0 N E - S T A G E T R A N S - V E S I C A L P R 0 S T A T E C T 0 M Y 529

ONE-STAGE TRANS-VESICAL PROSTATECTOMY

BY JOHN POWER, BRISBANE

SUPRAPUBIC prostatectomy is the old form of prosta- Conditions other than urinary may also demand tectomy which has undergone many modifications over the years.

The operation which I propose to describe is based on the Harris operation as described in detail in the article in the BRITISH JOURNAL OF SURGERY in 1934.

preliminary drainage.

PRE-OPERATIVE TREATMENT Investigation of the patient is minimal. Routine

culture and sensitivity tests of urine are done, and

FIG. 617.-Drawing of post-mortem spec+en of bladder and prostatic urethra, opened from the front, illustrating, the intra-urethral method of enucleation of the prostate described in the text. The broken black line and the arrows thereon indicate the course followed by the finger during the enucleation. The points a and b, opposite the antero-inferior aspect of each lateral lobe indicate the site at which the enucleation is begun on each siie; ,d and e The cut edges of the muscle of the anterior commissure ; :, The membranous urethra ; f, The verumontanum.

SELECTION OF PATIENTS The most suitable patients for this operation are

those where there is an obstructing mass of tissue at the bladder neck due to hyperplasia of the prostate.

Where the amount of prostatic tissue of this type is small, I believe they are better treated by trans- urethral resection. This also applies to mid-lobe obstruction, bladder-neck contractures, and median bars.

Calculous disease of the prostate where surgery is required is probably best dealt with by the retro- pubic approach.

The fitness of the patient for operation will depend on his general physical state, and more particularly upon his renal function and blood chemistry.

If the patient has not had any instrumentation prior to having been seen, urinary infection is not as a rule a problem. It is my considered opinion that the majority of patients with bladder-neck obstruction are fit for surgery with a minimum of pre-operative treatment. Harris, 23 years ago, advised at least 10 days’ preliminary pre-operative catheter drainage or in some cases a preliminary cystostomy for 28 days. Only a minority of patients will require preliminary drainage and rarely cystostomy. Preliminary drainage is limited to those who show evidence of impaired renal function or grossly infected urine.

FIG. 618.-Same specimen as Fig. 617 after enucleation of the. prostate. The heavy white lines outline the resulting cavity. It will be noted that the membranous urethra, the verumontanum, and the prostatic urethra aro-d and distal to it have been left intact. The anterior commissure has been divided in this specimen for the purpose of exposing the interior of the prostatic urethra ; during an actual operation it is left intact. The dotted black line surrounds the additional area which is commonly removed when the Freyer, particularly the open instrumental, method of prostatectomy is employed. a, The inter-ureteric bar; b, The trigonal muscle; c, The membranous urethra ; d and e, The cut edges of the muscle of the anterior commissure ; f, The verumontanum. (Semi- diagrammatic.)

where there is infection, suitable pre-operative treat- ment is ordered. Investigation of renal function is done by blood-urea estimations and intravenous urography.

I still find the indigo-carmine test a useful agent in the assessment of renal function. It is particularly useful for judging improvement in patients where renal efficiency is impaired at the beginning of investigation and treatment to improve it has been instituted.

With regard to the indigo-carmine test, Harris stated. “ This is regarded as the final renal test of operability ”. I do not necessarily subscribe to this.

The presence of a large amount of residual urine is no indication in itself for preliminary drainage providing the patient’s renal function is good and there is no sign of infection.

When practicable the patient arrives at the theatre with an empty bladder.

Pre-operative instrumentation or catheterization is not routinely practised. In some cases preliminary cystoscopy is done where the patient has had haematuria.

ANESTHESIA I have a personal preference for mid-spinal

anaesthesia given by an anaesthetic specialist, but 35

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should there be any reason against spinal anaesthesia then combined anaesthesia is used.

OPERATIVE TECHNIQUE The operative technique is based on the surgical

principles so ably advanced by Harris in 1934. These principles are :- I. Intra-urethral enucleation as illustrated in

Figs. 617, 618. This procedure is made easier by inserting two fingers of the left hand into the rectum.

At this point I diverge very widely from the classical Harris operation.

Until seventeen years ago, I always performed the primary closure of the bladder as described by Harris, but since 1940 I have always used suprapubic drainage for 48 hours after operation, occasionally longer. Nursing problems became acute and necessitated my doing this in the early war years. I found that a closed system of irrigation can then be employed. I believe this solves the nursing problem

FIG. 619.-Drawing of post-mortem specimen of bladder FIG. 620.-Same case as Fig. 619 after removal of the lateral and prostatic urethra opened from the front, and showing The trigone has remained undisturbed in its normal lateral lobe enlargement of the prostate with a perfectly position. Two hzzmostatic sutures are shown on each side. normal posterior commissure. (Semi-diagrammatic.)

lobes,

FIG. 621.-From the same specimen as Figs. 617, 618. The trigonal tongue is shown sutured in position as in the author’s operation. (Pre-inserted here for ready comparison with the previous figure and to emphasize how closely reproduced is the normal anatomical relationship of the trigone and prostatic urethra.) (Semi-diagrammatlc.)

Where there is no mid-lobe enlargement, the lateral lobes are removed as illustrated in Figs. 619, 620, the floor of the urethra being entirely preserved.

2. Rapid and easy control of haemorrhage by the classical Harris haemostatic sutures, as illustrated in Fig. 621.

3. Insertion of retrigonization suture. In my opinion close approximation of the trigone

and urethra (see Fig. 621), as described by Harris, is rarely achieved.

4. The anterior sutures I, 2, 3, as illustrated in Fig. 622, to restore internal meatus to the size of one’s little finger and to control any oozing that remains. These sutures are inserted after the catheter has been passed, usually using a 22 F. whistle- tip catheter.

These principles I believe to be essential for the successful application of the operation. At this stage there should be no active bleeding.

FIG. 6zz.-Second transverse obliterative suture inserted : plastic operation completed : catheter with silkworm-gut trans- fixion suture in position. The catheter is passed intact and the tip cut off after a second eye has been made.

Inset : Same stage before passage of the catheter. Note that there is no visible raw surface, that the trigonal flap lies on a plane below that of the rest of the bladder base and is firmly bedded in position, and that the lateral edges of the prostatic rim are deeply inverted, thus partly re-forming the side walls of the new prostatic urethra.

in these patients and limits the risk of contamination, and does not prolong the period of post-operative urethral drainage. This procedure was originally used by Mr. Stanley Roe. The patient should be fit for discharge from hospital in 14-18 days, except where complications arise.

Antibiotic treatment is based on pre- and post- operative sensitivity tests.

Post-operatively the patient is kept under observa- tion and treatment where possible until urinary infection is no longer a problem.

MORTALITY RATES No figures available, but only an occasional death

has occurred. COMPLICATIONS

I. Embolic. 2. Renal Failure.-Has been a very rare

complication with the single-stage operation. 3. Haemorrhage.-Primary and reactionary

hzemorrhage are rare. In most forms of prostatic surgery we still have an occasional secondary hzemorrhage.

4. Infections.-I have been rarely bothered with persisting urinary infection since the introduction of antibiotics.

5. Epididymitis.-In spite of the occasional occurrence of this complication I do not practise vas ligation.

6. Post-operative Obstruction.-I have had no personal experience of post-operative obstruction at the bladder neck with this operation. Like most urologists, I find urethral stricture follows trans- urethral resection more frequently.

7. Osteitis Pubis.-This appears to have been a very worrying complication after the retropubic operation, but has only occurred once in my twenty- eight years of urology, and therefore is very rare after transvesical prostatectomy.

In conclusion, I think this operation has a very definite place in prostatic surgery. It is com- paratively easy to execute, gives a high degree of comfort to the patient afterwards, and has few complications and a low mortality rate.

To be invited to contribute an article to the special birthday number of the BRITISH JOURNAL OF SURGERY to mark the eightieth birthday of my friend Sir Gordon Gordon-Taylor is an honour I deeply appreciate.

S U R G E R Y O F B A S A L - C E L L C A R C I N O M A 531

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SURGERY OF BASAL-CELL CARCINOMA

BY B. K. RANK, C.M.G., AND A. R. WAKEFIELD, MELBOURNE, AUSTRALIA

IN Australia, basal-cell carcinoma of the skin is of special and peculiar interest. Its aetiology is full of paradox. Though there is some weight to the general thesis, that this country provides a climate and an environment for which Northern European skins have not been conditioned (Molesworth, 1927), it is clear that the widespread incidence of this skin carcinoma cannot be reduced to any such clear-cut explanation. Southern European immigrants are by no means immune from its development. Admittedly more common in the hotter and drier regions and among outdoor habitub, it is certainly not confined to particular occupational groups as the terms ‘ mariner’s disease ’ of early British writing or ‘ cancer de cultivateurs ’ of the French might suggest. So, too, there are surprising excep- tions to its more common age incidence.

The very extensive medical literature on this subject from all countries in the post-war years covers much clinical and pathological discourse, but there is a scarcity of well-documented information on the efficacy of treatment. Such reports as do appear almost entirely concern the results of radio- therapy, which are expressed in general terms of a recurrence rate within an arbitrary period of three or five years-figures which are poorly documented and which are commonly quoted from one paper to another. Professor B. W. Windeyer, in a Hunterian Lecture, February, 195 I, merely stated without substantiation that “ it is possible to cure by radiation 95 per cent of rodent ulcers if they are free from bone or cartilage ”, and he developed the commonly copied thesis that choice of treatment depends on “ functional and cosmetic results ”. Some expres- sion from Australian surgeons on this subject is perhaps long overdue.

As patients with this disease are so often treated as out-patients, and as it is but rarely lethal, all massed statistics derived by means used for other forms of malignant disease are of necessity incomplete and, in general, so worthless that some anti-cancer organizations have ceased to collect and dissect them.

At the turn of the century, when relatively little was understood of the varied nature and behaviour of skin carcinoma, surgery had earned a bad reputa- tion in the treatment of this condition, which com- monly presented in an advanced stage-“ Noli me tangere ”. It was natural therefore that as radio- therapy was first widely introduced about this time it would have its most obvious and regular place in such conditions. Ever since then it has generally been regarded as the method of choice for treating skin carcinoma, surgery being relegated to a secondary place-more particularly for cases where radio- therapy has already proved ineffective.

In British writings the only strong recent plea for surgery as the method of choice in treating basal- cell carcinoma has been that of Wakeley and Childs in the British Medical Journal (1949). Their paper raised some heated correspondence, in answer to which they set out the only figures we have been able to find concerning results of surgery in recent years. In America, Gordon New (I949), of the Mayo Clinic, among others, has been a consistent advocate of surgery for this carcinoma.

In the past fifty years not only have the techniques of surgery and radiotherapy improved, but much has been learnt of the pathology and behaviour of skin malignancy. It is therefore timely for some critical and dispassionate review of this condition and the problems it raises. Not only is it a matter first and foremost of doing what is best for patients, or of