Another important point regarding catheterisation which should be remembered in cases of enlarged prostate where the instrument is em ployed for the first time in an examination with the view of detecting the amount of residual urine--if the whole of this he removed by the instru ment the surgeon should he prepared to inject a quantity of warm Boric solution and leave it in the bladder so'as to prevent the collapse which is liable to occur.
The various procedures of a palliative kind such as castration, the use of thermo-cautery puncture, permanent perineal drainage, McGill's suprapubic partial operation, section of the vas, &c., have been all finally abandoned for prostatectomy in every case where the disease is progressing and causing mechanical obstruction to the emptying of the bladder.
Age is no barrier to the operation, which has been often successfully performed on patients beyond 90 years of age.
After as complete a state of bladder asepsis as is possible has been obtained by irrigation, the administration of antiseptic drugs and, when much purulent cystitis has been present, by suprapubic drainage of the bladder, the operation of prostatectomy should be undertaken.
Since the introduction of Freyer's brilliant advance in prostatic surgery whereby enormously enlarged prostates may be removed suprapuhically by an operation only extending over a few minutes the perineal route in this country has been neglected. There cannot, however, be any doubt about the superior advantages of the perineal operation in selected cases as practised by Young of Baltimore, who has reduced the mortality of this operation to under 2 per cent.; the reports of the Johns Hopkins Hospital in r9o8 show that gr consecutive perineal prostatectomies were performed without a single death. Freyer's last statistics published in British Medical Journal of February r, 1919, of the suprapubic operation showed in his skilled hands a mortality of 3 per cent. in the last '200 cases. It seems probable that by a careful adaptation of each method to individual cases the mortality of prostatectomy in skilled hands should fall below r per cent. when malignant cases are excluded.
The suprapubic method is undoubtedly the best for the removal of all large prostates bulging into the bladder, and the perineal operation for smaller fibroid enlargements which project downwards, and in which the sheath and prostatic capsule are fused together. Malignant enlargements are more completely removed by the lower operation. The drainage is complete, the urethra is not torn, sexual power is seldom destroyed, and the patient may he permitted to leave his bed for a couch in the open air in 24 or 48 hours after operation. It is, however, agreed on by all authorities that perinea] prostatectomy should only be undertaken by the skilled and experienced surgeon, being a difficult and complicated operation.
Frcver's snprapubic operation consists in opening the freshly irrigated bladder above the pubes by a small incision capable of admitting the forefinger; the mucous membrane over the projecting tumour is torn through by the finger-nail or a blunt-pointed scissors so as to admit the entrance of the forefinger between the capsule of the prostate and the sheath formed by the prolongation of the recto-vesical fascia. By inserting
a couple of fingers of the other band into the rectum so as to make the tumour project farther into the bladder the enlarged gland is shelled out en bloc or in two pieces, the enucleation being commenced at the sides and terminated close to the pubes as the prostatic urethra is torn across at the junction with the membraneous portion of the tube. The enucleated gland is next delivered by the finger, scoop or forceps through the stretched suprapubic opening and the bladder irrigated by a stream of hot sterile saline solution. A rubber tube of large calibre is then inserted through the skin wound into the bladder opening and connected with a suction apparatus, or the wound is covered up by several thick layers of absorbent cellulose wadding which are to be removed at two-hourly intervals to minimise the excoriation of the skin caused by the urine continually welling up through the tube and trickling over the surface. The tube is removed front the 4th to the 7th day, and some surgeons drain the bladder by a catheter left in situ for 14 days to expedite the healing of the wound. The patient in about two to three weeks commences to pass urine by the urethra and the bladder wound is sometimes completely healed in about a month, though a pin-hole opening may remain for a much longer period.
I t is needless to say that before tearing through the mucous membrane a careful exploration of the bladder should be made by the finger for the discovery of a calculus or phosphatic debris, which should be extracted before attempting enucication of the prostate when the suprapubic operation is selected.
In feeble patients, especially if there be renal insufficiency, and in emergency prostatectomies it is preferable to perform the operation at two stages, the bladder being opened and drained through a small supra pubic incision under local anesthesia; after the patient has regained a further degree of strength and the renal functions have become re-es tablished„ a general anaesthetic or spinal anaesthesia being selected, the enucleation can more safely be proceeded with by enlarging the bladder wound. Some surgeons advocate spinal anaesthesia in every case where severe bronchitis or heart trouble increases the risk of chloroform or ether narcosis.
Malignant disease of the prostate is much more common than has been hitherto recognised; once the stony hardness so characteristic of the disease has been detected there should he no time lost in waiting for further developments. The best operative procedure is the above-mentioned perineal method of removing the diseased gland. In inoperable cases much relief may be obtained by drainage of the bladder through a supra pubic incision and frequent. flushing out of the vesical cavity by mild antiseptics. Cases formerly regarded as outside the pale of operation have been successfully dealt with by Young, who removes the entire prostate and seminal vesicles with the portion of the bladder below the ureters, afterwards suturing the membraneous urethra to the remaining part of the bladder wall.