Kulov, N.

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REVIEW OF THE RESULTS IN FIFTY PERINEAL PROSTATECTOMIESN. KulovIn the past several years it has been almost universally accepted that rgical behaviour was the method of choice in treatment of adenoma of the ostate. However, there still exist controversial statements insofar surgical iproaches are concerned. Seiler and Lanz, based on experience had with )2 prostatectomies carried out after the Harris-Hrinchak method, advocate le transvesical approach (quoted by 4, page 93). L. I. Dunaevski in his eatise on the prostate adenoma lends further support to the superiority of le transvesical access (1). At the same time, an other group of authors ke Turner and Best, proceeding from the analysis of results in 1694 pro- atectomies, carried out according to the perir.eal method, claim that the tter has considerable advantages, namely: low mortality rate, prompt covery with reduction of hospitalization terms (bed-days), few compli- itions and very good functional results (according to 5, page 84). This ethod is not widely spread, but yet there are authors (A. A. Chayka, A. Y. amski, Goldstein, Rvasini, Rizzi, Pisani and Enfedjiev in Bulgaria) insidering it very efficient, but with rather limited indications (quoted 3, page 121). By virtue of the fact that the problems related to the ope- tive management of the prostate adenoma continue to surge scientific terest, we wish to describe herein the immediate and late results of fifty ?rineal prostatectomies.Material and methodsSixty five patienfs with adenoma of the prostate were admitted for treat- ent in our surgical unit over a period of 5 years; 50 were operated on after l e  perineal method. As far as age is concerned the patients are distributed in l e  following manner: from £0—60 years — 4 patients, 60—70 — 25 pa: ents, 70—80 — 18 patients and 80—90 — 3 patients. The patients were irther divided into groups according to duration of the disease: 20 cases — years, 15 — 3 years, 10 — 4 years and 5 — more than 5 years. Of the total amber of 50 patients, 25 were admitted with dysuric troubles, with some of lem having a single time acute retention of urine. The remainder 25 pa- ents were admitted with complicated clinical picture: seven of them with :ute retention of urine, six with vesical calculi and frequent hemorrhages, ght — with infectiors of the urirary tracts, three — with diabetes and one — ith leukemia. The bac'terial agent in the majority of cases with infected uri- iry tracts proved to be Bact. coli, and very seldom — staphylococci and1 3 8 N. Kulov 2streptococci. The functional state of the kidneys was insatisfactory in six patients. In the latter group, the content of residual nitrogen in the blood exceeded the normal value, reaching in individual cases 80 mg %. In in­stances when the index was higher than 100%, mandatory treatment with anticoagulants was carried out until reduction of the index to 60 —70% was secured. Prior to surgical management, all patients with proved uroinfection, intoxication or obstruction of urine flow (stasis) were subjected to preopera­tive preparation. They were given antibacterial drugs as antibiotics, sulfa- nilamides, nitrofurazone preparations, depending invariably on the flora found. Thus, after medication of the bladder and the urinary tracts, and after improving the function of kidneys and cardiovascular system, the patients were subjected to operation. All interventions were carried out under intra- spinal anesthesia. Operation was performed through the perineal access after the Kirschner-Pfaumler method with a slight technical modification, suggested by the authors. It consists in the following: after enucleation of the prostate adenoma and performing the urethral plasty over a catheter, the anterior flap of the prostate capsule is invariably sutured to the bladder neck together with the urethral flap, whereas the posterior flap of the cap­sule is shifted quite a way off anteriorly and accordingly sutured. The tech­nical improvement described provides for the complete elimination of the cavity resulting from the enucleation of the prostate adenoma, and further­more, no pulling is exerted at the site of urethral plasty. After suturing the capsule in the manner just described, we insert, in all instances, a polyethy­lene tube for drainage, opening into the extracapsular space and remove it on the second postoperative day. The urethral catheter is usually removed on the 10th day after the operation.Results and DiscussionOf the total number of patients operated upon, three died — two of pulmonary embolism and one of pneumonitis, accompanied by phenomena of acute cardiac failure. In the remainder the postoperative period was une­ventful. Thus, on the basis of personal experience, it is assumed that uro­sepsis does not appear to be an essential factor for the lethal outcome. Our experience shows that the minimum term for the complete healing of wounds is 14 15 days, and in exceptional cases — up to 10 days. The preoperativecystitis observed in 8 patients subsided after the intervention. Restoration of free miction in these cases led to rapid, spontaneous cure of the cystitis as early as the initial three months. Cystitis persisted merely in one case with heavy diabetes; it was favourably influenced only after combined treat­ment was applied, but with frequent exacerbations. The following compli­cation was noted in the early postoperative period: persistent incontinence of urine in one patient in whom no great effect was marked even after resor­ting to adequate tonicizing therapy. For the appraisal of the late functional results, 47 patients were followed up from 6 months to 5 years after the ope­ration. The check-up examination in 46 patients showed: free miction, without residual urine; in three the residual urine amounted to 150 cc. Sphincterocystotonometric tests were not performed with our series; it is worth mentioning however, that in three patients it was carried out for3 Review of the Results in Fifty Perineal Prostatectomies 139complaints of diabetes. In all three patients, the cystotonometric curve was distinguished by data for bladder atony, hardly influenced by the tonici­zing therapy undertaken. Cases with development of stricture necessitating bougienage or resection were not observed, nor was sclerosis of the bladder cervix observed during studying of remote results. Some of the findings worth of special mentioning are that after the peritoneal operation flail anal reflexes, reduced tone of the anal sphincter and reduced sensibility of the entire anal region were established in almost all cases. The problem concerning loss of sexual potential was investigated by the authors with particular attention. No due consideration is given to this problem in the literature. In our series, 10 out of a total of 50 patients were with preserved preoperative sexual potency. Sexual impotence occurred in seven following perineal prostatectomy. Although the latter fact may be underestimated by some of the supporters of the perineal method, it is doubtlessly one of the mosi essential shortcomings of the method.Inferences1. We feel that infected urine, diverticula, neoformations, the large cal­culi in the urinary bladder, the augmented prostate, the insufficiency in renal function as well as the properly preserved sexual potency are all contra­indications to the use of the method described.2. Considering the relatively good postoperative results, anyway, secu­red by the creation of a normal continuity between the bladder and the urethra (by means of sparing the sphincters), we believe that perineal prostatectomy, though difficult technicalwise, might be applied in a restricted, carefully selected group of patients, in whom all the conditions required for one-stage prostatectomy are present.R E F E R E N C E S1. Д  у н а е в c к и, Л. И. Аденома предстательнон железм. Медгиз, 1959, 259.2. Е н ф е д ж и е в, М. Простатата, клиника и терапия на простатните заболявания,Д. И. Наука и изкуство, 1955, 175.3. С а б е л ь н и к о в, И. И. Гипертрофия предстательной железн. Г. И. Медицин-ском литератури, 1963, 121.4. S е i 1 е г, S t. и. L a n z .  О надлобковой трансвезикальной предстатектомии по Гаррис-Гринчаку. Schweiz, nied. Wschr., 1957, № 1, 13—17; реф. — Урология, 1958,4, 93.5. Т u r  п e r ,  R. D. a n d  B e s t .  Анализ 1694 случаев промежуточной простатек-томии по поводу аденоми простати. Jour, of Urology, 1957, т. 77, № 6, 853 863. Реферат — Урология, 1958, 6, 84.140 N. Kulov 4РЕЗУЛЬТАТЬ! 50 ПЕРИНЕАЛЬНМХ ПР0СТАТЗК0МИЙН КуловР ЕЗ ЮМЕАвтор делает разбор близних и отдаленннх послеоперативннх ре- зультатов 50 простатзктомий, сделанннх пометоду Киршнера-Пфлаумера, внося при зтом собственное улучшение в технику. Функциональньге ре- зультатн оцениваются как хорошие, но в то же время указьтается и на существеннне недостатки метода, как потеря половой потенции, умень- шение тонуса анального сфинктера, вял не анальнне рефлекси, понижен- ная кожная чувствительность перианальнон области.

REVIEW OF THE RESULTS IN FIFTY PERINEAL PROSTATECTOMIES

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REVIEW OF THE RESULTS IN FIFTY PERINEAL PROSTATECTOMIES

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