THE JOURNAL OF UROLOGY
Vol. 67, No. 1, January 1952 Printed in U.S.A.
RETROPUBIC PROSTATECTOMY AND INGUINAL HERNIA REPAIR LEANDER W. RIBA
W. HARRISON MEHN
From the Department of Surgery, Northwestern University Medical School and Passavant Memorial Hospital, Chicago, Ill.
The retropubic approach to the prostate is not new. It was utilized by Van Stockum in 1909, by Otto Maier in 1924, by Jacobs and Casper in 1933 and by Hybbinette in 1935. However none of these men developed the extravesical abdominal approach to a practical state, and it remained for Terence Millin in 1945 to devise a procedure which was usable. The advantages of the retropubic prostatectomy have been stated by many who have used this procedure. The increasing popularity among urologists is attested to by the number of case records being published. Millin was able to collect 1503 cases from the literature as early as 1948, and since that time many more have been added. During the past 18 months 14 retropubic prostatectomies have been performed upon carefully selected patients. It is the purpose of this paper to briefly present our results along with modifications of the Millin technique which we have found advantageous. In addition, a combined inguinal hernia repair and retropubic prostatectomy will be described. SELECTION OF PATIENTS
Preoperative evaluation of the patient is considered important and includes a careful history and physical examination, complete blood count and urinalysis, phenolsulfonthalein test, blood urea nitrogen determination, chest film and electrocardiogram. A preoperative excretory urogram is used routinely. The excretory cystograms gave valuable information regarding intravesical enlargement and the amount of residual urine (fig. 1 and 2). The criteria used for selection of our patients for retropubic procedures included 1) an evaluation of the patient as a suitable surgical risk, 2) an obstructive adenoma (estimated over 50 gm.), and 3) carcinoma of the prostate. Selection for retropubic prostatectomy included patients with vascular disease and previous coronary attacks. Because small fibro-adenomas (usually enucleated with difficulty), bladder neck contractures and median bars lend themselves well to transurethral methods and removal, they were not included. Those with a localized carcinoma of the prostate were prepared for a radical removal by the retropubic route. PROCEDURE
A spinal anesthetic frequently supplemented with intravenous sodium pentothal is used and the patient placed in a Trendelenberg position with the pelvis elevated. The abdominal wall is incised transversely about 1½ inches above the symphysis pubis (figs. 3 and 4). The external fascia of the rectus abdominis Read at annual meeting, North Central Section, American Urological Association, October 12, 1950. 106
RETROPGBIC PROSTJ,TECTOMY AND INGUINAL HERNL\. REPAIR
muscles is divided in the plane of the skin incision and the muscles are retracted laterally. The space of Retzius is thus widely exposed. Careful blunt dissection just posterior to the symphysis pubis with manual traction on the bladder and peritoneum will open the space just anterior to the prostatic capsule (figs. 5 and 6). Through the thin prevesical fascia the precapsular veins are visualized. These veins are ligated, divided with the fascia and pushed aside. This exposes
Fm. L A '1nd R
defect in bladder floor consistent with hypcrtroph,· of prostate.
FrG. 2. Showing ddeet in bladder floor consistent with hc·pert.rophc· of prostate. X ote "fish hook" appearance of ureters in B. Difficultc· in estimating size of ac!enoma from uro .. grams is evident by comparing weights of adcnomas removed in figure 1, A and figure 2, Li and B.
the anterior Rnrface of the true capsule, and large subcapsular plexus veins are Reen. Depending upon the 8ize of the adenoma 3 to 5 chromic catgut sutures (00) are passed through the capsule just distal to the intended line of the capsular incision. This row of sutures will help to control bleeding and later aids in closure. Hemostasis should be accomplished before the capsule is opened. Packs are not placed lateral to the prostate for this encourages bleeding, A transverse incision is made in the prostatic capsule just proximal to the hemostatic sutures
LEANDER W. RIBA AND W. HARRISON MEHN
With the capsule thus incised sutures may also be placed at the lateral angles of the incision to aid in retraction and later closure. The prostatic adenoma is visualized through the capsular incision. It is freed by blunt and sharp dissec-
FIG. 3. Intrapelvic inguinal hernioplasty. Anatomic relationships as seen from parietal side are indicated. Asterisks mark site of direct and indirect inguinal hernias. Note insertion of transversalis fascia into superior pubic ligament. Smaller figure indicates location of abdominal incision used. (After Mc Vay and Anson; and Jennings, Anson and Wright.)
FIG. 4. Intrapelvic inguinal hernioplasty. Placing of sutures for repair of direct hernia begins at pubic tubercle and is continued laterally to femoral vein. Sutures may be placed as in B to aid in closure of abdominal inguinal ring, indicated in indirect hernias. (After Mc Vay and Anson; and Jennings, Anson and Wright.)
tion, the apex is mobilized by sharp division of the urethra. Dissection tmrnrd the bladder neck is aided by a rectal finger. The inferior vesical arteries are identified as they enter the prostate near the bladder neck and are ligated. Careful control of these vessels prevents excessive blood loss and maintains good visualization
RETROPl"BIC PROSTATECTOJ\IIY AND INGUINAL HERNIA m~PAIR
FrG. 5. Procedure used for retropubic prostatectomy. 1, Bladder and peritoneum :1re retrncted manually revealing prost:1tic capsule. Hemost11tic sutures placed about veins. 2, Prostatic capsule incised transversely proximal to hemostatic sutures. 3, ,,_,.,,_,_.,_,w., bulging through capsular incision. Double loop of heavy chromic catgut suture in adenormt used for traction. -4, Adenonm dissected from capsule of prostate b:, blunt and sharp dissection. ii, Apex of adfmoma freed b)' sharp division of urethrn.
Fra. 6. 6, Traction on adcnonrn aids in freeing adenoma postcriorlv. foferior vcsical arteries exposed and ligated. Adenoma then divided at bladder neck. 7, Final inspection made for residual tags and spheroids and residual bleeding controlled with electrocoagulation. 8, Closure of capsule effected after Foley two way irrigating catheter has been inserted through urethra into bllldder. 9, Continuous suture of chromic catgut closes capsular incision. Second layer of interrupted sutures utilizing previously placd hemostatic sutures brings precapsular and prevesical fat and fascia over capsular incisiono
LEANDER W. RIBA AND W. HARRISON MEHN
of the operative field. The adenomatous tissue is then freed from the vesical neck. A V shaped portion may be excised from the posterior bladder neck to prevent later contraction. If the bladder neck is loose it can be sutured to the floor of the prostatic capsule. The cavity caused by removal of the adenoma is packed with a hot pack for 5 minutes, and after this time residual bleeders are controlled with forceps and electrocoagulation. A rectal finger will also aid in demonstrating residual tags and spheroids. A 24F Foley two-way irrigating catheter is introduced into the bladder through the urethra and the balloon distended within the bladder. In an occasional instance hemostatic agents such as oxycel or gelfoam are placed in the prostatic cavity during the closure. The capsule is sutured in 2 layers; the first is a continuous chromic catgut suture and the second is a series of interrupted sutures in which the hemostatic sutures placed prior to incising the capsule are utilized. This second row of sutures brings the prevesical and precapsular fat and fascia over the capsular incision. A soft rubber drain (Penrose) is inserted into the space of Retzius and brought out through a small stab wound just superior to the abdominal incision. If a hernia is present this is repaired prior to closure of the abdominal wall. The rectus muscles are brought together with 2 or 3 catgut sutures, the rectus fascia is closed with interrupted wire sutures with the knots directed into the muscle tissues, and the subcutaneous tissues and skin are closed with interrupted silk sutures. Closure is facilitated by readjusting the table to give a slight flexion at the hips. Routine vasectomies are carried out during the abdominal closure unless the patient objects to this precautionary procedure. POSTOPERATIVE CARE
Following surgery continuous irrigation with normal saline solution or water is preferred for 24 hours or until the return remains clear. Antibiotics (penicillin or dihydrostreptomycin) are used routinely. Patients are allowed out of bed after the catheter has been removed. The postoperative course is smooth and uneventful. Bladder spasms are infrequent and morphine is um1ecessary. The suprapubic drain is removed on the fourth postoperative day and the urethral catheter is removed on the fourth or fifth day. Voiding is usually satisfactory from the start. HERNIA REPAIR
The hernia repair which can be effectively accomplished through the same incision is a superior pubic (Cooper's) ligament repair. The anatomy of this region has been clearly demonstrated by McVay and Anson who show that the posterior inguinal wall is a composite of the caudal portion of the transversus abdominis muscle aponeurosis and the investing fascia of this muscle. The fascia of the inner or peritoneal port.ion is the transversalis fascia. In the area where the muscle is aponeurotic these are fused. The transversus aponeurotic fibers contribute to the sheath of the rectus abdominus muscle anteriorly (in the inguinal area) and insert into the superior pubic ligament (Cooper's) as far lateral as the femoral ring (figs. 3 and 4). The transversalis fascia divides at the lateral margin of the rectus muscle to invest the rectus muscle and thus form the rectus fascia.
RETROPUBIC PROSTATECTOMY AXD INGUI);_'\_L HERNIA REPAIR
Purposeful repair of inguinal hernias during the course of a retropubic prostatectomy is similar to the procedure in that the superior pubic ligament is utilized. McDonald and Huggins have done a simultaneous prostatectomy and inguinal hernia repair but have utilized separate incisions and a Bassini or Halsted type of repair. The transversalis fa8cia is sutured to the superior pubic ligament from the pubic tubercle to the femoral vein (figs. 3 and 4). Inferior gastric vessels will ustrnlly not lrnYe to be divided in order to accomplish this. If the abdominal inguinal ring is not closed snugly about the spermatic cord clo8ure ean be further accomplished by placing sutures in the fascia jm,t lateral to the abdominal inguinal ring as advocated by .Jenning", Anson and \Vright. Repair of a hernia can be satisfactorily accomplished by this method whether the hernia is of indirect or combined types. If an indirect hernia is encountered the sac is opened and the contents reduced into the abdominal ii. high ligation of the sac is easily accomplished. If the distal portion of the sac extruding into the inguinal canal or scrotum is not reducible it may be left in place. Should the transversalis fascia be of poor structure a fascial graft may be utilized. DISCUSSION
rpon admission to the hospital all patients had symptoms of progressive prostatic obstruction ·which were variable in degree and in duration, Three srnre admitted ,vith acute urinary retention (eases 1, 3, l1; table 1). In 3 patients (case;, 2, 5, 7) a previou8 diagnosis of carcinoma had been made, and m one of these 5) bilateral orchieetomies and bilateral ureteral transplants were accomplished to admission for a retropubic radical prostatectomy. In all cases the patients were considered as suitable surgical risks. The aYerage blood urea nitrogen determination ,Yas 18.4 mg. per cent, the highest value was 28.6 (case 13), In two patients a retropubic prostatectomy ,ms planned but was not accomplished because of the small fibrotic glands encountered; in addition these patients had urinary tract infections somewhat refractive to treatment. One was later to a transurethral resection, the postoperative urine shm,·ed numerous acid-fast bacilli. A total of 14 retropubic prostatectomies were performed; 11 were for adenomatous hyperplasia and 3 were radical procedures for carcinoma. The tissue removed yaried from 22 to 157 gm. with an average weight of 62 gm. Pertinent data are included in table 1. Several postoperative complications merit discussion (table 1). In case 1 the oxycel obstruction and infection ,Yere produced a stubborn B. pyocanem, infection. Incontinence and stricture in cases 2 and 7 were in patients in whom a radical prostateetomy was done. One patient (case 10) did not void well due to residual subvesical obstruction, and an additional 8 gm. of tissue was successfully removed transurethrally. This complication resulted from inexperience. There was postoperative bleeding in 1 case (No. 16). This patient had a strictured urethra and was preoperatively diagnosed a bleeder. The bladder filled up with clots 36 hours after surgery, necessitating suprapubic evacuation and drainage. Stricture formation in cases 11 and 13 may have been on the basis of a low grade infection (Hem. and non-hem. Staph. albus), for it has been shown
LEANDER W. RIBA AND W. HARRISON MEHN
Bitschai that an infectious process accounts for an excess amount of scar tissue with stricture. In addition it is our impression that the present latex Foley catheters appear to irritate and cause rapid contractions of preoperative urethral strictures. Epididymitis developed on the contralateral side (case 14) in a patient in whom only a unilateral vasectomy was done. (A vasectomy was performed in 13 of the 14 patients.) One death in the early postoperative period (fourteenth day) was in a patient who previously had had a bilateral ureteral transplant and bilateral orchiectomy. He died at home and no post-mortem examination was obtained. TABLE
POSTOPERATIVE DAY CASE
Oxycel gauze obstruction and infection Urgency incontinence
E. S. J.
2 3 4 5
C. G.G. B. J.C. C.E.T. R. C.
76 73 59
6 7 8 9 11 12
C.E. W. F.McC. E. S. L. M. C.S. J.C.M. W.E.J. E.M.E.
72 83 65 79 55 60 57
13 14 15 16
E.M. J. VanS. P. J. D. B. L.
66 73 49 62
12 4 5 13 13 5 Expired at home 14th Ureteral 8 post-op. day transplants Ad. 32 5 10 12 14 Urethral stricture CA Ad. 26 4 9 4 Ad. 130 10 Residual tissue Ad. 4 32 16 Urethral stricture Ad. 120 5 16 Hernia repair only. Small, infected adenoma (Hem. staph. albus) Ad. 30 5 Urethral stricture 110 Epididymitis (unilateral) Ad. I 24 5 15 Hernia repair only. Small, infected adenoma (tuberculosis) 22 26 Ad. 136 I Post-op. bleeding (severe)
28 51 90 170 c bladder
CAt Ad. Ad. CA
* Ad.-Adenoma t CA-Carcinoma
The transverse abdominal wounds healed without delay. We have found the transverse incision to be especially well adapted to the patient with an adipose abdominal wall (fig. 7). No incisional hernias and no untowa:r;d symptoms referrable to the wounds have developed. In all cases there was only a minimal serosanguinous drainage from the stab wounds, and these promptly healed with removal of the drains. Osteitis pubis has not occurred; we attribute this to careful hemostasis, avoidance of trauma to the periosteum of the pubis and absence of leakage from the prostatic capsule. No patients developed edema of the penis. There was only a low-grade febrile response following retropubic prostatectomy. The highest elevation of temperature in most cases occurred on the first postoperative day (average 100.9F) and the temperature rapidly fell to normal by
RETROPUBIC PROSTATECTOMY AND INGUINAL HERNIA REPAIR
the third or fourth The hospital stay following surgery averaged 15 days. The longest period ,ms 36 days in a patient (case 16) ,vho had recurrent severe postoperative bleeding. Follmving the use of the transverse abdominal incision (only 1 vertical incision in the series) we noted a satisfactory repair of inguinal hernias in some patients. One patient who had ,rnrn a bilateral truss for 35 years stated he no longer needed this protection. Another patient had a small right direct hernia which disappeared after retropubic prostatectomy through a transverse incision. Examination almost a year following surgery confirms the apparent disappearance of the hernias. In earlier cases in which the transverse abdominal incision ,ms utilized the rectus abdominus muscles ,vere divided trans-versely as an aid -in exposure. ln repairing the operative wound these divided muscles were reapproxi"
Fm. 7. Postoperative appearance of transverse al,dominal 1yound in obese patient.
mated 1vith horizontal mattress sutures in \rhich a large amount of the muscle tissue was embraced by the suture. By such a procedure the fascia of the rectus muscles (actually transversalis fascia continued medial,rnrd) ,ms tightened. FollmYing the disappearance of hernias in early cases ,Ye haYe utilized a more definitive repair ,vith suture of the transversalis fascia to the superior pubic ligament. In these rases the rectus muscles have been retracted and not divided. In a group of 16 selected patients eleven hernias were present, an incidence of 68 per cent. JvicDonald and Huggins found a 15 per cent incidence of hernias in 100 consecutive cases of prostatic hypertrophy. Of the 11 hernias 8 were unilateral and 3 bilateral; two of the unilateral group were indirect and the remainder of the hernias ,yere direct. In the first 6 patients 1Yith hernias (2 bilateral, 4 unilateral and all of direct type) upon whom a retropubic procedure was done no definitive hernia repair was attempted; the transverse wounds, including the incised rectus abdominus muscles, were closed with the rectus muscle and fascia suturing as described (table 2). In the patients with bilateral hernias, there was complete absence of hernias postoperative in 1 patient; in the other the hernia
LEADRER W. RIBA AND W. HARRISON MEHN
was absent on one side and was decreased in size on the other. This small hernia has since been repaired by a Bassini procedure. Of the 4 patients with unilateral hernias, 1 patient had a vertical incision to avoid a large sliding hernia. This hernia has since been repaired by a conventional approach. In the other 3 patients with transverse incisions there has been an absence of hernias postoperatively in 2. The last 5 patients with hernias were subjected to a superior pubic (Cooper's) ligament repair as described previously. One patient had bilateral direct hernias. Only one side was repaired at the time of the retropubic prostatectomy; the opposite side has since been repaired by the Bassini method. Four hernias were unilateral, in 2 the hernias were indirect. In 3 there was an absence of hernia following surgery. An indirect hernia recurred in the fourth case, a patient who had had 3 previous herniotomies. The recurrence manifested itself 2 months after we had repaired the hernia through a transverse abdominal TABLE
2. Status of hernias following retropubic procedure
Untreated hernias (6) Wound closure only 2 bilateral hernias (direct) bilateral cure-I unilateral cure-I (R. side, Bassini repair L. side later) 4 unilateral hernias (direct) Hernia cure-2 Vertical incision-I Treated hernias (5) Superior pubic ligament repair I bilateral hernia (direct) R. intrapelvic repair-successful L. Bassini repair later 4 unilateral hernias (2 indirect) Hernia cured-3 Recurrence-I (indirect) Bassini repair later
inc1s10n. Examination during the fifth (conventional) repair revealed that insufficient sutures were placed during our fourth repair attempt. Tighter closure of the abdominal ring could have prevented this recurrence. It is still too early to accurately evaluate the results of these hernia repairs, but to date they appear to be solid and successful. We have been favorably impressed with the retropubic operation for removal of the prostate. It provides an accessible method except in the presence of a very deep pelvis, when a suprapubic enucleation may be preferable. The bladder and peritoneum remain undisturbed and this results in less trauma, shock and hemorrhage. Large adenomas can be removed by the retropubic method in one stage. Bacon reports the successful removal of an adenoma of 602 gm. Extraand intracapsular hemorrhage can be controlled by the meticulous surgeon, and adenomatous tags removed under direct vision. The complications, not chargeable to the surgeon, are minimal. No special instruments were necessary to do the procedure. We have also found that a satisfactory hernia repair may be done
RETROPUBIC PROSTATECTOMY AND INGUINAL HERNIA REPAIR
L FIG. 8. Gross specimen of prostatic tissue with contained ejaculatory ducts.
FIG. 9. Photomicrograph of prostatic tissue with contained ejaculatory ducts. X 60.
LEANDER vV. RIBA AND W. HARRISON MEHN
in conjunction ,vith a retropubic prostatectomy without an appreciable increase in morbidity. In such repairs an anatomic restoration of tissues is possible with utilization of the superior pubic ligament. Functional results to date have been excellent. The postoperative sex function is undisturbed but can be improved with testosterone. Postoperative external ejaculation may remain absent due to incision or removal of the ejaculatory ducts proximal to the verumontanum (figs. 8 and 9). CONCLUSIONS
A series of 14 retropubic prostatectomies were done, 11 for adenomatous hyperplasia and 3 for carcinoma of the prostate. In these cases the functional results have been satisfactory. Modifications in the technique of Millin which have been found beneficial are included. No special instruments were found necessary. The transverse abdominal incision is of value in retropubic procedures and is especially adaptable to the obese abdomen. An intrapelvic hernial repair may be accomplished following a prostatectomy and just prior to closure of the abdominal wound. Such a repair is anatomically sound.
720 N. Michigan Ave., Chicago, Ill. REFERENCES BACON, S. K.: J. Urol., 59: 376-384, 1948. BACON, S. K.: J. Urol., 61: 571-574, 1949. BENEVENTI, F. A. AND ~OBACK, G. J.: J. Urol., 62: 663-671, 1949. BENEVENTI, F. A. AND TWINEM, F. P.: J. A. M. A., 140: 851-855, 1949. BITSCHAI, J. AND AxLER, G.: Brit. J. Urol., 22: 63-64, 1950. FARMAN, F. AND LEMON, K. A.: Urol. & Cutan. Rev., 53: 584-589, 1949. HYBBINETTE: (Cited by Millin.) JACOBS, L. C. AND CASPER, E. J.: Urol. & Cutan. Rev., 37: 729-732, 1933. JENNINGS, W. K., ANSON, B. J. AND WRIGHT, R. R.: Surg., Gynec. & Obst., 74: 697-707, 1942. LICH, R., JR., GRANT, 0. AND MAURER, J. E.: J. Urol., 61: 930, 1949. LICH, R., JR. AND MAURER, J.E.: Kentucky Med. J., 47: 81-86, 1949. LowsLEY, 0. S. AND GENTILE, A.: J. Urol., 59: 281-296, 1948. McDONALD, D. F. AND HuGGINS, C.: Surg. Gynec. & Obst., 89: 621-622, 1949. MILLIN, T.: Lancet, 2: 693-696, 1945. MILLIN, T.: J. Urol., 59: 267-274, 1948. Mc VAY, C. B. AND ANSON, B. J.: Surg., Gynec. & Obst., 88: 473-485, 1949. MooRE, T. D.: J. Urol., 61: 46-58, 1949. PRESMAN, D. AND RoLNICK, H. C.: J. Urol., 61: 59-74, 1949. VAN STOCKUM, W. J.: Zentralbl. f. Chir., 36: 41-43, 1909.