Freyer's transvesical prostatectomy

If a patient needs his prostatic obstruction relieved, there are three ways you can do it. You can use: (1) A modification of Freyer's method in which prostatic adenomas are removed through the bladder. (2) Ghadvi's method (23.21) in which they are removed laterally through the perineum. (3) The injection method in Section 23.22 which scleroses them with a mixture of glycerine and phenol.

Of the possible alternatives, Millin's retropubic operation is nicer for the patient, but it is more dependent on preliminary cystoscopy and is more difficult. It also needs good lighting, more help, and better postoperative care. Transurethral resection needs much skill and an expensive resectoscope. The advantages of Freyer's method are: (1) If you cannot cystoscope a patient, you can look into his bladder to exclude diverticula, carcinoma, and stones. (2) You can control bleeding more easily. (3) When well done, mortality is low. One of its disadvantages is that it normally requires large quantities of irrigating fluid, although we describe ways of doing without this.

When a prostate enlarges benignly, it does so because adenomas form in its lateral lobes. These are joined anteriorly by a narrow anterior commissure, which is the most anterior part of the prostate. As the adenomas form: (1) They compress the normal tissues of the prostate around them to form a false capsule. (2) They compress the prostatic urethra from side to side. Posteriorly the median lobe of the bladder enlarges superiorly and extends upwards into the bladder. With Freyer's method you open a patient's bladder through his abdomen, insert your finger in the plane between the adenomas and the false capsule, and shell them out. Doing this without injuring his membranous urethra needs skill.

One of the difficulties of any prostatectomy is that the raw bed of the prostate bleeds after you have removed its adenomas. There are several ways to reduce this bleeding: (1) You can use diathermy (if you have it) during the operation. (2) You can put a suture or two into his prostatic bed. (3) You can compress the walls of his prostatic bed with the balloon of a Foley catheter (the standard method). (4) As a last resort you can pack his prostatic bed, and leave the pack in place.

If he bleeds, the clot may obstruct his urethra and distend his bladder (clot retention). This opens up the vessels in his prostatic bed, makes the bleeding worse, and is the great hazard of prostatectomy. Prevent it by washing away the blood, as it collects, in any of the following ways. Base your choice on the availability of catheters and irrigation fluid: (1) You can leave a three-way irrigating Foley catheter (preferably plastic rather than rubber) in his urethra, and wash away the blood in his bladder with a stream of irrigating fluid. One channel is for the fluid to go in; one is for fluid, blood, and urine to come out; and one is to blow up the balloon. (2) You can insert a two- way Foley catheter through his urethra, and introduce fluid into his bladder through a suprapubic catheter. This can be either a rubber tube, as in C, and D, Fig. 23-26, or another Foley catheter. (3) You can put a two-channel Foley catheter in his bladder, give him quantities of intravenous fluid and frusemide, and let his urine wash the blood out of his bladder this way. (4) You can use suprapubic suction and no irrigation. (5) You can leave a large suprapubic tube in his bladder and remove clots with forceps. This is what Freyer did, but the suprapubic fistula you make takes a long time to close. It can use huge quantities of gauze, and urine may overflow from the suprapubic tube into the patient's bed. Not surprisingly, nurses hate this method! We describe two versions of it; one using bladder washouts which is highly recommended under difficult circumstances. (6) You can leave a catheter in his urethra, pass a de Pezzer catheter suprapubically, and pack his prostatic bed as in Fig. 23-27.

If you are going to irrigate his bladder, you will need about ten litres of fluid. This can be: (1) Intravenous saline[md]which is expensive and is likely to be scarce. (2) Sterile saline made from tap water. The disadvantage of this is that it may enter his circulation through his prostatic sinuses, and if it is not pyrogen free, it may give him rigors. (3) Sterile 3.8% sodium citrate (which is no better than saline).

If you have not been able to cystoscope him, you can inspect his bladder through his operation wound to exclude diverticula and tumours, and pass a sound to exclude a stricture. Unfortunately, you cannot always exclude bladder-neck fibrosis until you have felt inside his bladder. If you find this condition, you will have to cut a wedge out of his prostate as in D, Fig. 23-23, D, Fig 23-24, and J, Fig. 23-25.

Fig. 23-24 FREYER'S PROSTATECTOMY[nd]ONE. A, the incision. B, open the patient's bladder. C, put your finger into his internal meatus and remove his enlarged prostate. A finger in his rectum is only sometimes necessary. D, cut a wedge out of his bladder neck, E, close his bladder. Adapted from a drawing by Frank Netter, with the kind permission of CIBA-GEIGY Ltd, Basle (Switzerland).

MODIFIED FREYER'S PROSTATECTOMY INDICATIONS. Benign enlargement of the prostate[md]see Section 23.18. Carcinoma is better treated with oestrogens as in Section 32.32. If however, you happen to find a carcinoma incidentally, you can open up a sufficient channel to relieve the obstruction, as described below.

EQUIPMENT. An abdominal set (4.12), Langenbeck or bent copper retractors, a self-retaining retractor, such as Walton's, a vulsellum or Littlewood's forceps, suction, diathermy (if available), preferably a three-way irrigating Foley balloon catheter with a 75 ml balloon, or the alternatives described below.

ANAESTHESIA. (1) Ketamine with a relaxant (A 8.4). (2) Subarachnoid or epidural anaesthesia. (3) General anaesthesia. You can manage without a relaxant, but anaesthesia has to be deeper. Preferably, have at least two units of blood cross- matched (with due care as to HIV, Chapter 28a), and a drip running.

POSITION. Lay the patient on his back and give the table a mild head-down tilt. Stand on his left side, so that your right hand is in the most convenient position to enucleate his prostate, and so that you can, if necessary, put your left index finger into his rectum.

SOUNDING. If he does not already have a catheter in, and you have not done a cystoscopy, pass a sound to make sure he has not got a urethral stricture. If all is well, pass a catheter, and leave about 300 ml of saline in his bladder to make it easier to find when you operate.

THE INCISION depends on whether he has already had a suprapubic cystostomy.

If he has had no suprapubic cystotomy, make a Pfannensteil (Fig. 23-20), or less satisfactorily, a 7 cm midline incision immediately above his pubis longitudinally between his recti.

If he has had a suprapubic cystostomy, dissection will be easier if you start in an unscarred part of the wound. Make an elliptical incision round the wound, excise the skin edges and the suprapubic track, and split his rectus muscles. Dissecting the peritoneum off his bladder will be difficult, so cover your right index with gauze. Keeping the pulp of your finger in contact with his pubic symphysis, push your finger into his retropubic space. When you reach his prostate, rotate your finger through 180[de] and peel the peritoneum off the anterior surface of his bladder.

Insert stay sutures into the anterior wall of his bladder (A, Fig. 23-25), and then incise it in the sagittal plane.

CAUTION ! Don't enter his peritoneal cavity. If by mistake you do so, immediately suture it.

Put two fingers of your right hand into his bladder. Feel inside to exclude neoplasms and the orifices of diverticula. You can easily miss these. Feel his prostate and his internal urinary meatus.

If his prostate is enlarged, and you can easily get your fingers into his internal urinary meatus, enucleate the prostate as described below.

If his prostate is not enlarged, and he has a tight internal meatus which you cannot put your finger into, he has bladder-neck fibrosis, so see Section 23.20.

Fig. 23-25 FREYER'S PROSTATECTOMY[md]TWO. A, insert stay sutures and open the patient's bladder by making a stab incision between two Allis' forceps. B, inspect his bladder. C, to F, use your right and then your left index fnger to open up the plane between the gland and the false capsule. G, his empty prostatic cavity. H, mopping out his prostatic cavity. I, sutures being placed at 4 and 8 o'clock to control bleeding. J, cutting a wedge out of the neck of his bladder. K, the wedge complete. L, suturing a Foley catheter in place. After Maxwell Malament, from a publication by Ethicon Ltd, with kind permission.

TO ENUCLEATE HIS PROSTATE, remove the self-retaining retractor. Put your index finger into his prostatic urethra. Use your left index finger to split into the recess between the anterior commisure (which should remain in situ) and the left lateral lobe of his prostate at about 10 o'clock. Open up the plane between the gland and the false capsule as far distally as you can. Separate it through at least 90[de], and preferably 150[de]. Use your right index finger to repeat the procedure on the right side starting at about 2 o'clock, so as to free his prostate from within its bed (false capsule). There is usually a residual attachment distally. Pull his prostate up into his bladder to make this taut. Divide it near his prostate, either blindly with curved dissecting scissors or with your finger.

CAUTION ! (1) Divide the attachment close to his prostate, or you may damage his internal sphincter which surrounds his membranous urethra, deep and superficial to his perineal membrane. (2) Preserve his anterior commisure. Damage to either may lead to incontinence of urine or a stricture.

Remove his entire prostate, including its median lobe, by bringing it into his bladder with your index finger. If it is still lightly attached proximally to the mucosa of his bladder, separate it with scissors. Removing each lateral lobe separately may be easier. One will bring the median lobe with it.

If he is very fat, or muscular, you may be unable to reach the lower border of his prostate. So you will have to push it upwards with your left index in his rectum while you enucleate the adenomas from above. To do this, cover your left hand with two gloves, and protect your forearm with a sterile towel under the drapes.

When you have turned the lateral lobes into his bladder, feel the inside of his prostatic cavity, to make sure that no adenomatous masses have been left behind.

CAUTION ! You can easily leave a large mass of adenoma behind, so compare one side with the other. Use your fingers, sponge holders, or vulsellum forceps to grasp and twist off any remaining pieces of adenoma.

TO ENLARGE HIS BLADDER NECK, first check the position of his ureteric orifices. Cut a wedge out of his bladder neck in the 6 o'clock position level with his ureteric orifices and between them (J, in Fig. 23-25). The mucosa of the bladder overhangs the prostatic cavity, and if you don't do this he may get retention of urine later (''bladder-neck obstruction').

TO CONTROL BLEEDING insert two figure of eight sutures in the 4 and 8 o'clock positions (I, 23-25), taking care to avoid his ureters. Then put a tight gauze pack in his prostatic cavity. After 3 minutes, take it out and assess the amount of bleeding.

Put a purse string of catgut in the floor of his bladder, around what was his internal meatus. Blow up the balloon of a 50 or 75 ml Foley catheter, until it fits snugly in his prostatic bed (usually 30[nd]50 ml is required). This will help to stop bleeding. Then tighten up the purse string round it to hold it in place (L, 23-25). It will usually remain in his prostatic bed. Some surgeons put a large balloon in the prostatic bed directly without an initial purse string suture. It must be large: if you don't have one, insert a purse string suture first.

Alternatively, if bleeding is still brisk (unusual), tightly repack his prostatic cavity, and leave the pack in place for 15 minutes. Remove it. If his prostatic cavity is still bleeding, you may need to suture substantial bleeding vessels on either side of the bladder neck (if you have not already done so). Pack his prostatic cavity a third time, but this time pass a Foley catheter into his bladder. Either don't inflate the balloon, or inflate it when it is well up in his bladder. Use a long length of sterile 10 cm gauze, pack it round the Foley catheter, and bring the end out through the abdominal incision as in Fig. 23-27. Some surgeons have never had to do this.

Insert a ''2' monofilament suture through his abdominal wall and his bladder, and then through the holes in the catheter to hold it in place. Knot it over a button (L, 23-25). If he is confused postoperatively, this will prevent him from pulling out his catheter, even if the balloon bursts.

Fig. 23-26 IRRIGATION FOR PROSTATECTOMY. A, a three-channel Foley catheter. B, how to ''milk' a catheter to dislodge clots. Pinch it at ''x' between the finger and thumb of your left hand. Pinch it just distally with your right hand (''y'). Move the fingers of your right hand down the catheter (''z') keeping its lumen closed. Then suddenly stop pinching with your left hand. There will be suction along the catheter into the bag. C, a two- channel Foley catheter with suprapubic drainage through a rubber tube. D, how the tube enters the bladder. E, how it is folded. A second two-channel Foley catheter is an alternative.

IRRIGATION OR DRAINAGE [s7]FOR FREYER'S PROSTATECTOMY The purpose of irrigation is to remove blood clots, which encourage infection and block the drainage tube. Some surgeons don't irrigate routinely, and only do so if bleeding has been brisk. If you have had to pack his prostatic cavity to control immediate bleeding, he will probably need irrigating.

Choose one of these six methods. (1) is the best because there is no abdominal wound to leak. (5) and (6) are the least satisfactory, but are useful if there is severe bleeding which you cannot control, or you lack irrigation fluid. Where you can, tie the catheter in place with a suture to his abdominal wall (L, 23-25).

(1) A THREE-CHANNEL IRRIGATING FOLEY CATHETER. Introduce saline down one channel, and let it drain through another. Remove the catheter on day 8 to 12. There is no need to use a three- channel catheter if he also has a suprapubic catheter.

(2) A PAIR OF TWO-CHANNEL FOLEY CATHETERS one through his urethra and the other suprapubically. Pass a large 20 to 24 Ch two-channel Foley catheter through his urethra into his prostatic bed. Pass another (8 to 10 Ch) into his bladder through an oblique high suprapubic track. An oblique track will close more easily than a straight one. Introduce fluid through the abdominal catheter, and drain it through the urethral one. This is the best method for a beginner. If you don't have a second Foley, you can use a Malecot or a de Pezzer catheter suprapubically.

Remove the suprapubic catheter when the fluid is no longer bloody, usually on day 3 or 4. If you leave it longer it tends to leave a track which leaks. Remove the urethral one on day 8 to 12.

(3) A TWO-CHANNEL FOLEY CATHETER AND FRUSEMIDE. Give him a bottle of 5% dextrose alternating with one of 0.9% saline every 6 hours, with frusemide 40 mg twice daily for two days. In this way he will irrigate himself. Remove the catheter on day 8 to 12. This is expensive in intravenous fluids.

(4) CONTINUOUS SUPRAPUBIC SUCTION. Cut multiple side holes in a rubber tube, as in E, Fig. 23-26, bend it double, insert it into his bladder, and apply continuous suction with a pump or with jerricans (10-8). You can use this method with a pack, or a Foley catheter, in his urethra. If your pump exerts more suction than 10 cm of water, fit it with a bypass, as in Fig. 19-13.

(5) SUPRAPUBIC TUBE. Put a large (2 cm) rubber tube with two side holes into his bladder, so that it does not quite reach his trigone. Stitch it to his skin. Allow it to drain into dressings. Don't connect it to a bottle, because its purpose is to allow clots to be extruded. If clots block it, remove them with sponge-holders. Nurse him on a plastic sheet. Insert a urethral catheter.

On the 3rd or 4th day, when there are no more clots, withdraw the large suprapubic tube, and put in a small one. Cut two eyes in this, transfix it with a safety pin, and fix it to his abdominal wall with strapping.

On the 10th day remove the suprapubic tube, and allow the fistula to heal. To make sure that the torn end of his urethra is not obstructed by adhesions, pass a sound through it, or tie in an 18 Ch plastic catheter. This will keep him dry until his fistula has closed. Wash out his bladder daily with mercury oxycyanide 1/6000, or plain water.

Alternatively, here is a method which is highly recommended under difficult circumstances. Insert a large suprapubic drain into his bladder, and a urethral catheter. Wash out his bladder with water through his urethra, and let it wash the clots in his bladder up and out through the suprapubic tube. Continue washouts until clots have stopped, and the fluid which comes out is only a pale pink. When this happens, let him pass his urine through his urethral catheter, and leave the suprapubic tube in a little longer as a safety measure. With this method you can see the clots coming out, and make sure that his urethral catheter never blocks.

(6) PACKING THE PROSTATIC CAVITY. After you have enucleated his prostate, pull the urethral catheter further into his bladder, and pack his prostatic cavity firmly with a roll of gauze. Bring the end of the gauze out through the abdominal incision, as in Fig. 23-27. Place a de Pezzer catheter in the upper end of the incision. Start irrigating as soon as you have closed his bladder. Remove the pack at 24 hours if bleeding is controlled, and at 72 hours if it is not. Remove his urethral catheter at 10 days.

CLOSING THE ABDOMINAL WALL [s7]AFTER FREYER'S PROSTATECTOMY This is the same with all methods. Close his bladder with two layers of continuous ''0' or 2/0 chromic catgut, preferably on an atraumatic needle. Preferably insert the first one through the mucosa only, and use the second one to invert the muscle coat.

Insert a 2 cm wide corrugated rubber drain in his retropubic space, through a new incision, below the original Pfannensteil one. If you made a midline incision, put the drain to one side. Stitch it in place. Bring his rectus muscles together with a few catgut sutures, and close his anterior rectus sheath with continuous chromic catgut. Close his skin. There is no need to tie his vasa, because this does not influence the incidence of postoperative epididymo-orchitis.

POSTOPERATIVE CARE [s7]AFTER FREYER'S PROSTATECTOMY He must pass plenty of urine. So each 24 hours give him 2 or 3 litres of 0.9% intravenous saline, alternating with 5% dextrose, until he can take fluids by mouth (A, 15.5).

IRRIGATION METHODS. Teach the nurses to milk the catheter hourly (B, 23-26), until all the clots have gone, usually in 2 to 4 days. In methods (1), (2), and (3) continue irrigation with saline, just fast enough for his urine to be pale pink. It is usually necessary for 24 to 48 hours. You will need about 4 bottles of fluid in the first 24 hours, and less the next day. You may need to continue irrigation until the 4th day.

CAUTION ! Don't raise the irrigation bottle too high. If it is more than 60 cm above his bladder, and haemostasis has been poor, the fluid in his bladder may enter his circulation, especially if the outflow catheter is obstructed. Keep the drainage bottle on or near the floor, to make use of gravity.

Let down the balloon on the third day, unless there is much bleeding; if so, wait until bleeding stops. His prostatic cavity will then become smaller naturally, and there will be less danger of secondary haemorrhage.

Most patients are fit for discharge about the 10th day, unless they have been left with a fistula which has not yet healed, as in methods (5) and (6).

DIFFICULTIES [s7]WITH FREYER'S PROSTATECTOMY Besides the normal anaesthetic risks, and those listed below, the postoperative difficulties you will meet include epididymitis, septicaemia, deep vein thrombosis (unusual in the developing world), ileus (10.13), uraemia and oliguria (53.3), postoperative shock (53.1), and bladder tamponade.

If you find that he has CARCINOMA of his prostate, you will not be able to shell it out, because this causes much bleeding, and is difficult. So remove enough tissue with scissors (or diathermy) to leave an adequate channel for his urine. You should have reduced the chances of finding carcinoma of the prostate inadvertently by measuring his acid phosphatase, by X-raying his pelvis for secondaries, and by cystoscopy.

If when you open his bladder you find that THERE ARE NO ADENOMAS, he probably has BLADDER-NECK DYSFUNCTION. Relieve this by incising the neck of his bladder, as in the next section.

If you find DIVERTICULA in his bladder, leave them: they will become smaller now that you have relieved his obstruction, unless they were very large. Removing them is difficult, so try to refer him for this later.

If he BLEEDS from his prostate after his return to the ward, within 48 hours of the operation (reactionary haemorrhage, not uncommon), all that is usually necessary is to keep the catheter clear by milking it hourly. If his urine is a deep red- wine colour, speed up the irrigation, and consider washing out his bladder. Raise the foot of his bed if his blood pressure is low. Give him morphine. If necessary transfuse him. Occasionally, you may have to take him back to the theatre, reopen his wound, and control bleeding from his prostatic bed.

If he has a DISTENDED PAINFUL BLADDER and no urine drains, he has CLOT RETENTION. This is one of the most feared complications of prostatic surgery, and occurs within the first 72 hours. He has bled severely, and the blood in his bladder has clotted and obstructed the catheter. Transfuse him as necessary. Take a metal ear syringe and inject 50 ml of sterile saline into his bladder and immediately aspirate it.

CAUTION ! Don't inject more than 50 ml, or you may burst his bladder, and don't try this method more than once. If you are lucky, you will dislodge the clot.

If you fail to dislodge the clot, take him to the theatre, remove the catheter under general anaesthesia, insert a 24 Ch metal catheter, wash out his bladder through this, and replace the Foley catheters. If this fails, open his bladder, remove the clots, and pack his prostatic cavity, as in Fig. 23- 27.

If he BLEEDS 8[nd]12 DAYS AFTER THE OPERATION (secondary haemorrhage, quite common), it usually settles. Many cases are not severe, and will stop on their own. If he does not stop bleeding (rare), dilate his suprapubic fistula (if he has one) with Hegar's dilators, and remove the clots from his bladder with sponge forceps. Reinsert a urethral catheter, and wash his bladder through this until the fluid is nearly free of blood. Then put in a large suprapubic drain, and send him back to the ward. You may occasionally need to pack his prostatic cavity with gauze (23-27); but avoid doing this if you can, because it requires formal re-opening of the wound. If it is necessary, take him back to the theatre, reopen his prostatic bed, and control bleeding. If he does not have a suprapubic fistula, this is what you will have to do.

If he is INCONTINENT OF URINE, you can reassure him that this is almost certain to improve during the next 3 months. It is more likely if you damaged his external sphincter at operation, and it can be permanent. The symptoms of urge incontinence are common in patients who had these symptoms preoperatively; they usually resolve spontaneously.

If he develops a SUPRAPUBIC FISTULA, it will probably close spontaneously before he leaves hospital. If it is slow to heal, his lower urinary tract is probably still obstructed. So drain his bladder with a urethral catheter for up to 10 more days.

If he has a FURTHER ATTACK of retention of urine some months or years later, dilate him with bougies (23.8). If this fails, you may have to do a wedge resection of the neck of his bladder. This is very unlikely to happen, if you routinely excise a wedge of tissue from the back of the neck of the bladder when you remove the prostate.

Fig. 23-27 PACKING THE PROSTATIC CAVITY. Where technology and facilities are limited, this method may still have a place in controlling bleeding at operation and afterwards. A, inserting the pack. B, the prostatic cavity packed, with one end of the pack coming out of the wound, for removal after 24 hours.