THE TECHNIC OF SUPRAPUBIC PROSTATECTOMY AND DETAILS OF AFTER-TREATMENT.

BY HORACE PACKARD, M.D., PROFESSOR SURGERY BOSTON UNIVERSITY.

PROSTATECTOMY AXIOMS.

1. THE MINIMUM OF ANAESTHESIA.

2. BREVITY OF OPERATIVE TECHNIC.

3. IMMEDIATE AND PERFECT CONTROL OF HEMORRHAGE. 4. CONVALESCENCE WITHOUT SEPSIS.

Prostatectomy, as an established operation, appears to have taken its place among the great operative procedures of surgery and is destined to become as firmly fixed in the surgical world as ovariotomy, hysterectomy, and appendectomy.

The question of whether the prostatectomy of the future shall be by the suprapubic or perineal route, is one upon which there is still a divergence of opinion. It is never safe to make prophecies upon unsolved surgical problems. Five years ago the writer felt fully convinced that the perineal route was, and would continue to be, the best method of attacking the prostate gland for the relief of prostatic obstruction. Subsequent discoveries in the anatomical relations of the organ and a riper experience have necessitated a complete reversal of thought and practice. This change of fact has been brought about by the following amply demonstrated and easily demonstrable facts :

1. Complete and perfect enucleation of the prostate gland can be made by the suprapubic route in more than ninety-nine per cent.

of cases.

2. Prostatectomy by the suprabubic route can be completed from start to finish in from four to ten minutes.

3. The gain to the patient in the brevity of operation and consequent minimizing of shock is equalled only by the transitory anesthesia and absence of post anesthetic disturbances. (The patient almost undeviatingly awakens from the anesthesia before leaving the operating table.)

4. The two most important post-operative accompaniments, hemostasis and maintenance of asepsis or approximate asepsis, can be more easily accomplished through a suprapubic wound than through a perineal.

5. The patient can be kept more comfortable, with less of wet and drip from the bladder, after the suprapubic operation.

6. Convalescence without persistence of urinary fistula is more certain following the suprapubic method.

7. There is far less danger of wounding the rectum by the suprapubic route.

The general condition of the patient, while having no relation to the technic of the operation is of so much importance that I can not forebear urging the closest scrutiny in the matter of the daily ex

cretion of urea and the total of solids in the urine. Nutrition and repair are so closely related and the outcome of any operation is so wholly dependent on repair, that assurance of adequate assimilation and nutrition should be the sine qua non of every proposed prostatectomy, since most of the patients are past the prime of life and many in advanced senility. I beg to acknowledge my indebtedness to Dr. S. H. Blodgett, specialist in renal diseases and urinary analysis, for his valuable aid in working out this matter in its special relation to prostate cases. If, on urinary analysis, the urea and total solids are found to be much below normal, it is my custom to put the patient on a diet rich in nitrogenous foods for a few days, and again subject the urine to analysis. If the kidneys have responded by an increased output of urea and solids the patient is considered a suitable case for operation, irrespective of whether there is pus in the urine, and irrespective of whether that pus originates from the bladder or kidney, or both. The age of the patient, per se, is of no consideration some men are as old at seventy as others are at eighty.

Anesthesia and Prostatectomy. What method of anesthesia, and what anesthetic is best adapted to prostate cases is still open to argument. That it is desirable to limit the period of anesthesia to the briefest possible time and the amount of anesthetic to the smallest quantity, all surgeons are in tacit agreement. In furtherance of this object the patient is placed upon the operating table and all preparatory steps, such as sterilizing the field of operation, irrigating the bladder, etc., are completed before the anesthetic is administered. Initial anesthesia with nitrous oxide gas and the immediate substitution therefor, of ether, has given the best results. The necessary period of anesthesia by any method is usually so brief that as a rule the patient is awake before his removal from the operating room, and no postoperative effects are apparent.

The writer has had no experience with spinal anesthesia, and in view of conflicting reports from other sources has felt constrained. to adhere to methods which have been tried and not found wanting. Anesthesia of all my prostatectomy cases is conducted by Dr. F P. Batchelder, the most expert anesthetist whom I have ever known. He knows in every case before beginning the anesthesia, the condition of the heart's action and what the kidneys are doing. He takes full charge and responsibility of the administration of the anesthetic with full privilege of changing to chloroform, or chloroform and oxygen, or ether and oxygen, or suspending all anesthesia at any moment. It is understood, however, that each case when all is ready for the first incision, will have nitrous oxide gas administered to the point of unconsciousness, which takes about thirty seconds. Ether vapor is then turned on and a mixture of the two is breathed for about sixty seconds more. The gas is then turned off and thereafter ether vapor is used until the close of the operation, unless some condition arise which leads the anesthetist to resort to changes above referred to. The anesthetic is removed immediately on completion of the operation. During the adjustment of the dressings the patient usually regains consciousness, opens his eyes and admonishes that he is not yet asleep, and is surprised when assured that the operation

is over and he is about being returned to his room. Anesthesia is conducted with the Packard inhaler, which permits rapid changes from one anesthetic to another, and admixture of anesthetics in any way desired.

Preparatory Steps Immediately Preceding the Operation. The bladder is always irrigated immediately prior to the operation. This may be done in the patient's room it is somewhat desirable that it be so done, since it shortens the time which he must otherwise lie on the operating table. It does not matter much whether an antiseptic solution or plain boiled water is used for this purpose, since if cystitis be present with pus in the bladder, no amount of irrigating with antiseptics will sterilize it. On the other hand if the urine be clear and there be no cystitis, no antiseptic is called for. Whether the bladder has been irrigated in the patient's room or not, the first step, after the patient is arranged on the operating table is scrubbing the external genitals, the pubic region, the lower abdomen, and removal of the pubic hair; in other words the sterilizating of the field of operation. A soft rubber catheter of about No. 22 French scale is passed into the bladder, or if by chance that will not go, a Mercier tip woven catheter is used. One or the other will, as a rule, pass these failing some kind of a metallic catheter is used. It is most convenient for irrigation to have an elevated irrigating bottle or tank with a rubber tube leading from it equipped with a hard rubber catheter nozzle and stop cock. When irrigation is complete the bladder is filled to the point of toleration, the stop cock shut, and the catheter allowed to remain in. While this preparation has been in progress by the assistant, the surgeon has drawn a rubber glove on his right hand and takes his place on the patient's right. The tout ensemble at this point is, or should be, as follows: The bladder is full of the irrigating fluid, the catheter is in the urethra and bladder, the irrigator nozzle is still connected with the catheter, with the stop cock shut, the anesthetist is at the head of the table, with the apparatus ready to begin anesthesia at the signal from the surgeon ; a nurse is specially detailed to preside over an immersion bowl containing at least three pairs of rubber gloves. Two skilled assistants are also desirable, one opposite and the other at the left of the operator.

The surgeon gives the signal to the anesthetist to begin the anesthesia, and awaits his return signal that anesthesia is sufficiently progressed to begin the operation.

At the last moment before the first cut is made the stop cock is opened and more water allowed to run in to further distend the bladder. Palpation should now demonstrate that the fundus of the bladder is far above the pubic bone. This lifts the peritoneum sufficiently away from the field of operation so that with ordinary care there is no danger of wounding it.

These seemingly elementary details are thus given in extenso, because they have been worked out and are closely followed for the purpose of saving time, thus making the period of operation and anesthesia for these aged and often feeble patients as brief as possible.

With this introduction your attention is invited to the first part of the subject of this paper, viz. :

The Technic of Suprapubic Prostatectomy. The primary incision is made two inches long, longitudinally, exactly in the median line immediately above the pubic bone. It will be recalled that the pyramidalis muscles reinforce the recti muscles at this point, therefore the anatomical arrangement is somewhat different from that two or three inches nearer the umbilicus. More thickness of muscular tissue is exposed than in the ordinary incision of abdominal section. The tendinous and muscular tissues are quickly cut through and the finger carried down into the cavum Retzii. The connective tissue filling this space is quickly cleared from the bladder wall with the tip of the forefinger, and a stripping movement upward helps to insure that the peritoneum is lifted away from the anterior bladder wall. The distended bladder is readily felt as an elastic resisting convex surface.

The point of the knife is now pushed through the bladder wall, preferably entering it well down toward the base of the bladder, and with the cutting edge upward. Quickly, before the water in the bladder has had a chance to escape, complete the incision toward the fundus at least an inch and a half long. The gush of fluid from-the bladder wound is immediate and copious, but without giving it a chance to all flow out, quickly plunge the forefinger of the left hand deep into the bladder cavity. At once the catheter will be felt, identifying the vesical orifice of the urethra, and coincidently the prostate gland. Feel for possible stone in the cul de sac back of the gland, and if one be present lift it out with a stone forceps. All is now in readiness to enucleate the gland.

The forefinger of the right hand is passed into the rectum until the prostate is felt; the legs of the patient having been widely separated. By pressing the prostate forcibly forward, the finger in the bladder at once appreciates that it can sweep all over and around the prostate gland and determine its size, outline, consistency, lobulation, size of the urethral opening, etc. The tip of the finger in the bladder now scratches a hole through the bladder mucous membrane covering the most prominent part of the gland, making the initial opening preferably at a point near the margin of the urethral opening where the sheath is absent. This, if correctly done brings the tip of the finger down upon the surface of the capsule.

Care should be observed not to break through the capsule, but on the contrary carefully insinuate the finger laterally until it is appreciated that a distinct line of cleavage is established. This shows that the enucleation is rightly begun, i.e., that the finger is gliding between the capsule and the sheath. Now, with strong upward and forward pressure of the finger in the rectum, the enucleating finger sweeps boldly and rapidly around and above and below the prostate and ordinarily in about one minute's time the gland is lying loose in the bladder. With suitable forceps it is lifted out through the suprapubic wound. At the same moment the assistant opens the stop-cock, and the irrigating fluid is allowed to flow freely.

The essential part of the operation is now done, and should not

have occupied more than from four to nine minutes.

Different cases differ materially in the ease or difficulty of enuclea

tion. Some prostate glands turn out like a horse chestnut from its shell. Others present difficulties calling for exhibition of all available strength. I have more than once felt lameness of the muscles of the upper arms and trunk the day following a difficult case.

Unless enucleation can be completed within five or six minutes, the operator must change to the other side of the table, thus reversing hands. Such strenuous exertion quickly tires the muscles of the hand and forearm.

The question naturally arises, are there ever cases which can not be enucleated by this method. Freyer, whose published cases exceed in number those of any other operator, reports having met one such case only. The writer has had one case in which no line of cleavage could be found between the capsule and the sheath. For those cases the instrument herewith figured has been devised; a prostatome for safely taking away such masses of tissue as offer obstruction to the urethral opening. It is, as will be observed, a loop knife, on the plan of the Gottstein knife used for adenoids, (Ill. No. 1) but is provided with a cutting edge modelled after the Christie bread knife.

Illustration No. 1. Prostatic Curette

Details of after Care. With this explanatory digression let us return to the closing steps of the operation, which are brief, and directed with three objects in view :

1. Prevention of hemorrhage.

2. Prevention of sepsis.

3. To facilitate the after care of the patient.

Hemorrhage often stops promptly of itself, which will be indicated by the fluid of irrigation in a few moments coming clearer and clearer from the abdominal wound. In the few moments that this test is going on the cut edge of the bladder, mucous membrane is picked up on each side and fastened with a single suture of silk or Pagenstecher thread to the skin of the corresponding side. Two deep sutures penetrating the skin, sheath and muscle, are inserted near each angle of the wound and left for the moment untied.

All the painful part of the operative technic is now over and the anesthetic may be withdrawn.

If by this time the bleeding has not appreciably and positively stopped, this combined prostatic hemostat and syphon drainage tube is adjusted. (Ills. No. 2 and 3.