The choice of operation

Abstract

THERE are four different operative approaches to the prostate-transurethral, suprapubic or transvesical, retropubic, and perineal. TRANSURETHRAL PROSTATECTOMYTransurethral procedures were initiated more than a century ago, but the techniques as we know them today date from the early 1930's. TWO principles of transurethral prostatic surgery are currently applicable. One employs a wire loop activated by a highfrequency current to cut tissue, while the other utilizes a tubular steel knife for the purpose. There is gcneral agreement that obstruction due to a fibrotic prostate or to a prostatic carcinoma is best dealt with by endoscopic resection. A preoption for the electrically activated wire loop or for the cold knife punch as the apparatus for resection is a matter of personal preference. T o become a proficient resectionist requires long and patient practice, and once the facility has been acquired, the urologist usually elects to continue with the instrument to which he has become accustomed.If there is acceptance of the absolute indications for the transurethral approach, there is wide variation of opinion and practice on its use in the treatment of obstruction due to the adenomatous gland. At several centres in this country, and in a proportionately greater number in North America, transurethral resection has taken command and is employed for prostates of up to 100 g. or more in wcight-over 90 per cent of patients receiving this form of treatment. Other exponents elect for open operation if the gland is estimated to be more than 40 or 50 g. The procedure becomes technically more difficult with the increase in the amount of tissue to be removed. The laborious extirpation of large prostates by morcellation can be a time-consuming exercise for the patient as well as for the surgeon, and cannot be classed as a minor procedure.Initially I included in the scope of resection, for which I have always used the loop electrode, the smaller varieties of adenomatous glands and, rarely, larger ones when the patient was considered to be an especially poor operative risk. But now I reserve resection for the fibrous gland, the sclerotic bladder neck, and the malignant obstruction. I no longer consider the transurethral operation safer than open operation for the adenomatous gland and therefore offering advantages to the aged and debilitated. The advancements in the techniques of open operation combined with an awareness of the importance of asepsis in prostatic surgery and in the control of infection, the facility to compensate blood-loss by transfusion, and prcsent-day anaesthesia permit the use of the operative method most suited to the type of prostate causing the obstruction. SUPRAPUBIC PROSTATECTOMYThe transvesical approach continues to be systematically used by many surgeons. The work of Walker greatly influenced the development of suprapubic prostatectomy in the 1920's. Measures to combat haemorrhage and infection were much less effective then than now, and there was but little knowledge of the significance of fluid and...