THE MANAGEMENT OF ENLARGED PROSTATE Lecture delivered at the Royal College of Surgeons of England on 8th April 1954 by E. W. Riches, M.C., M.S., F.R.C.S. Surgeon and Urologist, The Middlesex Hospital. The word "management" implies the conduct of the case; it has also a dictionary definition of trickery or deceitful contrivance, but most of the tricks are only the application of the results of experience, and each surgeon will have well-tried methods of his own which he finds effective. In the present connection it will be used to indicate the manner of treating the patient and it will be taken to include the preliminary assessment, the decision whether or not to operate, the method of treatment, including some operative details, the after treatment, and the complications. Patients with enlargement of the prostate may present in a number of ways, and from the clinical aspect they fall into four groups: 1. Those with urinary symptoms. 2. Those in whom prostatic enlargement is found on routine examination but whose main complaint is not urinary. 3. Patients with acute retention of urine. 4. Patients with chronic retention of urine. Many men now seek advice at an earlier stage than formerly, and some expect operation too soon, but there are'still those who come too late when serious renal damage has already occurred. Group 1.-Patients with Urinary Symptoms The patient who comes with urinary complaints presents the least difficulty. His age is generally more than 60, and although men in the early fifties occasionally require surgical treatment they are often better treated expectantly as long as they can be seen regularly. The prophylactic removal of a normal prostate by any route is not to be recommended and may be followed by an increase of symptoms and a high incidence of complications. The need for operation depends on a combination of symptoms and signs rather than on any one single factor such as the amount of residual urine, or the number of times micturition occurs in the night. The symptoms and signs must therefore be considered. Obstructive symptoms are the surest indication for operation and are due to changes in the bladder neck and the prostatic urethra caused by the enlarged gland. Alterations in the act of micturition such as difficulty or delay in starting, especially when the bladder is overfull, a poor vertical intermittent stream with a terminal dribble, the need to sit down to micturate and to open the bowels at the same time are all characteristic. An intelligent patient learns to avoid over-distension. To estimate the force of his stream it is better to watch him pass urine if he can do it in 120 THE MANAGEMENT OF ENLARGED PROSTATE company; a stream of good projectile power is usually an indication that prostatectomy is not yet needed. Increasedfrequency of micturition is more noticeable by night than by day. The bladder loses its capacity for adaptation to its content; some urine enters the posterior urethra and starts the reflex desire to void so that there is urgency as well as frequency. Increased frequency alone is not one of the best indications for operation and as Ogier Ward (1953) has pointed out, it is by no means always relieved by prostatectomyon the contrary it is sometimes made decidedly worse. A man may wake for other reasons, such as having cold feet, and may get into the habit of emptying his bladder on waking; wearing bed-socks will sometimes reduce nocturnal frequency. Pain is absent unless there is cystitis or prostatitis; even a bladder stone does not always cause pain as it is cushioned by the residual urine. The presence of a stone when the prostate is enlarged is, however, a definite indication for prostatectomy and the stone is removed at the same time. Haematuria occurs in about 11 per cent. of benign cases; the bleeding is initial, painless and bright red in colour. It is an indication for further investigation and possibly for operation. Signs. The main objective sign is the palpation of an enlarged prostate on rectal examination. The best position both for patient and examiner is with the man lying on his back with the knees and hips flexed. The gland can be felt with the sensitive pulp of the right index finger and the left hand can be used to press down above the symphysis and make the examination bimanual if the bladder is not too full. The size, consistency, mobility and tenderness of the prostate must be estimated, and the presence of firm nodules or of infiltration assessed. The distinction between benign enlargement and early malignancy is often very difficult, but at a later stage the malignant prostate feels hard and fixed and extensions of growth can be felt at its upper lateral angles. Examination of the cardio-vascular system, the central nervous system, the abdomen, the external genitalia, and the urine must not be omitted. The differential diagnosis lies between prostatic obstruction, urinary infection, urethral stricture and the neurogenic bladder of tabes. It is not wise to pass a catheter solely to estimate the amount of residual urine; a knowledge of the exact amount is of little practical value and catheterisation opens the risk of introducing infection. The presence of urinary infection can generally be detected by inspecting and smelling the urine; its nature and the sensitivity of the infecting organism can be found by the bacteriological examination of a mid-stream specimen and medical treatment may then show that prostatectomy is unnecessary. If the symptoms are present but the prostate is not enlarged it may be necessary to pass a bougie in order to exclude or diagnose a stricture, and if there has been haematuria other causes of bleeding must be excluded by cystoscopy, but if the prostate is enlarged this is always done in the theatre immediately before operation. Cystoscopy when the 121 E. W. RICHES a) W Cd a1 _. _ O ) ;a W0 0 - ._ , ok 00co - a ) Q >V I:> 4 12< 0 *-4D CC. 0 I: I ) 0 r C ,U * oz _s, o0 bb 122 THE MANAGEMENT OF ENLARGED PROSTATE prostate is much enlarged is apt to cause fresh bleeding or to precipitate acute retention, and is not advisable for out-patients. This investigation should not be long delayed as 10 per cent. of patients with benign enlargement of the prostate and haematuria were found to have carcinoma of the bladder as well (Riches, 1954). Treatment If both symptoms and signs are present in sufficient degree, operation will be advised, and obstructive symptoms carry more weight than the others. A frequency of twice nightly alone is not sufficient justification for operation, but if the frequency is enough to disturb sleep or to regulate social or business activities operation is indicated. Fig. 2. Oval filling defect in the bladder caused by enlarged lateral lobes with no middle lobe. The left ureter is hooked. 123 E. W. RICHES Some patients can continue under expectant treatment. They must empty the bladder regularly, avoid all excesses and sudden changes of temperature, and particularly they must obey the call to micturate when it comes and avoid enforced retention. If expectant treatment is to be used the patient must be seen regularly; an intravenous pyelogram at the outset will give a good idea of the state of the bladder and kidneys and the quantity of residual urine (Fig. 1). Hormones have been used in treatment but with little success. Testosterone has a tonic effect on the bladder but none on the size of the prostate. Stilboestrol, so effective in malignant disease, has no effect on benign enlargement. Its use may disguise a carcinoma and frustrate early diagnosis. If carcinoma is suspected the serum acid phosphatase should be estimated before it is given. Group 2.-Casual Finding When prostatic enlargement is discovered as a casual finding in the course of a general examination for some other condition it does not necessarily mean that the prostate should be removed. If the main complaint is not urinary operation is probably unnecessary, but if there is a history of a recent hernia or piles associated with straining it is probably wise to operate. Leading questions about urinary symptoms are valid if signs are present, and an intravenous pyelogram may show confirmatory evidence of prostatic obstruction in the shape of hooking of the lower ends of the ureters or a filling defect in the bladder base. The alteration in the angle of entry of the ureters into the bladder is valuable as an early sign of upper tract obstruction. An oval filling defect in the bladder base is, however, more often caused by enlarged lateral lobes, which can be felt per rectum, than by a middle lobe projection which cannot (Fig. 2). In the latter case the filling defect is more localised, and a flattened bladder base may be produced by subtrigonal enlargement (Fig. 3). Group 3. Acute Retention Occasionally acute retention is the first symptom of prostatic obstruction, but more often there are some preceding symptoms although the patient does not mention them. The most frequent exciting cause of acute retention is enforced holding of urine when the bladder should be emptied. A long train journey without access to a lavatory acts in this way, and a long car drive in the winter in the company of ladies should be avoided by a modest man. The detrusor muscle becomes overstretched and cannot overcome what may normally be a minor degree of obstruction. During the war we saw many cases of " shelter retention." A sudden move from a hot room into the cold night air, especially after a good dinner may also precipitate retention when the prostate is already enlarged; alcohol in excess may promote a rapid diuresis and cause the patient to forget to empty his bladder. Campbell Begg (1954) has recently 124 THE MANAGEMENT OF LNLARGED PROSTATE Fig. 3. Filling defect produced by middle and lateral lobe enlargement with subtrigonal hypertrophy. The ureters are hooked. drawn attention to the frequency of acute prostatitis as a cause of acute retention and to the dangers of immediate prostatectomy for this condition. Prostatic retention must be diagnosed from stricture or an impacted calculus in the urethra. This may involve the passage of a urethral bougie or catheter. Acute retention is a painful condition and the first desire and duty of -the doctor is to relieve the pain. This can best be done by removing the 'cause, that is, by emptying the bladder, and the rational way to do it is by passing a catheter. The patient's agreement to go into hospital should first be obtained. One attack of retention is the precursor of others and 125 E. W. RICHES is an indication for operation. Occasionally one catheterisation will restore micturition, but more often the retention recurs and repeated catheterisation becomes necessary, and the more often it is repeated the more certain becomes the introduction of infection with all its sequelae. In acute retention there is no need for slow decompression of the bladder. There is always need, however, for skill and gentleness in passing the catheter; trauma to the urethra is more serious than infection and must be avoided at all costs. The best catheter to use is a small stiff rubber Tiemann's which can be boiled or a gum-elastic bicoude which can be kept sterile in formalin vapour and rinsed before use. The newer plastic catheters of similar shape have much to recommend them; they can be boiled and they retain their smooth surface longer than a gum elastic. Never use a rough catheter or use a catheter roughly. If the doctor is not skilled in catheterisation it is better to empty the bladder by the more tedious method of suprapubic aspiration with a lumbar puncture or serum needle. It should be inserted well above the pubes and passed in a downward and backward direction. In some clinics the use of the catheter is forbidden and cases of acute retention are treated by immediate prostatectomy, the pain of retention being relieved by morphia until operation can be arranged. This method permits of only the minimum pre-operative investigation and treatment, but is a useful one under suitable conditions. It entails " a full time urological service backed by radiological and pathological facilities throughout the 24 hours" (Fergusson, 1952). It is the practice in my clinics for the pain of acute prostatic retention to be relieved by suprapubic aspiration or a single catheterisation; the patient's general condition is assessed, his blood urea estimated, and an emergency intravenous pyelogram done. Prostatectomy is then carried out before the bladder has had time to fill again unless some contra-indication is found. In this way " midnight operations " are usually avoided. In most instances one finds that the patient has already been catheterised before his admission, but a one-stage prostatectomy under antibiotic and chemotherapeutic cover is still safe. The sharp differences of opinion in the use of the catheter amongst urological surgeons throughout the country were shown by the correspondence in the British Medical Journal starting on December 6th, 1952, and continuing until March 7th, 1953. All the writers, however, were agreed on the fundamental need of avoiding infection. Group 4.-Chronic Retention. The term " Chronic" implies that the retention has been present for a long time and in this condition there is little or no pain; the patient may be quite unaware of his grossly distended decompensated bladder (Fig. 4). The condition, however, is more serious than acute retention; long continued back pressure will damage the kidneys, and renal tissue whichislostcan neverbe replaced. Symptoms of uraemia may mimic those 126 THE MANAGEMENT OF ENLARGED PROSTATE of gastro-intestinal disease; loss of appetite, dryness in the mouth, loss-of the sense of taste, loss of weight, constipation, nausea and vomiting are amongst the common complaints. Drowsiness by day, sleeplessness by night and mental changes are the precursors of uraemia, and if the urine Fig. 4. Chronic retention with overflow. There is enormous distension of the bladder, hydronephrosis on the right side and no excretion on the left. The patient had been catheterised before admission and the urine was infected. Good recovery after two-stage prostatectomy although the bladder remained atonic for some weeks. is also infected the outlook is most serious. The bladder is full and there may be overflow incontinence. The finding of albumen in a clear urine is an indication of renal damage. In chronic retention do not pass a catheter; there is no pain to relieve and the sudden emptying of a bladder distended for a long time may 127 E. W. RICHES produce such changes of pressure in the kidneys as to give rise to their flooding with arterial blood and blockage of the tubules. Haematuria is followed by gradual anuria and death in uraemic coma. The damaged kidneys are more susceptible to infection and acute pyelonephritis may supervene on catheterisation and cause death; it is difficult to see how it can cause the rapid onset of the renal bleeding which sometimes occurs and this must be a decompression phenomenon. It is remarkable how well such patients may get along until someone interferes with them. The worst treatment of all is to empty the bladder by catheter and allow it to fill again; any drainage established must be maintained until prostatectomy. The patient should be sent into hospital where full blood chemistry estimations are made. His treatment there will vary with the views of the surgeon. If the blood urea is less than about 100 mg. per 100 ml. and the intravenous pyelogram shows some excretion, and the urine is not infected and the general and cardio-vascular conditions are satisfactory it is our practice to do a one-stage prostatectomy. If any one of these conditions is not fulfilled, we prefer to drain the bladder first, but a poor general condition is a more potent reason for drainage than a poor renal function. When the patient is first seen it is impossible to forecast how long drainage will be required; prolonged drainage by urethral catheter inevitably leads to infection in a closed bladder, and when drainage is needed we therefore prefer to insert a small (16F) suprapubic catheter. It is put in obliquely from a point well above the pubes and gives a watertight fit (Riches, 1943). The bladder is decompressed over a Kidd's U-tube for 12 hours and then allowed to drain freely into a bottle containing formalin (4 ozs. of 10 per cent. solution). The air inlet to the bottle is protected by a filter containing formalin tablets (Fig. 5). When the general condition has improved and the blood urea is stabilised, even if it is still above the accepted normal, prostatectomy is performed. The high insertion of the catheter leaves a virgin field through which the operation can be done with adequate exposure. Associated Medical Conditions affecting Treatment Acute retention may supervene on a mild degree of chronic retention in patients who are confined to bed for some other illness such as cardiac failure or pneumonia. The use of a mercurial diuretic in such a case is often the precipitating cause of retention. These patients are unfit for immediate prostatectomy and must have a period of drainage during which their medical treatment is continued. For them the small suprapubic catheter is life-saving; it can be inserted under a local anaesthetic. Apart from those in whom the urinary symptoms become acute many of these patients have more or less serious medical conditions which require investigation and treatment. Allanby (1952) investigated a series of my prostatic cases and recorded the results in more than 100. He pointed out the benefits accruing from delaying operation until the men could be 128 THE MANAGEMENT OF ENLARGED PROSTATE properly investigated, given breathing exercises and made as fit as possible. The absolute contra-indications for prostatectomy from the cardiovascular aspect are cardiac failure until compensated, cardiac ischaemia due to coronary artery disease, very recent coronary thrombosis (within six weeks) or recent symptoms of cerebral arterio-sclerosis, and syphilitic aortitis with incompetence. Many of these patients can be made fit for prostatectomy by medical treatment during a period of suprapubic drainage. Hypertension, valvular disease without incompetence, and arrhythmias are not considered contra-indications, and operation has not been forbidden on account of respiratory disease alone. There may be seasonal reasons for deferring operation in a patient with bronchitis or r OARMALIN. TABLETS whAPPED IN GAuIfE. 4- 40 IoPOdLI Fig. 5. Antiseptic drainage bottle for indwelling catheter, whether suprapubic or urethral. emphysema, and one would not operate in cases of active pulmonary tuberculosis, carcinoma of the bronchus or pulmonary failure. A diabetic should be stabilised before prostatectomy. Scorer (1953) treated 150 patients with retention by suprapubic catheterisation and stressed the value of the method in the older men desperately ill in a medical ward. There is rarely need for a formal suprapubic cystostomy but if it is done let the catheter enter well above the pubes and run obliquely down to the bladder with a watertight junction. The low suprapubic tube entering just above the symphysis and passing straight into the bladder from the lower end of a long vertical incision should never be seen, although it often is. It leaks and smells and leaves a scarred field for the second stage of the operation. 129 10 E. W. RICHES The Surgical Treatment To return to the one-stage operation which is used in the majority of cases there are some important points which are applicable whether the retropubic operation of Millin (1945) or the Harris operation (1934) or Wilson Hey's method (1945) is used. I prefer the retropubic route because it gives the best exposure of the prostatic cavity. The same care is needed before transurethral resection. Pre-operative Tests The preliminary tests of renal function done in every case are the blood urea, and an intravenous pyelogram, unless the blood urea is more than 100 mg./100 ml. when there will probably be no visible excretion. A urine concentration and dilution test is also performed in doubtful cases. A general examination is made by a physician; this includes an electrocardiograph in most cases. Operation A transverse skin incision gives adequate exposure and heals more kindly than a vertical. The most important part of the operation is the removal of the prostate; it should not be hurried but should be done gently and with care to preserve the mucous membrane from the verumontanum downwards (see Figs. 2 and 3). The main arterial vessels entering at the postero-lateral angles should be secured or sealed by diathermy before they are divided, and bleeding should be controllable without the use of any form of pack. The trigone, which forms a shelf between the bladder and the prostatic cavity, should be widely resected, and the raw area remaining closed by sutures of fine plain catgut. This will expedite the complete re-epithelialisation of the cavity (Fig. 6). Any urethral catheter used for drainage should be anchored by a sling stitch passed through the abdominal wall rather than by stitches to the penis. A plastic catheter seems less liable to produce a urethral stricture than does a red rubber one; it should rarely exceed size 20 (F). The catheter should drain to a formalin bottle (Fig. 5) and should be removed as early as possible; 48 hours is generally enough. Any true diverticulum present should be excised at the same operation (Fig. 7). Bilateral vasotomy should be performed. Post-operative Care Cover against infection is given by penicillin, 300,000 units twice daily, and sulphadiazine, 0 5 g. four times daily, for five days unless there is some specific infection present which is sensitive to other substances. A fliud intake of five pints a day is aimed at. Liquid paraffin is given from the second day, with an added aperient such as cascara on the second evening. 130 THE MANAGEMENT OF ENLARGED PROSTATE -4 Fig. 6. Autopsy specimen from a patient who died from pulmonary embolism 16 days after retropubic prostatectomy The bladder neck has healed. The patient is allowed up after 48 hours; he uses a commode rather than a bedpan. During the first 12 hours gentle irrigation of the catheter by a modified Canny Ryall syringe using sodium citrate (3-8 per cent.) may be necessary to keep the catheter clear of clots Routine irrigation of the bladder is not practised. Complications Most patients now leave hospital about two weeks after operation, but it takes up to two months for the prostatic cavity to heal. In consequence there may still be some frequency or other evidence of urinary infection at this stage. As a course of sulphonamide and penicillin and -possibly other antibiotics has already been given it is better to use a milder urinary antiseptic if further treatment is considered necessary. An acid urine is better than an alkaline and hexamine is more useful than potassium citrate. 131 10-2 E. W. RICHES Epididymitis is generally prevented by ligature of the vas, but still occurs in a few cases. It takes a less severe course than when the vas has not been tied, and it is treated by rest and support; its occurrence may be an indication for further chemotherapy. Osteitis pubis, an infective complication, is fortunately rare; it produces prolonged disability but some cases are said to have been relieved quickly by cortisone. If the bladder has been over-distended for many weeks before operation it may remain atonic; in such a case daily catheterisation may be necessary, combined with Carbachol (oral) 1 tab. b.d. and testosterone linguets, 10 mg. daily. Fig. 7. Chronic retention with a diverticulum of the bladder and reflux up the left ureter. The diverticulum was excised at the time of prostatectomy. 132 THE MANAGEMENT OF ENLARGED PROSTATE Fig. 8. Atonic bladder persisting for two years after prostatectomy in a case of long-standing chronic retention. A few of these cases are improved by an extensive partial cystectomy. Fig. 8 shows the bladder nearly two years after prostatectomy; it held a gallon before operation and despite preliminary drainage has never recovered its tone. Chronic retention with overflow had been present for a long time and this man is going to have a partial cystectomy. Post-prostatectomy obstruction at the bladder neck is less common with the modern practice of trigonectomy; it is treated by endoscopic 133 E. W. RICHES resection. A meatal stricture sometimes occurs. If there is a diminution in the stream it is wise to pass a metal bougie. Incontinence is rare and usually transient after open operation for benign enlargement. Conclusions Without attempting to assess the relative merits of transurethral and open operations one can say with certainty that the results of prostatectomy have improved greatly during the past ten years. The ability to close the bladder rather than leave in a large drainage tube has shortened convalescence and made it less uncomfortable. Good results, however, depend on the absence of infection and gross renal damage. The mortality is about 4 per cent. and is mainly due to medical conditions. The mortality is doubled in cases of retention; catheterisation in these cases introduces the risk of infection and should be avoided or limited to one act. An indwelling urethral catheter is almost always followed by infection and although prostatectomy may still be safely accomplished, the incidence of post-operative complications is increased. Where drainage for more than two days is likely to be needed the small high suprapubic catheter has many advantages over the urethral catheter. There is still a place for the two-stage operation; the indications for it are medical conditions, gross renal damage and serious urinary infection. REFERENCES ALLANBY, K. D. (1952) Arch. Middx Hosp. 2, 162. BEGG, R. CAMPBELL (1954) Lancet 1, 340. FERGUSSON, J. D. (1952) Postgrad. med. J. 28, 35. HARRIS, S. H. (1934) Brit. J. Surg. 21, 434. HEY, W. H. (1945) Brit. J. Surg. 33, 41. MILLIN, T. (1945) Lancet 2, 693. OGIER WARD, R. (1953) Modern Trends in Urology (Edit. Riches) p. 248, London, Butterworth. RICHES, E. W. (1943) Lancet 2, 128. (1954) Trans Med. Soc. Lond. (In the press). SCORER, C. G. (1953) Lancet 2, 1222. DIARY FOR AUGUST There will be no lectures at the College during August. DIARY FOR SEPTEMBER Wed. Thurs. Wed. Wed. Mon. Tues. 8 9 15 22 27 28 Second L.D.S. Examination begins. College closed for Staff Outing. Pre-Medical Examination begins. First Membership Examination and D.C.H. Examination begin. D.Orth. Examination begins. Surgical Lectures and Clinical Conferences begin. Final Membership Examination begins. 134