The early days of prostatectomy for benign prostatic hypertrophy.
Abstract: The syndrome of bladder neck obstruction, often leading to retention of urine, in ageing men has been recognised since earliest times.

Catheterisation for the relief of urinary retention was used by the ancient Chinese and Egyptians and is described in the writings of the Indian surgeon Susrata, who flourished in Benares sometime after Christ. Although many of these cases were the result of urethral stricture from trauma or gonorrhoea, we can assume that, in older men, the cause was often benign prostatic hypertrophy (BPH).

KEYWORDS Bladder neck obstruction / Benign prostatic hypertrophy
Subject: Prostatectomy (History)
Author: Ellis, Harold
Pub Date: 10/01/2011
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Oct, 2011 Source Volume: 21 Source Issue: 10
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 272168043
Full Text: Surprisingly, accurate descriptions of the prostate, and of its enlargement in the elderly, do not appear until the 16th century. In 1538 we find the first illustration of the prostate gland. This was in the 'Tabulae Anatomicae' of Andreas Vesalius, the father of modern anatomy. We then have to wait till 1788 for John Hunter, that great surgeon of St. George's Hospital, whose museum at the Royal College of Surgeons is his lasting memorial, to give a detailed account of bladder obstruction caused by hyperplasia of the middle and lateral lobes of the prostate and to note its effect on the thickening of the bladder musculature and the dilatation of the upper urinary tract - the kidneys and ureters.

It is now well recognised that BPH is the accompaniment of ageing. Sir Benjamin Brodie, also of St. George's, wrote as long ago as 1849: 'When the hair becomes grey and scanty, when specks of earthy matter begin to be deposited in the tunics of the arteries and when a white zone is found in the margin of the cornea, at the same time the prostate becomes increased in size'.

After Joseph Lister's work, the antiseptic technique of catheterisation was taught to the patients

In the late 19th century, all sorts of measures were tried to shrink the enlarged prostate, including massage per rectum, galvanic electric current and injection of sclerosants such as silver nitrate. However, prior to the advent of prostatectomy, the man with retention of urine due to an enlarged prostate was usually condemned to the 'catheter life', the patient being taught to catheterise himself three or four or more times a day. The necessary equipment comprised a gum elastic catheter and lubricant, which were carried in a pocket case or concealed inside a hollow walking stick! After Joseph Lister's work, the antiseptic technique of catheterisation was taught to the patients. Henry Thompson quotes two patients, one aged 90 who had been catheterising himself for 20 years, while the other had performed the procedure on a record 35,000 occasions!

In 1827, Jean Amussat in Paris reported that after he had removed a bladder stone via a suprapubic incision into the bladder, he went on to excise with scissors a mass projecting into the bladder from the prostate. The patient recovered and was relieved of his obstructive symptoms. This no doubt represents the first example of a prostatectomy. However, the era of prostatectomy had to await the twin benefits of general anaesthesia, (1846 onwards), and antiseptic surgery, heralded by Joseph Lister in 1865. Early pioneers were William Belfield of Chicago and Arthur Fergusson McGill, of the General Infirmary at Leeds, in the 1880s. After enucleation of the prostate, the bladder would be drained by a suprapubic tube.

However, it was Sir Peter Freyer, of St. Peter's Hospital, London, now the Institute of Urology, who popularised the suprapubic operation, so that it came to be called 'the Freyer prostatecomy'. His success was no doubt due to the fact that he used a large suprapubic tube that allowed free escape of any clots in the bladder, which could be washed out via a urethral catheter. The disadvantage was that it might take weeks for the suprapubic fistula finally to heal. The operation remained in use right up to the mid 20th century. As a young house surgeon, I assisted my chief with many such cases over 60 years ago and I can remember well the many hours I spent washing out blood clots and changing catheters on these poor old gentlemen. A different approach to removal of the enlarged prostate was via the perineum - the perineal prostatectomy. This was introduced by Hugh Young in Baltimore, USA, in 1903. Although quite popular in America, it never really caught on in the UK; I never saw it used, nor did I hear of other British surgeons employing this approach.

In 1945 Terence Millin, of All Saints Hospital, London, introduced the retropubic prostatectomy. This involved opening the prostatic capsule, enucleating the enlarged gland, suturing the capsule and draining the bladder by a transurethral catheter. This operation had the great advantages of leaving the bladder intact, efficient closure and rapid healing of the capsule of the prostate and a much shorter and more comfortable convalescence. Surgeons are very good at adopting advances in technology. It was not long after the invention of the electric light bulb that Max Nitze, a Berlin urologist, adapted a miniaturised bulb to produce the cystoscope in 1877, and to revolutionise urological diagnosis. By 1911, Hugh Young, already mentioned as the father of perineal prostatectomy, carried out transurethral resections of the prostate using a cutting punch fitted to the 'scope. Haemorrhage was a problem until the introduction of the electric cautery. Today the great majority of prostatectomies for benign disease are carried out by the transurethral approach, (transurethral prostatectomy, or 'TUR').

In recent years, pharmacological treatment has been introduced which is often effective in the management of men with BSP. These agents are either alpha blockers, which relax the plain muscle component of the gland, or testosterone inhibitors, which act on the glandular elements. Surgery is now more limited, and is required mainly for patients who fail to respond to medical treatment.

Provenance and Peer review: Commissioned by the Editor; Peer reviewed; Accepted for publication August 2010.

Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE1 1UL.

About the author

Professor Harold Ellis

CBE, FRCS

Emeritus Professor of Surgery, University of London; Department of Anatomy, Guy's Hospital, London

No competing interests declared
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