Prostatectomy

This consists in removing the hypertrophied glandular elements. It is performed either suprapubically or through the perineum.

When done through a suprapubic incision a median enlargement (so-called median lobe) can readily be removed by dividing the mucous membrane with the finger-nail or scissors and shelling the growth out with the finger. In this case there is practically no sheath to go through and the amount of bleeding will be proportionate to the varicose condition of the veins. If large lateral growths are to be removed then there is still no fibrous sheath to be entered, but only the thin, filmy capsule and fibromuscular layer of prostatic tissue covering the hypertrophied glandular masses: hence for its division Freyer uses his finger-nail only. As the fibrous sheath is not divided there is no bleeding from the prostatic venous plexus in its layers.

In perineal prostatectomy two methods are used. In the first the membranous urethra is opened by a median incision and then a lateral cut made into the enlarged prostate on each side. The finger is then introduced and the hypertrophied glandular masses enucleated with the finger. In the second method a curved or A-shaped incision is made from the central tendon of the perineum toward each side between the rectum and tuberosities. The sphincter ani is then detached from the central tendon and pushed back while the transverse perinei muscles are pulled forward. The muscular fibres between the rectum and membranous portion of the urethra

(page 438, recto-urethralis muscle) are then divided and the rectum pushed back (Fig. 455). This exposes the prostate; its outer capsule or sheath is then incised and the growth removed with the finger or forceps. In order to prevent injury to the ejaculatory ducts Young enucleates through two lateral incisions, thus leaving a middle strip in which the ejaculatory ducts are contained. According to Gosset and Proust (Manuel de la Prostatectomie, Paris, 1903) the fascia between the prostate and rectum (aponeurosis of Denonvilliers) is composed of two layers, an anterior one on the prostate - its sheath - and another posterior one on the rectum. When the recto-urethralis muscle is divided the incision should likewise divide the posterior or rectal layer, which is then pushed back with the rectum. Thus is formed the "espace decollable retroprostatique" or separable space and the anterior layer or sheath of the prostate is exposed.

Fig. 455.   The parts involved in prostatectomy. The external sphincter ani has been divided at the central point of the perineum and with the lower portion of the rectum has been drawn back, thus putting the recto urethralis muscle on the stretch and exposing the prostate to each side.

Fig. 455. - The parts involved in prostatectomy. The external sphincter ani has been divided at the central point of the perineum and with the lower portion of the rectum has been drawn back, thus putting the recto-urethralis muscle on the stretch and exposing the prostate to each side.

Abscess

Inflammation and abscess of the prostate follow injury and infection from the introduction of catheters or bougies and also from gonorrhoea. The hot and enlarged gland can readily be felt through the rectum. The bladder and rectal symptoms are marked. Pus tends to discharge either into the urethra or rectum, more rarely it may point in the perineum behind the triangular ligament and in front of the anus. Abscesses breaking into the urethra may leave a large cavity, which becomes a receptacle for pus, urine, and calculi, and hastens a fatal issue. When breaking into the rectum intractable fistulae may result. Prostatic abscesses should be opened by an incision in the perineum just anterior to the anus, the finger being introduced into the rectum to avoid wounding it.