prostatic surgery, ranging from the operator who finds almost no indications for the transurethral approach to the one who treats practically one hundred per cent of his cases by this means. The younger generation of urologists is more enthusiastic about endoscopic prostatic surgery than are its elders, and men who have been schooled in centers where this operation is in current usage are more ardent supporters than those who have served their apprenticeship where the older types of prostatectomy prevail. Thus, a urologist’s training is the prime influence which molds his judgment concerning the relative merit of the different operative methods.

Indications for endoscopic surgery

The indications for endoscopic surgery vary within wide limits, depending chiefly upon the surgeon who is to perform the operation. If he has had adequate training and extensive experience in endoscopic surgery, the indications for him will include the removal of prostates weighing up to 150 to 200 grams, the resection of bladder tumors as large as 4 to 5 cm. in diameter, the crushing of stones up to 3 to 4 cm. in diameter and other procedures which are technically difficult. Surgeons who have not had this extensive training and experience, or who are unequipped in other ways to perform the more difficult endoscopic procedures, will limit the use of this approach to the small sized lesions. If a surgeon has had no training or experience in endoscopic surgery, there is no indication for its use by him; it is better for him not to attempt it. For the average urologist, endoscopic surgery is indicated for relief of bladder neck obstruction due to prostatic carcinoma which does not respond to hormone therapy and for removal of bladder neck contractures, median bars and the smaller prostatic adenomas. Small bladder tumors, small stones and sometimes Hunner ulcers and other intravesical lesions can usually be removed more successfully by the average urologist through the endoscopic approach than by open surgery. The ultimate factor determining the approach best suited to a given case is the operator himself. If he has established proficiency at removing large prostates and other lesions endoscopically, there is no contraindication to continuance of this method in his hands.

Abnormalities of both color and contour within the bladder

The endoscopic appearance of most bladder diseases varies in different individuals and at different times in the same individual. Therefore, in the classification used here, several different descriptions of the same lesion may be given depending upon its appearance at the time of endoscopy.