Roger W. Barnes

Early Carcinoma of the Prostate: Comparison of Stages A and B

Stage A--occult, latent, preoperatively undiagnosed, incidentally found, stage I or T0--carcinoma of the prostate has been considered to be an earlier stage than stage B--II, T1 or T2, palpable nodule. In a comparative study of 118 patients with stage A lesions and 115 patients with stage B lesions we have found more focal lesions in A than in B. The A lesions were also less highly malignant than the B. However, the survival of patients with A lesions was a little less than those with B lesions. Age differences and more extensive growth before a detection may account for the differences. Patients with diffuse lesions and those with the more highly malignant lesions had a shorter survival than those with focal lesions and with a lower grade of malignancy in stages A and B. All available preoperative diagnostic data and a through histopathological examination of the surgical specimen are necessary to accurately stage prostatic carcinoma. Other well recognized diagnostic tests, such as the lymphangiogram, acid phosphatase value bone scan and so forth, are also necessary to accurately assess the extent of the disease.

Complications of transurethral resection of bladder tumors: prevention, recognition and treatment.

Between 1931 and 1971, 373 patients underwent transurethral resection of bladder tumors for cure or for control of the neoplasms. Complications included perforation of the bladder wall (5 per cent), hemorrhage requiring transfusion (13 per cent), infection (24 per cent) and postoperative mortality (1.3 per cent). Patients in whom perforations occurred had approximately twice as many infections and twice as much hemorrhage as the entire group but there were no postoperative deaths of those with perforations. Morbidity and mortality can be reduced in patients with perforation by 1) using isotonic irrigating fluid, 2) avoiding over-distension of the bladder, 3) maintaining postoperative free drainage through the catheter and 4) diagnosing and treating hyponatremia.

Fibrous contracture of bladder neck Cause, prevention, and treatment

Through a retrospective study of bladder neck contracture it was found that bladder neck resection and incision were equally effective for treatment of postoperative bladder neck contractures. It was also found that incising the bladder neck at the end of transurethral resection of the prostate (TURP) did not cause vesicoureteral reflux and did not improve the incidence of postoperative bladder neck contracture.

Tactile litholapaxy--safe and efficient.

Tactile litholapaxy is a safe procedure and is not difficult to learn. It can be used for stones up to 5 cm. in diameter unless the stone is very hard. The bladder is distended with irrigating fluid, the lithotrite passed, the jaws opened, and the lower jaw depressed against the floor of the bladder and vibrated to allow the stone to roll on to it. The upper jaw is depressed against the stone, the threads at the handle are meshed, and the stone is crushed. Fragments are crushed in like manner and are then washed out through a resectoscope sheath. It is easier to do and more efficient in both length of operating time, absence of complications, and shorter hospital stay when compared with visual litholapaxy and cystolithotomy.

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.