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SUPRAPUBIC PROSTATECTOMY.
By K. F. D. Waters, B.A., B.M., B.Ch., F.R.S.S. (Edin.), Deputy Medical
Superintendent, St. Stephen's Hospital.
Suprapubic prostatectomy is an operation which is so frequently necessary in
elderly men, whose general health is usually poor, that any modifications of
technique, which reduce the mortality and the incidence of complications, especially
of sepsis, become of great importance.
The cases on which this paper is based number 63. They were consecutive
cases and entirely unselected. The youngest patient was aged 48, and the eldest 82,
and there were three others aged 80 or more ; 29 of the patients were 70 or over,
and the average age was 67.5. There was one death from heart failure one month
after operation; and only 3 cases had complications. One developed a slight
epididymitis, which soon subsided, and the other two, diaphragms across the
internal urinary meatus. These were easily relieved by the passage of a metal
catheter.
Preliminary
investigation
The blood urea was always examined and if it was over 50 a two-stage operation
was performed. If retention of urine was present, it was relieved by tying in a
catheter, and 15 ozs. of urine were drawn off every 4 hours until the bladder was
empty. The bladder was washed out twice daily with mercury oxycyanide 1 in
4,000 both through and alongside the catheter to prevent the urethritis which
otherwise occurs. The catheter was removed as soon as the patient was able to
pass urine normally. Every patient was given a 10-day course of acid sodium
phosphate and hexamine, and saline aperients. When catheterization was
necessary to relieve retention the blood urea was not determined until the end of
10 days. At the end of that period every patient who still had cystitis or blood
urea over 50 had the operation performed in two stages, the bladder being drained
until the cystitis cleared and/or the blood urea fell to within normal limits. During
this period, also, attention was given to the general condition of the patient. Chronic
bronchitis was treated by ammonium carbonate and belladonna mixture, and
myocardial weakness by digitalis.
Technique.
The night before the operation the patient was given 7 to 10 grains of medinal
to ensure a good night's rest. On the day of operation an injection of 1 c.c. of
omnopon or grain of heroin was given one hour before operation. Immediately
before operation grain 1/6 of ephredine was given intramuscularly, followed in two
minutes by spinal anaesthesia by means of 1.5 c.c. of stovaine or 12 c.c. of percaine.
Spinal anaesthesia was always used because of the perfect muscular relaxation
obtained, of the absence of shock, and of the fact that many of these patients were
not suitable subjects for general anaesthesia.
The bladder was never distended with fluid before operation in order to avoid
the passage of a catheter, as the ideal was if possible to operate on the case before
ever a catheter had been passed, though of course this was not possible in a case
that had retention of urine.
A 3-inch incision was made above the pubes just to the left of the mid line,
its exact situation depending upon whether the operation was to be done in one or
two stages. In a one-stage operation the incision began over the pubes and
extended upwards for 3 inches ; in the two-stage operation the incision began 1 inch
nearer to the umbilicus, the reason for this being that when the second stage was
done, sometimes weeks later, only a small sinus surrounded by scar tissue was left,
and by incising directly downwards from the sinus to the pubes there was no fear of
opening the peritoneum. It was found to be unnecessary to excise the scar tissue
round the sinus as the wound healed perfectly without so doing. After the skin
incision the anterior rectus sheath was incised just to the left of the mid line, the
rectus drawn outwards, and the finger inserted in the lower end of the incision and
the prevesical fat and peritoneum swept upwards with a swab and pushed out of the
way under the upper end of the wound, being kept in place there by the swab. The
bladder was thus exposed and two catgut slings inserted through a bloodless area,
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