Urology

The Prostate.—For chronic inflammatory lesions of the pros tate and seminal vesicles diathermy is valuable and acts, not only on the gland itself, but also on the arthritic and other complica tions so frequently associated with gonorrheal prostatitis and vesi culitis. In cases of enlarged prostate where operation is impossible owing to age, cardiovascular changes, advanced renal disease, etc., a fair measure of relief can be obtained by medical diathermy or by deep X-ray therapy. In all other cases prostatectomy is un doubtedly the correct procedure. The type of enlargement most suitable for operation is that due to chronic lobular prostatitis with pronounced adenomata; the second type, chronic interstitial prostatitis or fibrous prostate, presents many difficulties to the operator but should be removed whenever possible, as it causes a severer degree of obstruction and consequent impairment of the renal function than the adenomat.ous variety. Before deciding on an operation the chemical tests of renal efficiency should be car ried out, for the type of operation selected will depend almost entirely on these tests. Careful preliminary treatment, often last ing several weeks, is nearly as important as the operation itself.

After much discussion, the majority of urologists have decided in favour of the suprapubic operation in one or two stages. The two-stage operation has reduced the mortality from uraemia to a negligible quantity and is indicated in all cases with renal deficiency, severe cystitis, retention, or four or more ounces of residual urine. The Thomson-Walker operation is undoubtedly an improvement on the somewhat crude but remarkably effective operation practised by Freyer. It takes longer but eliminates the risk of post-operative stricture. The perineal operation, performed almost exclusively by Young of Baltimore, is in England reserved for carcinoma and for the fibrous type of prostate. Here the advantages of control of haemorrhage and perfect drainage are outweighed by the dangers of pelvic cellulitis, perineal fistula and incontinence of urine.

In about 25% of patients with symptoms of prostatic obstruc tion but without palpable enlargement of the prostate, a careful cystoscopic examination reveals the presence of a ridge of hyper trophied tissue, either on the posterior lip of the prostate over hanging the internal meatus, or projecting upwards from the floor of the prostatic urethra and constituting the so-called median bar. For the relief of this type of obstruction H. Young invented his well-known punch, later improved by Kenneth Walker, by adapt ing it for diathermy. (See ELECTROTHERAPY.) Hitherto, treatment of prostatic carcinoma by radium has been so unsatisfactory that many surgeons have ceased to use it. Diathermy has been more or less successful in conferring relief, but the results can hardly be described as brilliant. Whenever possible, Young's perineal resection appears to be the most satis factory procedure; failing this, excellent results have been some times obtained from deep X-ray therapy.

The Testis.—Steinach of Vienna performed vasoligation in senile rats with a view to increasing the internal secretion of their testes and thereby stimulating their failing energies. For two to

four weeks after bilateral division of the vas between ligatures no appreciable change was noticeable. The rats then began to show a return of sexual excitement and vigour, in some instances equalling that of young males. This was followed in rapid succes sion by a return of pugnacity, increase in muscular energy and a copious growth of fur. The change lasted for about six months, when the animal gradually lost his youthful appearance and powers and became senile again, eventually dying within a few weeks of the onset of the change. Steinach found that the opera tion induced degeneration of the seminal epithelium (later followed by regeneration) and an increase in the interstitial tissue. In man the operation has been attended by very variable results. The greatest successes appear to have occurred in cases of premature old age ; when performed for impotence alone it is not so satisfac tory, and is quite useless if the testis be already atrophied. Some cases of arteriosclerosis have been greatly benefited by it.

Testicular Grafts

(see from lower animals have been employed for many years with more or less similar results, viz., improvement shortly after implantation, fol lowed by atrophy and absorption of the graft, and a return on the part of the patient to the original condition. Voronoft in 1920 used testes of anthropoid apes and found that they survived for three years or longer, and that the initial improvement in the patient's condition was maintained. Kenneth Walker has on several occa sions employed a healthy human ectopic testis. He concludes that the life of a hetero-graft is not longer than two years. that absorp tion of the graft does not necessarily imply a return of the patient to his former condition, and that permanent improvement is probably due to increased growth in other endocrine tissues stimulated into activity by the graft.

Tuberculous Epididymitis.

When this disease is advanced castration is indicated, but when it is localised to the globus major or minor epididymectomy is now regarded as the correct procedure. The full extent of the disease must always be determined with care.

The Urethra.

The great improvement in urethroscopes has simplified the diagnosis and treatment of urethral conditions. With the Joly type of posterior urethroscope, diathermy can be applied where formerly a serious cutting operation was necessary. There is now an increasing tendency to revert to former methods and to treat stricture of the urethra by gradual dilatation with metal sounds or gum elastic urethrotomy being reserved for resilient and cartilaginous strictures and those complicated by fistulae. If contraction recurs after internal urethrotomy many surgeons advocate excision of the stricture and axial anastomosis. When a large amount of cicatricial tissue has been excised, the gap has been successfully bridged in one case by implantation of the patient's appendix, and in another by a child's prepuce fashioned into a canal around a catheter.

(See also BLADDER AND PROSTATE DISEASES.)