TRANSACTIONS OF THE

SECTION OF GENITOURINARY SURGERY

NEW YORK ACADEMY OF MEDICINE Meeting of February, 16, rgq

THE CHAIRMAN, DR. FREDERICK T. LAU, PRESIDING

COMMISSURAL PROSTATIC HYPERTROPHY

With Lantern SIide Demonstration Not prepared for pubhcation

ALEXANDER RANDALL, M.D.

PHILADELPHIA

(by invitation)

A DISCUSSION was presented of the origin and Iocation of prostatic hyper- trophy, citing the works of TandIer

and Zuckerkandl, AIbarran and Motz, Motz and Perearneau, LowsIey and others, pointing out that there had been a ten- dency to dogmatize that the hypertrophy- ing prostate consistentIy had its origin of growth in onIy one Iocation and that the above authors disagreed as to this Iocation.

From a persona1 series of 12 I 8 autopsies studied, concIusions had been drawn that it was impossibIe to correIatethe findings with the idea that hypertrophy invariabIy originated in or at one fixed area. Hyper- trophy may originate in any Iobe of the prostate with the exception of the true posterior Iobe. If such were the case, the findings from this autopsy series couId not heIp but give definite types of hypertrophy according to its origin. In other words, one shouId find individua1 specimens iIIustra- ting IateraI Iobe hypertrophy, hypertrophy in the posterior commissura1 gIanduIar tissue, hypertrophy in the subcervica1 gIand of AIbarran, or combinations of any or a11 of these. LateraI Iobe hypertrophy had been aIways biIatera1, in Dr. RandalI’s experience, though at times one Iobe had acquired greater growth than the other:

he had found specimens in which middIe Iobe hypertrophy was present without IateraI Iobe enIargement. Further, this middIe Iobe hypertrophy partook of a dif- ferent contour according to whether the origin was in the posterior commissura1 tissue or in the subcervica1 gIand of AIbar- ran. In other words, there are two gland eIements anatomicaIIy present in the mid- Iine posteriorIy, either of which may undergo hypertrophy independentIy of the other, or independentIy of IateraI Iobe growth, and they present a picture aIlow- ing of their recognition preoperativeIy by the cystoscope, or at the operating tabIe. The differentia1 diagnosis between these types was described according to the dif- ferences cystoscopicahy as we11 as by recta1 examination.

There are differences of surgica1 hand- Iing of these cases according to the type of hypertrophy present. Preoperative recog- nition shouId aIter the surgica1 approach in order to cause the minima1 amount of damage, aIIow of a cIean enucIeation and minimize the IikeIihood of postoperative bIeeding. These factors Iikewise couId not but inffuence the compIeteness and perma- nency of cure, and decrease a definite post- operative morbidity which has so regmarly fohowed prostatectomy.

In the suprapubic operation (a) where onIy biIatera1 hypertrophy is present, each Iobe shouId be separateIy enucIeated; (b) where there is hypertrophy in the Iateral Iobes and aIso in the posterior commissure, enucIeation starting about one Iobe shouId foIIow the Iine of the faIse capsme under the posterior commissure and across the mid-

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NFW SERIES Var. II, No. ; Section of Genito-Urinary Surgery American JW~~ d surgery 479

line and the apex of the trigone, and thence directly into the Iine of dIeavage and about the opposite lateral Iobe, the hypertrophic tissue to be thus removed in one mass; (c) where there is hypertrophy of the sub- cervical glands, it being recognized that such Iie without the normal prostatic cap- sule and covered onIy by mucous mem- brane, such a lobe couId be immediately pinched off from its pedicIe without fur- ther manipuIation.

In perineal prostatectomy the same ruIes hold true in regard to separate or tota adenectomy according to whether there is hypertrophy only in the lateral Iobes, or in the Iateral lobes and the posterior com- missure. When the operation is by the perineal route, one shouId not fai1 to Iook for, recognize, and remove a coexisting subcervica1 hypertrophy, remembering that it wouId not be removed from within the capsule and ofttimes Iies as an intravesical projection free of any attachment to other hypertrophied gIand tissue.

As the normal histoIogy presents two masses of gland tissue Iying in the midline, and presenting so-caIIed middIe Iobes when hypertrophied, but having separate origin and separate anatomica encapsulation and a differing surgical significance, we should in the future eschew the use of the term middIe lobe and speak of such growths as arising either from hypertrophy of the posterior prostatic commissure or from hypertrophy of the subcervica1 gIand.

Discussion

DR. EDUTIN BEER: It is aIways interesting to hear Dr. RandalI for he has aIways some- thing new to say and usuahy something con- vincing. Whether tonight is the exception to the rule, I do not know. I notice he was not entireIy convinced himself, for in the presentation of his charts, he spoke of middIe Iobes though he was trying to get away from this nomencIature and taIk about commissura1 hypertrophies. Is it a wise change to favor commissura1 instead of middle Iobe? I doubt it, for one wouId be forced to taIk about a posterior commissural h>-pertrophy if one wished to refer to that which has been called middIe-Iobe hypertrophy as

there are two commissures at the badder neck. This sureIy is not as simple as speaking of middIe lobes.

The AIbarran gIanduIar hypertrophy as a cIinica1 entity is a rarity here. I do not think that 2 per cent of the cases of prostatic involve- ment that come my way for operation are of the AIbarran type. If we dismiss that tJ-pe, I beIieve what Dr. RandaII said is absoluteIy borne out by my experience. I beIie\-e that ZuckerkandI and Tandler hit the nai1 on the head in their studies in which they calIet1 atten- tion to the fact that a11 the adenomatous masses deveIop anterior to the ejaculatory ducts though not always from the middle lobe. They are often latera m their origin as well as in the floor of the posterior urethra above the verumontanum.

The posterior Iobe becomes compressed against the capsule as the middIe and latera Iobes deveIop their adenomas.

Whether it is so important in the surgery of latera and middIe lobe enIargement to know exactIy what we are going to encounter before we start operating, I doubt. I beIieve we need an accurate picture if the approach is perinea1, but for the suprapubic approach, I do not beIieve such an extensive preoperative study is essential even though we usually cystoscope a11 these cases.

The important thing to remember from this presentation is that in post-mortem studies the commissura1, or middle Iobe as \ve used to caI1 them, adenomas start in much earher than do those in the IateraI Iobe, and in the sixth decade, the two combined become the typical picture of prostatic obstruction.

DR. 0. S. LOWSLEY: This is a real contribu- tion to a subject that interests us all. Dr. RandaII has made a study of a very Iarge series of cases and it is most interesting to me that he has reached the same conclusions that I have held since I studied this subject first from the embryoIogica1, and Iater from the pathologica point of view. My series comprised 250 cases, which is very much smaIIer than this wonderfu1 series reported on by Dr. RandaII. I agree with him absoIuteIy in everything that he says. It is very seIdom that I agree with anyone in every- thing on one subject; but I believe that hyper- trophy may begin in any one of the four sections of the prostate, for we a11 fee1 certain that it does not occur in the posterior lobe. Dr. RandaII said it becomes a compressed

480 A merican Journd of Surgery Section of Genito-Urinary Surgery MAY, 19+,

structure, aIthough in middIe Iife it is of equa1 importance to the individua1.

Dr. Beer is entirely wrong about our New York Iack of subcervica1 group enIargement. 1 found that 23.7 per cent of the maIes over thirty years of age had more or Iess enIarge- ment of the subcervica1 group. When the growth is small, these patients pass from offIce to of&e, from city to city, and are discouraged by the statement that they are nervous or neurasthenic and to “forget about it.” They wiI1 be found to have subcervica1 enIargement, but are very seriousIy affected because they suffer from frequency of urination, and if they have to pass urine every hour or haIf hour during the night they wouId naturaIIy become neur- asthenic. One must examine them very care- fuIIy and Iook f or a subcervica1 enIargement. The true middIe-Iobe enIargement is quite rare, as Dr. RandaII pointed out.

Regarding operation: unti1 Hinman’s modifi- cation came out, it was my custom to do 40 per cent of these operations suprapubicaIIy for the simpIe reason that when the subcervica1 group took part in the disease I found we were better abIe to remove the mass in its entirety from above; but since using Hinman’s modifica- tion, we find that we get such good vision of the bed and of the vesica1 orifice that we are abIe to approach the orifice much better, and are abIe in most instances to get out very Iarge sub- cervica1 masses. We have recentIy removed a subcervica1 mass as big as a smaI1 Iemon.

It is very interesting to me to have Dr. RandaII subscribe so thoroughIy to the views which I have suggested, primariIy from the embryoIogica1 standpoint; and I think the reason TandIer has changed his viewpoint is to make it fit the embryoIogy which has been compIeteIy eIucidated since he and ZuckerkandI wrote their quite remarkabIe contribution to this subject. Of course, their observations were accurate to an extent, but our embryoIogica1 studies of the prostate have made it possibIe to expIain the pathoIogica1 conditions much more satisfactoriIy.

DR. H. H. MORTON: I wish to thank Dr. RandaII for the priviIege of hearing the best description of the pathoIogica1 anatomy of the prostate that I have ever Iistened to. We have a11 of us accepted the theory of prostatic hypertrophy as expounded by TandIer and ZuckerkandI because of the weight of their names in pathoIogy and uroIogy. The theory is an attractive one, i.e., the hypertrophy

beginning in the subcervica1 portion of the prostatic gIands arid graduaIIy encroaching on the healthy prostatic tissue, pushing it out of the way of the new-growing hypertrophic tissue unti1 the oId true prostatic tissue forms an enveIoping capsuIe at the periphery with the newIy formed hypertrophic mass encIosed within it.

We have heId to this idea because we had no better one. Some three years ago I did some work on the pathoIogica1 changes in hyper- trophied prostates in Professor Bauer’s Iabora- tory in Vienna, and we couId not make the facts, as we saw them through the microscope, fit in with the TandIer and ZuckerkandI theory. We found the hypertrophy of tubuIes and muscuIar fibers extending a11 through the prostate in a11 of its Iobes, and we faiIed to find the thinned-out remains of the origina prostate at the periphery. At that time we had no rea1 expIanation of our findings, but tonight, in his beautifu1 demonstration, Dr. RandaII has cIearIy shown what we had suspected but were not sure of, namely, that the hypertrophic change in the prostate may be universa1 and not confined to one particuIar group of gIands, or it may affect onIy one Iimited part of the gIand.

Dr. RandaII’s expIanations have aIso been most heIpfu1 in directing the IogicaI surgica1 approach for the remova of hypertrophied prostate, and he has shown how important is the study of the form and direction of the hypertrophy before deciding whether the prostate shouId be approached through the perineum or from above.

DR. JOHN MORRISSEY: SuppIementing Dr. RandalI’s exhibition, I wouId Iike to exhibit a specimen from a case that I operated on four weeks ago. The patient was a man forty-two years of age who had suffered from retention for five years, and had had a Young’s punch operation three years ago;. he was reIieved of his retention for a time, but it returned, and when I saw him three months ago the residua1 urine was again 16 ounces. I did a Young’s punch operation on him at the time without much benefit and he bIed for three months after the procedure. He then went into the hospita1 and by perinea1 prostatectomy I removed this specimen, a good-sized posterior Iobe growth. WhiIe it does not correspond to the AIbarran type, stiI1 when it was takenout it was in a IameIIa of its own, separated from the two IateraI Iobes. The bIadder did not empty itseIf unti1 this was removed. You can

New SERIES VOL. II. No. 5 Section of Genito-Urinary Surgery American Journal of Surgery 481

see on the upper surface a smaI1 indentation where I took out a fair-sized piece when I did the Young’s punch operation.

I have not had much Iuck with the Young’s punch operation, and many others compIain of the same Iack of success; I think it is due to the fact that these cases are not properIy seIected. This may occur in cases which shouId be subjected to a prostatectomy, and not have a Young’s punch operation; yet when that is carried out and the symptoms continue, the failure is charged against the punch operation. Within the past ten days I have used Dr. Dr. Braasch’s instrument in two cases, one with 6 ounces of residua1 urine and the other with I I ounces residua1; and while they are only seven and nine days oId the cases have done very weI1. That is the procedure where, after the remova of the obstructing portions, the prostatic area is fuIgurated, as advised by Dr. Rumpus, and a11 bIeeding is checked in that nay. That disposes of the difhculty in the Y’oung’s punch operation. I think it requires nice judgment to decide whether the case is one in which to use the CoIIings’ operation, or one in which the obstruction can be removed with the Braasch or Young’s punch operation, which requires a radica1 procedure with compIete removal of the obstruction, or as I have done in this case.

DR. H. JECK: Dr. RandaII Iaid stress on the preopcrntive study of cases of prostatic hyper- troph>- which wouId determine IargeIy the type of operation. I hope he will tell us more of the particuIar type of operation he empIoys for each type of obstruction. Dr. Lowsley men- tioned the enIargement of the subcervica1 group in young men who are called neur- asthenics. I wish he wouId teI1 us how he recog- nizes that type of subcervica1 group enIarge- ment. What is the cystoscopic picture and just what does he do for them?

DR. CLYDE COLLINCS: It was my priviIege in 1920 to spend a month with Doctor RandaII in PhiIadeIphia. I Tvant to recommend to a11 of you who have the time and opportunity to visit his clinic and see his wonderfu1 coIIection of museum specimens; one sees there ten or fif- teen examples of every type of prostatic obstruction that occurs.

DR. F. T. LAU: There is no question of the absoIute importance of a good cystoscopic study and thorough knowIedge of prostatic or commissura1 enIargement before we decide what type of operation to use.

DR. RANDALL (closing) : Dr. Beer has caught me in my weak point and quite properIy criticized my referring to middle Iobes while speaking of my- lantern slides. It is purely a bad habit from past usage, and my attempt this evening to differentiate them for you being in my own mind a question of recent birth, I inadvertently- slipped while speaking of the slides.

I must agree with Dr. LowsIey that the sub- cervical hypertrophies are far from infrequent and as I showed you in my statistics they form 30 per cent of the hypertrophies when occur- ring aIone, and if combined with the biIatera1 enIargements, their frequency immediateIy augments that figure.

I was most interested in Dr. Alorton’s refer- ence to his experiences while in Vienna and it somewhat explains the change of attitude which Tandler and Zuckerkandl have taken in the recent edition of their book.

What I was particuIarIy anxious to dwell upon was the choice of varration of the opera- tion according to the type of hypertrophy present. I am convinced that there are debnite preoperative pictures to be diagnosed from the cIinica1, cystoscopic and rectal examination which wiI1 place each prostatic patient in a definite group and will classif)- him as to the type of hypertrophy present. For instance, we have a11 seen the individual with hypertrophp and sudden comptete retention, whom in- dweIIing catheter drainage for a fe\v days or more wiI1 tide over the acute retention, and on removing the catheter he mill again start voIuntarv urination and will be found to have IittIe or no residua1 urine. This is the type which has onIy biIaternI estravesical Iobe hypertrophy. This couId be proved by both recta1 and cystoscopic examination and at operation two separate Iobes will be found and shouId be separately enucleated. A second type wiI1 be the individua1 who over a period of years has been enjoying fair health, but when examined wiI1 be found to be carrying a Iarge residua1 urine which no amount of preliminarv treatment wiI1 vary. Such a case wiI1 in all probabiIity present on recta1 and cvstoscopic examination, in addition to Iateral lobe enIarge- ment, hypertrophy in the posterior commissure. At operation such an hvpertrophy shouId be removed as one mass which will incIude both IateraI Iobes attached to one another by the hypertrophic commissura1 tissue. In either of the above types suprapubic or perinea1 pros-

482 A m&can JournaI of Surgery Section of Genito-Urinary Surgery MAY, 1927

tatectomy can be successfuIIy performed, though here I personaIIy Iike to make a differ- entiation, removing the commissura1 enIarge- ments suprapubically and the simpIe biIatera1 ones perineaIIy.

Where the subcervica1 gIands hypertrophy, I fee1 it is aIways best to approach such a case through the suprapubic incision because of the anatomica origin of the enIargement and the fact that such Iobes are aIways intrasphincteric, as we11 as an intravesica1. These, I grant, are refinements of diagnosis and operative tech- nique which, though they are not absoIuteIy essentia1, have decided influences upon con- servative surgery, minimizing injury, offsetting hemorrhage, and giving greater assurance of permanency of cure.

PRESENTATION:of INSTRUMENTS

A MODIFICATION OF THE MCCARTHY PANENDOSCOPE FOR CONTINUOUS

IRRIGATION

CLYDE W. COLLINGS, M.D.

We have modified McCarthy’s panendoscope by pIacing a smaI1 meta tube from the inflow faucet down to the end of the sheath. A smaI1 groove on the obturator permits it to pass easiIy by this meta tube.

The purpose of adding this feature to the McCarthy endoscope is to get rid of the annoyance of stopping a urethra1 or bIadder operation to remove the water from the bIad- der, which, too, interefers with the progress of the operation, for the eIectrode has to be ad- justed again.

With continuous irrigation the inflow and outflow can be niceIy adjusted so that the bIadder is not overdistended. AIso the bubbles from the high frequency current are washed away. The irrigating medium washes away any bIeeding that may occur. LastIy, a constant degree of distention of the prostatic urethra and bIadder may be maintained.

PRESENTATION OF CASES

THREE CASES OF PROSTATIC INTRUSION OPERATED UPON BY THE ELECTROTOME CUTTING CURRENT

CLYDE W. COLLINGS, M.D

CASE I. W. B., aged sixty-one years, admitted to Lexington Hospital December 3, 1926 with a compIaint of inability to pass urine.

Previous and famiIy histories essentiaIIy negative.

Present IIIness: In June, 1926, the patient began to wet the bed at night; he was passing his urine every haIf hour by day and night, with marked urgency. He has experi- enced much diffIcuIty and burning for the past three years. Mouth very dry since the onset of present iIIness. He has been very nervous of Iate and the famiIy thought the patient’s “mind was going off.”

On December 3, 1926, he was referred to Dr. Archie Dean at the MemoriaI HospitaI. Because of the great Ioss of weight he was thought to have a carcinoma. Cystoscopy by Dr. Dean reveaIed a median bar at the vesica1 outlet, deep bas fond, and a marked elevation of the fIoor of the bIadder neck as the urethro- scope was withdrawn into the posterior urethra. Creatinine 2.3 mg.; non-protein nitro- gen 90. PhenoIsuIphonphthaIein test: trace in the first two hours. Urine very cIoudy and Ioaded with pus. By recta1 examination the prostate was found sIightIy enIarged, reguIar, firm throughout, with no suggestion of car- cinoma. An indwelling catheter was tied in the urethra.

December 7, 1926, eIectrotome excision of prostatic bar, under cauda1 anesthesia. In- dweIIing catheter for three days after the operation. The symptoms of renaI insufflciency were more marked for the first few days after the operation. After the remova of the catheter the patient has continued abIe to void.

December 13, 1926. Discharged from the hospita1. N. P. N. 40; creatinine 1.5.

December 16, 1926, urinates three or four times at night, every two hours during the day, burning is about gone. Urine cIoudy but not bIoody. Voids 8 ounces at a time. Residuum 4 ounces.

December 21, 1926: Residuum 3 ounces. December 27, 1926: Residuum z ounces.

Urinates twice during the night, every 2 or 3 hours during the day.

January 3, 1927: urinates twice in the night, every three or four hours in the day. Residuum, I ounce. BIood pressure I 601 I 00. Urine contains Iess pus.

January 17, 1927: Residuum I ounce. February 16, 1927 (nine weeks after opera-

tion) : Residuum 136 ounces; indigo-carmine 4 C.C. intravenousIy appeared in ten min- utes in fair concentration. Has gained 21 pounds.