Brukin, Morris

van den Bulcke, C.

English

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17 May 1969 S.A. MEDICAL JOURNAL 583SUMMARYCongenital hepatic fibrosis is a rare cause of otherwise unex-plained hepatomegaly and portal hypertension in children andyoung adults. The recognition of the disorder is of importancein that these patients would be suit::.ble candidates for porta-caval shunts since liver function is usually very ;:dequate. Thefamilial occurrence· noted in several instances indicates thep.eed for investigation of the family of the affected proband.The G.se reported here was diagnosed only at autopsy, butsubsequent investigations of the family hr-ve shown 2 memberswith pyelographic findings suggestive of congenital cystickidneys and one with a raised alkaline phosphatase levelwhich may indicate underlying liver disease.We wish to thank Dr J. O. Burger, Medical Superintendentof Oraote Schuur Hospital, for permission to publish. Thiswork was supported in the University of Cape Town by theCSIR.REFERE 'CESI. MaeMahon. H. E. (t929): Amer. J. Path .. 5. 499.2. Kerr. D. N. S.. Harri,on. C. ., Sherloek. S. and Walker. R. M.(1961): Quart. J. Med.. 30. 91.3. Campbell. G. S.. Biek. H. 0 .. Paulsen. E.. Sober. P. H.. \Vatson.C. J. and Vareo. R. L. (195): 'ew Engl. J. Med.. 259. 904.4. Van der Schoot. J. B. (1955): 'ed. T. Geneesk .. 99. 2579.5. Ivemark. B. T .. Oldfelt. V. and Zetterstrom. R. (1959): Acta paediat.(Uppsala). 48. I.6. Kerr. D. N. S.. Warriek, C. K. and Hart-Mercer. J. (t962): Clin.Radial.. 13. 5.EXPERIENCES WITH NO-CATHETER PROSTATECTOMY*MORRIS BRUKIN, M.B., B.CH. (RA!'m), F.R.C.S. (EDIN.) AND C. VAN DEN BULCKE, Urological Registrar, AddingtonHospital, DurbanThe challenge of finding the ideal form of prostatectomyhas produced a variety of approaches with staunch pro-tagonists of each. No single procedure, however, willprove ad:q uate for the \ ariety of pathology encountered,and the surgeon must be equipped to deal with all types.The ideal operation' must secure complete removal notonly of all existing obstruction, but also of all potentiallyobstructing tissue, minimal mortality, easy convalescenceand rapid return to normal health and urinary function.The operation, moreover, should not be outside the scopeof any urologist.We employ the standard retropubic procedure, omittingthe use of a catheter. This omission eliminates a potentcause of infection and morbidity that so often accom-pany catheter drainage.This procedure is not original and has been describedby Debenham and Ward' (81 cases), Hickinbotham et al.'(106 cases), Macalister' (299 cases), and Spencer' (132cases). In our series of 70 cases selected for no-catheterprostatectomy some modifications have been introduced,the most important of which has been the use of normo-tensive anaesthesia, in contrast to the hypotensive anaesthe-sia employed by the previous authors. We are so impressedby the lowered morbidity, minimal demands on post-operative nursing care and easier convalescence, that wewish to report our results.METHODAnaesthesiaOur first case was a patient of 83 years, who was hyper-tensive with a blood pressure of 210 / 110 mm.Hg. Inaccordance with the procedure recommended by the pre-vious authors, we requested our anaesthetist to employhypotensive anaesthesia. However, the patient instead. received a routine Pentothal, gas and oxygen anaestheticwith muscle relaxants, and this has been the pattern inmost cases. Choice of anaesthetic has always been left tothe discretion of the anaesthetist, and a hypotensive tech-nique has never been employed. We have not encounteredany anaesthetic complications, despite the old age (Fig. I)and the high blood pressure (Fig. 2) of the patients in ourseries.'Date received: 20 August t968.9Operative TechniqueA straightforward retropubic prostatectomy is done.Obvious b:eeders in the prostatic fossa are usualiy access-ible and are coagu'at~d. A co ti:1Uous ha-omostat'c sutureapproximates the bladder neck down to the prostaticfossa. This usually controls most of the blefdim': andavoids undermining the trigone, a point which facilitatespassage of a catheter into the bladder should this becomenecessary in the postoperative period. This suture mustcarefully avoid the neighbouring ureteric orifices. Thisensures that any transient postoperative anuria is not dueto occlusion by the suture. A urethral catheter is insertedinto the bladder before closure of the anterior prostaticcapsule. After closure a thorough bladder wash-out isperformed to assess the amount of active bleeding thatmay be occurring, and the watertightness of the capsularclosure. It is then possible to decide whether the cathetershould be removed or not. If judgement indicates asuitable case, the catheter is withdrawn after about 40 m\.of water have been instilled. A latex tube drain is left inthe retropubic space, the open end of which receives asmall rubber suction bulb.Postoperative RoutineIn order to ensure an adequate diuresis, intravenousfluids are administered until such time as the oral fluidintake is adequate. An appropriate antibiotic is adminis-tered from the outset. For analgesia, Omnopon or pethidineis prescribed. A blood pressure and pulse chart arerecorded half-hourly and then hourly for the first 24hours, as indicated by the requirements of the situation.A urinal is placed between the thighs and over the penis.Samples of any voided urine are decanted into test-tubes and labelled with the time of voiding. Observationsindicate the degree of haematuria. The rest of the urinecan be discarded after measuring.The patient is encouraged to sit out of bed on the firstpostoperative day, and to walk around from the secondday. The retropubic bulb drain is checked hourly andemptied as necessary. The amount of drainage is alsocharted and an intake/ output chart is kept. The retropubicdrain is extracted 24 hours after cessation of drainage,usually by the 3rd postoperative day.17 Mei 1969Postoperaiive Spontaneous Mictu-ritionIt was our routine with the firstfew cases to strongly encouragepatients to void into the positionedurinal. This was probably bad poli-cy, as a few of the patients andsome of the nursing staff were pre-cipitated into a minor panic. Thepatients should rather be reassuredthat everything is fine. Somepatients feel a continuous desire tovoid but are unable to do so. Theonly help we give these patients isto sit them up over the edge of thebed, which often facilitates urina-tion for the first time. Fig. 3 indi-cates the range of time elapsing be-fore the first voiding, with a meanof 5-} hours. As long as the patientis not distressed by the continuouspain of a distended bladder, and aslong as there are no clinical signsof concealed haemorrhage, wehave resisted the temptation tocatheterize during the first 24hours. Ultimately, heavily blood-stained urine will be passed, theurine becoming clear betweenthe 2nd and 3rd postoperativedays.It is noteworthy that a clot n:-tention never supervened in thefirst postoperative days and thatthere were only 3 patients whopassed some very large blood clotsper urethra, painlessly and easilywithout straining. These clotscould never have been transmittedthrough an indwelling catheter.One of these 3 patients had asecondary haemorrhage on the10th postoperative day, with clotretention due to much smallerclots than described.SedationOne of the advantages of thisprocedure is the almost painlesspostoperative course. There are nocatheters to become plugged withobstructing clots, no painful blad-der wash-outs, and no bladderspasms. There is no necessity fordistending the prostatic fossa withan inflatable balloon catheter orfor leaving such a catheter in thebladder, sometimes on traction.The average requirement of pethi-dine during the whole postopera-tive period was only 100 mg.,despite the order for sedationwhenever necessary..B.t'.0. ge.systoliCoLia.stolic....I \I II \I \I \r--.J \I \" \'--"""\\\\'-:--,,'----\\\S.A. TYDSKRIF VIR GENEESKUNDE-to- 60 -to- 70 -to- 80 -to- 90Fig. 1. Age of patients in years.lOO 150 ~OO .t50Fig. 2. Blood pressure of patients.50506/5"/830I~10nUlflbor ofnumber ofpCLbcnts3658417 May 1969 S.A. MEDICAL JOURNAL 5857ghou~sPostoperative34315Pre-operative39256/4-TABLE I. BACTERIOLOGY OF URINE108Of patients with sterile urine pre-operatively, 25%acquired a postoperative urinary infection, probably dueto dissemination during enucleation of an already infectedBACTEIDOLOGY OF URINETable I indicates the numbers of patients with sterile urinepre- and postoperative1y. It will be seen that 75% ofpatients with sterile urine pre-operatively, remained sterilepostoperatively.to occlusion of the ureters by suture ligation. In- onepatient a catheter recovered only 100 ml., and the retro-pubic drainage was 100 ml. After 36 hours the total out-put was 360 ml., but thereafter diuresis occurred. A secondpatient had complete anuria for 36 hours, with a bloodurea rising to 91 mg./100 ml. Thereafter spontaneousdiuresis occurred without further complication. We havenot been able to investigate this phenomenon further, forby the time it was recognized the problem had resolved.Nevertheless, some anxious moments were endured.Retropubic DrainageThe average drainage from the retropubic space was135 ml. in the first 24 hours, with extremes of 0 - 970 ml.The average drainage during the second 24 hours was26 ml., witIr extremeliooQf 0 - 344-ml. Only when the amountof retropubic drainage exceeded the urethral output after24 hours was the catheter replaced, as this indicatedfailure of watertight capsular closure. The retropubic drainwas removed 24 hours after cessation of drainage.UrineSterileInfectedNot doneFig. 3. Time of postoperative micturition.63""mbe, ofpo.ti..nt,./0Transitory OliguriaWhen catheter prostatectomies with subsequent bladderwash-outs are performed, it is rarely possible to obtain anaccurate measure of urinary output during the first 48hours. A transitory oliguria or anuria can thus be masked;but it becomes readily apparent with the no-cathetertechnique. We feel -that this condition is an indicationfor catheterization if after 24 hours no urine has beenvoided and no discomfort is present. It becomes imme-diately important to be sure that this anuria is not dueCATHETERIZATIONAt OperationWe have employed a catheter ormodified our approach at theoperation in certain circumstances.These include cases presentingwith severe clot retention (1); tech-nical inability to secure adequatehaemostasis (l case controlled bytraction with a Foley-bag catheter);cases with hypotonic bladders;and failure to secure water-tightcapsular closure (due to tears,difficult enucleation, and carci-noma with invasion of the capsule).Difficult access to the retropubicspace by virtue of previous surgeryin the area or anatomical difficul-ties, and the presence of any otherassociated bladder pathology (tu-mour, diverticulum, stone, .etc.)have also been indications forchanging the plan and employinga catheter.PostoperativeUrinary retention beyond 24hours was an indication for cathe-terization in one patient with a hypotonic bladder and alarge amount of residual urine pre-operatively. Twopatients developed transitory hypotonic bladders with urin-ary retention, probably due to the administration of de-trusor relaxant drugs. These had been prescribed prophy-lactically to avoid bladder spasms, but as they have neveroccurred these drugs have since been omitted.Primary clot retentions were not encountered but wouldno doubt be an indication for replacing the catheter. Onepatient developed a secondary haemorrhage with secon-dary clot retention on the 10th postoperative day, andanother a slough retention 3 weeks later. Failure of water-tight capsular closure with excessive retropubic leakage ofurine required a few days of catheter drainage in 3 cases.One patient with postoperative psychosis, hypertension,diabetes, and ultimately fatal uraemia, was more easilymanaged with a catheter. One patient developed a retro-pubic abscess and fistula due to imperfect drainage ofthe retropubic space on the 10th postoperative day,although the urine was sterile. Two patients were cathete-rized for transient postoperative oliguria in order tomonitor their urinary outputs more accurately. Thus 17%of patients required to be catheterized in the postoperativeperiod.586 S.A. TYDSKRIF VIR GENEESKUNDE 17 Mei 1969gland. Histology has confirmed the presence of prostatitisin some of these cases. Twelve. per cent of patients withpre-operative infection had sterile urine postoperatively,and 88% of patients with pre-operative infection hadpersistent urinary infection postoperatively.Tbus a total of 52~~ of patients had sterile urine on dis-charge. Doubtless these figures could be improved uponas numerous patients with retention were maintained oncatheter drainage while awaiting surgery. These delayswere due to limitations imposed by theatre availabilityand other routine ward problems. Postoperative infectionseventually disappeared and, apart from 2 patients withlate orchitis, one of whom had had prophylactic vasectomy,they did not constitute a cause for prolonged or increasedmorbidity. It also appears that the presence of pre-operative infection is no contraindication to this pr,ocedure.CONCLUSIONSIt appears to us that the no-catheter operative techniqueand postoperative management, as described, more closelyfollow the tenets of the ideal prostatectomy than anyof the standard recognized procedures.In the absence of hypotension, bleeders are not masked,and in almost every case they have been adequately se-cured. In fact, we have found that the absence of ahypotensive technique does not materially affect theoperative procedure. Blood lost during operation is re-placed by transfusion as usual. The final decision whetherto leave a catheter in or not is made at the operatingtable and will become more positive as one's personalexperience and assessment of the conditions increase. Whenin doubt, the surgeon must readily accept the require-ments of the situation.The benefits to the patient are striking. Painful bladderspasms, and urinary drainage tubes and bladder wash-outs-a potent source of infection-are eliminated. Occasionallarge clots which would no doubt have produced a clotretention have been voided easily per urethra. The temp-tation to catheterize in tbe early stages is som:::timesstrong, but our results show that it was only necessary in17 % of cases. Early spontaneous micturition is gratifyingto the patient; and in the absence of any restricting tubt sand drainage apparatus, the patient is not anchored tohis bed and ambulation is possible by the first or secondpostoperative day. The patient's demands on nursing careare fewer, and the nursing staff are appreciative of thediminished nursing requirements. Convalescence is easier,hospitalization is reduced and expenditure not overstrained.SUMMARYOur experiences with 70 cases of no-catheter prostatectomyare described. Certain modifications in the technique have beenintroduced, notable among which is the absence of necessityfor hypotensive anaesthesia. Postoperative management is de-tailed and the events occurring during this period are observedand analysed. The impression gained thereby indicates thatthe advantages bestowed by this procedure folJow more closelythe tenets of the ideal prostatectomy than any other.We wish to thank the Medical Superintendent, Dr J. E.Cawthorne, for permitting access to records of the patientsoperated on in Addington Hospital, that have been included inthis series, and Messrs V. Larsen and F. Nel of the UrologicalDepartment, Addington Hospital, for their cooperation andvaluable assistance in this project.REFERENCESI. Millin. T. (1947): Retropubic Urinary Surgery, p. 2. Edinburgh:E. & S. LivingslOne.2. Debenham. L. S. and Ward. A. E. (1960): Brit. J. Urol.. 32, 178.3. Hickinbotham, P., Turner, W. D. and Sarma, K. P. (1967): J. Uror.(Baltimore), 97, 899.4. Macalister, C. L. O. (1967): J. Roy, Coil. Surg. Edinb., 12, 244.5. Spencer, J. (1967): Brit. J. Surg., 54, 340.CONGENITAL HEART DISEASE IN THE BANTU: AN AUTOPSY ANALYSISOF 123 CASES*Ro ALD L. VAN DER HORST, M.B., QI,B., M.MED. (PAED.) (CAPE TOWN), Part-time Paediatrician and Cardiologist,AND J. WAI WRIGHT, M.D. (SHEFFIELD), Professor of Pathology; From the Cardio-Thoracic Unit and Departmentof Pathology, University of Natal, DurbanCongenital heart disease is being reported with increasingfrequency in the South African literature. Extensive clini-cal experience has been reported from Cape Town' andDurban.' Reports of autopsy studies on heart malforma-tions are limited to the small series of Becker (13 cases)'and Siew (33 cases): Thjs report analyses 123 autopsystudies of congenital heart disease in Bantu patients atKing Edward VIII Hospital. Cases previously reported'are not part of this study.METHODS OF ANALYSISThe records of the Departments of Paediatrics and Pa-thology were searched for Bantu patients in whom acardiac malformation had been found at necropsy duringthe period 1 January 1961 - 31 December 1967. This wasfound to be the only reliable method, since many caseswith pathologically proved cardiac malformations werenot recorded in the medical registry. The available clinicaland postmortem records of these cases were analysed. In*Paper presented at the 6th Biennial Congress of the Southern AfricaCardiac Society, Johannesburg, 5 - August 196 .many instances, clinical records were inadequate andneither X-rays nor electrocardiographic studies were under-taken. The results give an indication of the relative fre-quency of the major types of malformation; but toey arenot a true reflection of the total incidence of congenitalheart disease in the Bantu, for the following reasons:(a) The series does not include patients admitted tothe wards in whom a clinical diagnosis of congenital heartdisease was made, or those who died and in whomautopsy was not permitted.(b) Although 85% of all patients dying during 1961/1962 were submitted to necropsy, this figure fell to 50%in 1966/1967 as a result of increased work load andshortage of staff, the greatest reduction being postmortemexaminations on infants and young children.(c) The large numbers of autopsies performed by eachpathologist restricted study and only the major cardiacdefect may have been recorded.(d) Because of the shortage of beds and the high turn-over of patients in the maternity wards, at least 70~~ ofmothers and infants are discharged from hospital within 24

Experiences with no-catheter prostatectomy

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Experiences with no-catheter prostatectomy

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