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the bladder drawn up and opened sufficiently to admit one or two fingers, and the
prostate enucleated in the usual way with either the forefinger or the fore and
middle fingers of the right hand. The enucleation is made very much easier if the
prostate is pushed up from the rectum by two fingers of the left hand. I have
never found this lead to any sepsis, though if I have to insert the fingers of my left
hand in the rectum I leave the assistant to close the wound. After the prostate
has been separated, it is either withdrawn from the bladder whole or split up inside
the bladder in two pieces if it is very large, a big opening in the bladder being thus
avoided, because a small incision through the bladder wall promotes rapid closing.
When the prostate has been removed the bladder is irrigated for two or three minutes
with mercury oxycyanide at 120 degrees to check haemorrhage. A large tube f inch
in diameter is inserted into the bladder and is so placed that it is about 1 inch off
the base and is sutured to the skin to keep it in this position. The swab holding
back the peritoneum is now removed. While the wound is being closed the
irrigation with hot antiseptic fluid is continued through the large drainage tube.
The catgut slings are tied together round the tube, and this is usually sufficient to
close the opening in the bladder wall, but if it is not so, the bladder must be sutured
snugly round the tube. A small tube is placed in the prevesical space behind the
pubes and the wound closed, the rectus sheath by one or two interrupted catgut
sutures and the skin with one or two salmon gut sutures. The irrigation is then
stopped and the wound dressed.
In the two-stage operation the first stage merely consists in the insertion of a
de Pezzer self-retaining catheter to drain the bladder. The second stage only
differs from the operation described above in that a scalpel is inserted through the
sinus into the bladder and cuts down on to the pubes.
The bladder is irrigated through the tube four hourly during the patient's
waking hours for the first 24 hours if there is bleeding, otherwise only twice, and
after that daily. The prevesical tube is removed after 48 hours, the large tube
from the bladder on the fifth day. The daily irrigations are continued through the
sinus until it is too small for the fluid to escape properly. Acid sodium phosphate
and hexamine are continued as before operation and large quantities of bland fluid
are given to drink. No Hamilton Irving apparatus is applied, but the wound is
dressed with sterile gauze which is changed as soon as it is soaked through, and if the
wound becomes at all sloughy it is filled with boracic crystals. It is not necessary
to keep the patient in bed for more than a week, though as the patients are liable
to be very wet with this method of dressing they are more comfortable if kept in
bed until the sinus is healed. The patient usually passes urine normally from the
tenth to the fifteenth day after operation ; if he has not done so by the twenty-first
day a catheter is passed. This was only necessary on two occasions, and in each
case a diaphragm had formed as mentioned above. The suprapubic sinus is usually
closed not later than the end of the third week. There were no cases of abnormal
haemorrhage. There were no cases of septic complications except one very mild case
of epididymitis.
Aftertreatment.
The feature of this technique is the fact that a catheter is not passed from start
to finish of the case, unless it is absolutely necessary by reason of retention of urine
before operation or failure to pass urine by the twenty-first day after operation.
Nor is a haemostatic bag inserted to check haemorrhage, but reliance is placed upon
irrigation with hot antiseptic fluid. It seems from this series of cases that sepsis
with its grave complications is due, not to the bruising resulting from the fingers in
the rectum pushing up the prostate, but from the insertion into the bladder of
foreign bodies, such as catheters and Pilcher's bags. It is true that this is only a
small series, but, even so, the mortality of 1.6 is remarkably low, and the percentage
of septic complications 1.6 is also far below that of any previous recorded series.
Commentary.
A series of 63 cases of suprapubic prostatectomy is recorded with a mortality
of 1.6. The one fatal case died one month after operation from heart failure.
Technique differs from that usually adopted in the fact that a catheter is never
Summary.