Report of Two Successful 
Cases of Prostatectomy. 
BY 
LUCIUS W. HOTCHKISS, M. D., 
Attending Surgeon to the J. Hood Wright Memorial Hospital; 
Assistant Surgeon to Bellevue Hospital, New York. 
REPRINTED FROM THE 
'Metu Xwcfc jftaWcal Journal 
for January 2, 1S97. Reprinted from the New York Medical Journal 
for January 2, 1897. 
REPORT OF 
TWO SUCCESSFUL CASES OF PROSTATECTOMY.* 
By LUCIUS W. HOTCHKISS, M. D., 
ATTENDING SURGEON TO THE J. HOOD WRIGHT MEMORIAL HOSPITAL J 
ASSISTANT SURGEON TO BELLEVUE HOSPITAL, NEW YORK. 
The first case I have to report is that of a man, sixty- 
seven years of age, who was twice a patient during my 
service at the J. Hood Wright Memorial Hospital. 
He was first admitted in November, 1895, with an 
attack of acute retention of urine, which his physician 
had been unable to relieve by the use of the catheter 
and for which suprapubic aspiration of the bladder was 
resorted to. 
His previous history was indefinite, but indicated 
that he had been suffering for some time with difficulty 
in emptying his bladder. He was in possession of a dirty 
catheter which, he said, he had -been in the habit of 
using occasionally for several months. At this time he 
had a very acute cystitis, and the prostate could be felt 
as a very large tumor projecting backward toward the 
rectum. His urine was very foul, and the calls to uri- 
nate were very frequent. The amount of residual urine 
varied from four to six ounces or more. He was treated 
by rest in bed and daily irrigations of the bladder with 
various solutions. Under this treatment he improved 
considerably, his residual urine diminished in amount, 
* Read before the Society of Alumni of Bellevue Hospital, Novem 
ber 4, 1896. 
Copyright, 1897, by D. Appleton and Company. 2 
TWO SUCCESSFUL CASES OF PROSTATECTOMY. 
and he was quite comfortable. The size of the prostate, 
as evidenced by rectal touch, seemed somewhai? de- 
creased, and at the end of about a month, when he was 
discharged to become an out patient, he could pass his 
urine himself without much difficulty. He was instruct- 
ed how to keep his catheter clean and how to use it. At 
this time he was anxious to have some operation per- 
formed for his permanent relief, but his apparently fee- 
ble condition and the fact that he had improved so 
much under palliative measures led us to decide against 
it at that time. 
On January 22, 1896, he was readmitted to the hos- 
pital, suffering with another severe attack of cystitis. 
He had failed to report as advised, and had neglected 
the instructions as to the necessity of cleanliness in the 
me of the catheter, his nature and environment being 
such that cleanliness seemed an impossible attainment. 
Examination at this time revealed a very much en- 
larged prostate. A catheter was made to enter the blad- 
der with considerable difficulty, and about four ounces 
of very turbid ammoniacal urine were withdrawn. His 
temperature was normal. The urine was 1.019 specific 
gravity; alkaline; full of pus and albumin. The old 
man was suffering intensely with vesical pain and fre- 
quent and difficult urination. He was much worn from 
loss of sleep, and appeared quite feeble. He was put to 
bed, and his urine drawn and bladder irrigated twice a 
day with a solution of permanganate of potassium, 1 to 
2,000. 
Under this treatment he obtained some relief, but 
on February 10th suffered from an attack of reten- 
tion. The catheter withdrew fifteen ounces. From this 
time until the end of the month, when the operation 
was done, he continued to have pain and did not stand 
catheterism so well. As it did not seem possible for 
a patient to maintain catheter life safely under the 
conditions in which he was obliged to live, a suprapubic 
cystotomy was determined upon, with a view to main- 
taining permanent drainage in case it should not be 
found feasible to remove the prostate. TWO SUCCESSFUL CASES OF PROSTATECTOMY. 
3 
On February 29, 1896, a little over a month from the 
date of his admission, ether was administered and a su- 
prapubic cystotomy done in the usual manner. After 
opening the bladder the large prostatic tumor could 
be felt by the finger. The enlargement of the lateral 
lobes seemed most marked, and the contact of their 
opposing sides with the prostate congested would seem 
to explain, in this case, the mechanism of his frequent 
attacks of retention. The middle lobe also projected 
somewhat, but did not constitute a distinct bar to the 
urethra] outlet. 
The pelvis of this patient was very deep, and consid- 
erable difficulty was experienced in enucleating the 
gland. An assistant aided me very much, however, by 
pushing up the prostate through the anterior wall of the 
rectum with his finger. The mucous membrane was 
spared as much as possible, and an attempt was made at 
a clean enucleation. This, however, was impossible, and 
the large succulent growth was removed piecemeal by 
the fingers and scissors. The specimen shows, I think, 
those portions of the median and lateral lobes which 
projected into the bladder and encroached upon the 
urethral outlet, and, though it is shrunken somewhat 
in the alcohol, represents a prostate of large size. 
There was considerable oozing of blood during the 
enucleation, and the operation was prolonged and diffi- 
cult. At its close the cavity of the bladder was packed 
with gauze, and drainage established by means of a 
large catheter through the suprapubic wound. Shock 
considerable; good recovery from ether. There was 
some haemorrhage during the night which yielded readily 
to irrigation of the bladder with hot saline solution. 
The patient went along very comfortably for about ten 
days, the temperature never rising above 100° F. On 
the 11th of March, following an attempt to remove the 
suprapubic drainage-tube,the temperature went to 103.8° 
F., and the patient had considerable pain. The tube 
was reintroduced and left for a few days more, the 
wound in the meantime granulating nicely, and tem- 
perature falling nearly to normal. By the end of March 4 
TWO SUCCESSFUL CASES OF PROSTATECTOMY. 
the patient was able to pass a small amount of urine 
voluntarily and the wound had nearly closed. 'After 
this time, -when he began to sit up, the leakage became 
less, and he was able to pass more urine through the 
natural channel. On April 2d it was found that the 
catheter passed eight inches before entering the bladder, 
whereas just before the operation the urethral distance 
measured ten inches before the urine flowed. A rectal 
examination showed but very slight enlargement at the 
situation of the prostate. 
On the 6th of April he could retain his urine for sev- 
eral hours and pass voluntarily seven ounces. No urine 
comes through the fistula, though there is slight leak- 
age when the bladder is distended during irrigation. 
The patient has slight dribbling away of urine from the 
urethra w'hen standing. 
May 2d.-The wound is closed. 
11 th.-The patient is discharged. 
As a result of this rather severe procedure in an 
old man a very good functional result was obtained. 
The patient was seen about two months ago. He has 
discarded the catheter, is able to pass his urine volun- 
tarily, and says he feels very well. I am unable to state 
exactly whether he still has residual urine or how long 
the intervals are between the acts of urination. His con- 
dition when he left the hospital was certainly good, 
and has evidently much improved since that time. I 
shall endeavor at some later time to make more accu- 
rate observations upon the final result of the operation. 
The second case which I have to present is one of 
perineal prostatectomy in a man sixty-six years of age. 
This patient was admitted to Bellevue Hospital on 
August 24, 1896, and the following brief history was ob- 
tained: Since the age of twenty he has had several 
attacks of gonorrhoea. Ten years ago he began to have 
serious difficulty in urination, which culminated in an TWO SUCCESSFUL CASES OF PROSTATECTOMY. 
5 
attack of retention which was relieved by aspiration of 
the bladder above the pubes. He remained in the hos- 
pital for a time and an external urethrotomy was per- 
formed for the relief of his strictures. As a result of this 
operation his condition was much improved, but in a 
few months his trouble in urination began to return. 
He says he has used the catheter occasionally ever 
since this time, and for the three weeks preceding the 
date of his admission to Bellevue he had used it con- 
stantly. He had suffered from frequent and painful 
urination for a long time, but for the previous three 
weeks the irritability of the bladder had become so in- 
tense and the spasm so painful that he had been obliged 
to pass water every few minutes, and had frequent at- 
tacks of retention, for which he resorted to the catheter. 
On admission he presented symptoms of a very acute 
cystitis and his sufferings were intense. A catheter with- 
drew six ounces of urine, which was alkaline, of low spe- 
cific gravity (1.010), and full of pus and mucus. 
The patient could obtain no rest by night or day on 
account of the extremely painful tenesmus of the blad- 
der. This clearly was not a case for rest in bed, with 
catheterization and irrigation. It was a case which 
seemed to call for immediate and free drainage of the 
bladder. 
On August 25th ether was administered and a median 
perineal cystotomy performed in the usual manner. Pre- 
vious to the operation the capacity of the bladder had 
been proved so small that the perineal route had been 
chosen as the simpler method of entering the small con- 
tracted viscus. 
On examination of the bladder through the perineal 
wound by the finger, the lateral and median lobes of the 
prostate could be felt very much enlarged. The en- 
croachment on the calibre of the urethral outlet of the 
bladder, in this, as in the other case, seemed to be due 
to the apposition of the greatly enlarged lateral lobes 
of the prostate. Tearing through the mucous membrane 
over these enlarged prostatic masses with the finger nail, 
I succeeded in enucleating with some difficulty nearly 6 
TWO SUCCESSFUL CASES OF PROSTATECTOMY. 
the entire prostate. I regret that the specimen has been 
lost. The prostate, in this case as in the other, seemed 
rather soft and succulent. The middle portion was the 
most difficult to remove, being almost beyond the reach 
of my finger. 
At the completion of the operation the bladder was 
drained by a large catheter through the perineal wound 
and siphonage arranged for after the patient was put to 
bed. The haemorrhage was moderate, the shock com- 
paratively slight, and the patient rallied well from the 
ether. 
His bladder was irrigated twice daily with a weak so- 
lution of permanganate of potassium. 
On September 3d, the tenth day after the operation, 
he was sitting up. His symptoms were at once relieved 
by the operation and his convalescence was uninter- 
rupted. He was discharged September 22d, a little less 
than a month from the date of his admission. At this 
time the perineal wound had healed save for a small 
granulating surface. There was no fistula. The patient 
could pass his urine himself without pain. His cystitis 
had improved so much that urinary examination, Sep- 
tember 12th, showed no albumin, and it was much 
clearer, although still alkaline.* I have not seen the pa- 
tient since his discharge from the hospital, but consider 
the result, as regards function of his bladder and im- 
provement of his cystitis, as very good. 
In comparing and contrasting these two cases of 
prostatectomy we are struck with certain points of simi- 
larity as regards the probable mechanism of urinary 
obstruction in both patients. 
In both we notice, as a result of the establishment of 
free bladder drainage, an almost immediate recession and 
disappearance of distressing pain and tenesmus. 
I was struck with the comparative ease and readi- 
* The patient reported at the hospital three months after the opera,- 
tion, and said he could pass urine as well as when he was a boy. TWO SUCCESSFUL CASES OF PROSTATECTOMY. 
7 
ness with which the prostate could be removed by the 
perineal method in this case, a method which is now 
generally abandoned on account of the difficulty in many 
cases of reaching and dealing with the enlarged gland. 
The method proposed by Alexander, of a combined su- 
prapubic and perineal prostatectomy, would seem in 
many cases to be a most practical operation, combining, 
as it does, many of the advantages of both methods. 
In the first case the suprapubic drainage was, as it 
often is, most uncomfortable for the patient. The dress- 
ings were constantly wet for the first few days and needed 
repeated changes, as did the bed linen and clothes of the 
patient. This seems unavoidable in the many cases 
where, for various reasons, the bladder opening can not 
be closed tightly about the tube and where it is essential 
to maintain bladder drainage for some time. The dis- 
comforts to the patients of this method of drainage, as 
compared with those in case of the perineal method, 
seem incomparably greater. I do not wish to be under- 
stood, however, as drawing definite conclusions from 
these two cases. My object in presenting for your con- 
sideration these cases of prostatectomy is not to put 
forward any new principle in the treatment of prostatic 
obstruction, but rather to call to your minds the underly- 
ing principle of success in these operations of prosta- 
tectomy-viz., the complete removal of the obstruction 
to urination and the establishment of free bladder drain- 
age. 
Remembering that the operation is designed to pro- 
long life in a class of sufferers who are frequently en- 
feebled by age and in whom the bladder trouble is often 
complicated by lesions of other viscera, especially the 
kidneys, we should not be surprised if the mortality 8 
TWO SUCCESSFUL CASES OF PROSTATECTOMY. 
seems disproportionately large. The unfavorable condi- 
tion of many patients who are the subjects of this opera- 
tion is one which the surgeon must accept beforehand 
as a factor in increasing the death-rate. This fact is 
strikingly illustrated when we recall the fact that the 
operation of castration, which under ordinary circum- 
stances has no mortality, shows in these cases of old 
prostatic disease a mortality nearly if not quite as large 
as the much more serious operation of prostatectomy. 
According to the recent statistics of Cabot,* out 
of two hundred and three cases of castration for en- 
larged prostate there were thirty-nine deaths, a mortal- 
ity of 19.4 per cent. The same author collected reports 
of twenty-two cases of ligature and division of the vas 
deferens, with seven deaths. He attributes the high 
death-rate in these so-called minor procedures to the 
fact that in castration for enlarged prostate the diminu- 
tion of the size of the organ is often so slow as to be of 
little immediate use in stopping the back pressure on 
the kidneys, which is especially harmful at a time when 
the operation has laid a fresh stress of work upon them. 
The mortality rate in cases of suprapubic prostatec- 
tomy was, in the earlier series of cases, estimated as high 
as twenty-five per cent. Later tables show that with 
increased familiarity in the technics it is safe to place it 
at a considerably lower figure. Cabot thinks it safe to 
place it below twenty per cent., and considers it fair to 
assume that with added experience in the operation the 
death-rate will be greatly reduced. 
With a mortality no greater or slightly less than that 
of castration for prostatic hypertrophy, with the fur- 
ther advantage of allowing thorough exploration of the 
* A. T. Cabot, Annals of Surgery, September, 1896. TWO SUCCESSFUL CASES OF PROSTATECTOMY. 
9 
bladder for other possible conditions, and with the pos- 
sibility of complete removal of the obstruction and thor- 
ough drainage of the bladder, the operation certainly 
should be ranked as a thoroughly justifiable and satisfac- 
tory method of procedure in properly selected cases. 
In cases of prostatic obstruction, complicated by an 
intense cystitis, some method of treatment which in- 
cludes free bladder drainage as well as the removal of 
the enlarged gland would seem to be imperative. The New York Medical Journal. 
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