Six Successful and Successive 
Cases of Prostatectomy. 
by 
Eugene Fuller, M. D., 
NEWYORK. 
REPRINTED FROM THE 
Journal of Cutaneous and Genito-Urinary Diseases 
for June, 1895. [Reprinted from the Journal of Cutaneous and Genito-Urinary Diseases for June, 1895.] 
SIX SUCCESSFUL AND SUCCESSIVE CASES OF PROSTATECTOMY. * 
By EUGENE FULLER, M. D., 
New York. 
AT the present time the management of those suffering from the 
severer grades of senile prostatic hypertrophy is being much 
discussed. By the severer grades of this disease are meant such 
cases as are not amenable to or tolerant of the catheter. In order to 
relieve them, the urinary outflow must be diverted from its customary 
channel or the obstruction must be removed. The only way to divert 
the urinary flow is by the establishment of a permanent hypogastric 
urinary fistula, an unsatisfactory procedure which has happily found 
little favor in this country. The methods, however, which have been 
advocated for the removal of the obstruction are numerous. These 
methods can best be divided into two classes. Under the first class 
are grouped those operative procedures which aim to directly remove 
the obstruction; under the second, those whose aim is to cause an 
atrophy in the obstructing gland by interfering with its nerve or blood 
supply. Double castration seems to cause more or less atrophy of the 
prostate, probably by interfering with the nerve supply to the part, 
while ligation of both internal iliac arteries apparently to some extent 
accomplishes the same result by shutting off the blood supply. The 
only true argument against the first group of procedures, whose aim is 
the direct removal of the obstruction, is their mortality. This, of 
course, is a strong argument, since the subjects are elderly and, owing 
* Read before the American Association of Genito-Urinary Surgeons at the Niagara 
Meeting, May, 1895. , - ' • . 
COPYKIGHT, 1895, BY I). APPLETON AND COMPANY. Original Communications. 
to the nature of their disease, prone to renal insufficiency. Everything 
else is in favor of direct removal, for in all cases tlie operator slioulcl 
be able to thoroughly remove the obstruction. He should also be able 
to accomplish this without permanent injury to the vesical neck by 
reason of lacerating or tearing away the mucous structures. When 
once such an obstruction is thoroughly removed the patient can be 
safely assured that he will never suffer from prostatic hypertrophy 
again. 
In almost all cases also the use of the catheter can be entirely dis- 
pensed with after convalescence from the operation is wholly estab- 
lished, the apparently atonied bladder gradually regaining its muscular 
force until finally it throws off a full forcible stream. In many in- 
stances previous evidences of renal trouble, due to pyelitis caused by 
dilatation of the ureters and pelves, gradually disappear as these mus- 
cular structures also in like manner as the bladder regain their tone. 
As a result of all these changes and regenerations, the patient at the 
end of six months or a year after the operation is apt to report hale 
and hearty, declaring that he feels ten years younger and that his act 
of urination is all that he could desire. lam well aware that many 
surgeons will consider that the foregoing statement in favor of the 
radical removal of the obstruction is too rose-colored, and will point to 
the indifferent results obtained in many instances by earlier operators 
to sustain their opinions. I, however, hold that the argument against 
prostatectomy on the ground that the results to be expected from it 
are indefinite and unsatisfactory is a false one, and that it is based on 
cases where the removal of the hypertrophy at the time of the opera- 
tion was incomplete. In many of the earlier unsatisfactory cases the 
object of the operator was simply to chisel out, as it were, a canal 
through the obstruction at the vesical base connecting the post-pros- 
tatic vesical cul-de-sac with the membranous urethra, no attempt 
being made to remove lateral obstructions or the rigid hypertrophies 
surrounding the prostatic urethra. If, however, all the hypertrophies, 
median, lateral, and round about the prostatic urethra, are removed as 
they should be, and as they can be by adopting the method I advocate, 
then I claim that the results, as far so the bladder is concerned, are, 
barring mortality, satisfactory. 
As regards double castration, the only argument in its favor is that 
it ought to be accomplished with little or no danger to life, and that it 
offers a chance for relief. 
This argument should be given the greatest weight in such cases as 
are evidently past making, from a physical standpoint, the struggle 
attendant on the radical operation. Six Successful and Successive Cases of Prostatectomy. 
3 
Against it it can be said that it is not applicable to cases represent- 
ing an emergency where, owing to tbe condition of the prostatic ob- 
struction, catheterization is impossible and speedy free drainage is 
imperative. Three of the cases to be reported by me represent exam- 
ples of this description. 
It emasculates the man submitting to it; and although it may be 
said that men in their sixties, the age of most of these sufferers, have 
no further need—or ought to have no further need—of their testicles, 
still my experience has been that most prostatics dread the loss of their 
testicles more than the dangers attendant on a radical operation, and 
that if they feel that their adviser is competent to remove their pros- 
tates they choose the more radical procedure. 
Castration is not expected to accomplish the same radical relief 
that thorough removal does. It is still in its experimental stage, and 
just how much in the way of real prostatic atrophy it causes in senile 
hypertrophy is not as yet an established fact. In soft, succulent hyper- 
trophies it probably accomplishes much ; while in hard, fibrous ones— 
and especially if these be also infiltrated with lime salts, as every now 
and then occurs—it is hard to see how such a procedure as castration 
could accomplish much. 
Nothing can be said in favor of the operation to accomplish atrophy 
of the prostate by ligating both internal iliac arteries, since the dangers 
attendant on it are probably fully as great as those attached to the di- 
rect removal of the obstruction, while the benefits to be expected from 
it are indefinite and at best only partial. 
Since the final results from prostatectomy are good if only the 
growth is thoroughly removed, the operation is surely destined to be- 
come popular and general if it can be shown that the mortality from it 
is moderate; for the great majority of these cases at the time when 
prostatectomy is first suggested to them have, as it wTere, come to the 
end of their rope, medically speaking, so that if the operation is not 
done little remains to occupy the medical attendant aside from admin- 
istering anodynes and holding the hand until death occurs. Therefore 
any radical procedure which offers to the patient and his family at 
such a time fair prospects of relief is apt to be accepted. 
The objects of this paper are to show that prostatectomy can be 
successfully accomplished with comparatively small mortality, and to 
present to the profession the operative methods by which I have at- 
tained my results. 
In the earlier operations of this nature not only was the prostatic 
obstruction in many instances imperfectly removed, thereby giving 
imperfect and unsatisfactory results, but the death-rate also was large. 4 
Original Communications. 
The chief causes for death were haemorrhage, generally primary, some- 
times secondary; shock, oftentimes intensified or caused by the re- 
moval of vesical tampons, always a difficult matter, which had been 
tightly packed into the bladder to stop haemorrhage; sepsis, which 
was favored and intensified by extensive damage to the vesical walls 
in the prostatic region, and by the open and exposed state of the supra- 
pubic wound ; defective drainage; and kidney insufficiency. 
To avoid as far as possible these mishaps I have adopted the fol- 
lowing procedure : The patient is placed flat on his back, neither the 
Trendelenburg position nor the Petersen bag being commonly found 
necessary. The bladder is carefully washed out, and then left moder- 
ately distended to the extent of from eight to twelve ounces. The 
next step is to open the bladder suprapubically, the general directions 
which had been laid down by Keyes being followed. The forefinger 
of the left hand is then introduced into the bladder, the location and 
extent of the prostatic obstruction determined, and the vesical opening 
of the urethra located. In the right hand is grasped a pair of rough, 
serrated-edged scissors with a long handle. These scissors are slipped 
along the left forefinger to the urethral opening, and are made to cut 
through the bladder wall in that region. The cut extends from the 
lower margin of the internal vesical opening of the urethra backward 
for an inch to an inch and a half. The blades of the scissors being 
rough and serrated, make an incision which bleeds but little. Then 
one of the forefingers, whichever the operator may find the more con- 
venient, is slipped through the vesical hole made by the serrated scis- 
sors, while at the same time the fist of the other hand makes firm 
counter-pressure against the perinseum. By means of this counter- 
pressure the prostatic growth is brought well into the reach of the 
forefinger of the other hand, which is employed all this time in enucle- 
ating the prostatic obstruction en masse, or piece by piece, as the case 
may be. This enucleation can be easily and speedily accomplished in 
this manner, and should not be desisted in until all the lateral and 
median hypertrophies, as well as all hypertrophies along the line of 
the prostatic urethra, have been removed. The vesical walls at the 
base, as elsewhere, are very elastic and dilatable, so that it will be 
found that the little cut made through the bottom of the bladder will 
be large enough to admit of the passage through it of the enucleated 
prostate. 
[Figs. 1 and 2 accompanying this article are natural-sized illus- 
trations of prostatic hypertrophies which I have enucleated in the 
manner described. In Fig. 1 the whole hypertrophy was removed in 
one piece, while in Fig. 2 the obstruction came away in three pieces, Six Successful and Successive Cases of Prostatectomy. 
Fig. I.—Dr. Fuller’s specimens of prostatic hypertrophy removed by enucleation (natural size.) 
Showing the entire hypertrophy enucleated in one piece. 
Fig. 2.—Showing the hypertrophy enucleated in three pieces, two lateral and a median. 6 
Original Communications. 
representing two lateral and a median hypertrophy. The hypertrophy 
shown in Fig, 1 was taken from my case shortly to be described as 
Case E, while those in Fig. 2 were taken from Case F.] A perineal 
section is then made, and a large size (twenty-six American) soft rubber 
tube is passed through the perineal cut, and the cut through which 
the prostate was enucleated, into the bladder. After this, hot-water 
irrigation is employed for some minutes to wash out blood clot and to 
stop oozing. Then the suprapubic wound is closed by a deep layer of 
catgut sutures which include the bladder wall, and by a more super- 
ficial layer of silkworm gut (Florentine) sutures. About in the middle 
of the cut the catgut stitch is omitted and a deep Florentine gut suture 
is taken, which includes the vesical walls and the whole extent of the 
lateral abdominal walls. This suture, however, is not tied at the time 
of operation, thus allowing a rubber suprapubic drainage tube to tem- 
porarily remain in position. At the end of four or five days, however, 
this suprapubic drain may in most instances be removed ; then this 
last Florentine ligature can be tied, thus entirely closing the supra- 
pubic cut. It is best not to remove these Florentine sutures till after 
the patient is up and about, as without their firm support there is often- 
times a tendency for the soft scar tissue of the wound to give, thus 
allowing a considerable spreading of the abdominal structures. 
My method of enucleating the prostate through a small hole made 
in the base of the bladder is accomplished by a technique almost the 
opposite of that advocated by JSTicoll, of Glasgow, in the lancet, April 
14, 1894, and by Alexander, of New York, independently of Nicoll, at 
the May (1894) meeting of the American Genito-Urinary Association. 
These gentlemen enucleate the prostate through a spacious perineal 
wound, that gland being brought into the reach of the perineal finger 
by the pressure exerted downward and forward by the finger or fingers 
of the other hand introduced into the bladder through a suprapubic 
incision. Then after such enucleation a dependent incision is made 
into the bladder and perineal drainage established. My first case of 
enucleation by my method was performed early in May, 1894, before 
1 was aware of Nicoll’s publication, and before Alexander had also 
reported that method. I can say of my method of enucleation that 
by it the prostatic hypertrophy can be easily and thoroughly removed 
without damage to the structures composing the vesical neck, and that 
haemorrhage resulting from it has always been of little consequence. 
Owing to the slight amount of bleeding, I have always found it fea- 
sible to sew up as I have described the suprapubic cut, and have never 
experienced trouble from secondary haemorrhage. The after treatment 
consists largely in careful and thorough vesical irrigation in conjunc- Six Successful and Successive Cases of Prostatectomy. 
7 
tion with the internal administration of a large amount of diuretic 
water in order to keep the kidney secretion free and active. By the 
adoption of this method I feel that the customary causes of death after 
prostatectomy can be in large measure avoided, and in substantiation 
of my opinion I have to report the following six successful and 
successive cases. Five of these cases illustrate directly the method of 
enucleation just described by the suprapubic route. In one of them, 
however, it was possible to remove the growth through the perimeum 
without resort to the suprapubic cut. 
Case A.—Sixty-six years old. First seen early in May, 1894. 
Having been called in an emergency at midnight, I found the patient 
straining violently on a full bladder. For eighteen hours he had been 
unable to urinate, though for the last few hours there had been a 
dribbling from overflow. He had bled freely from the meatus as the 
result of vigorous and unsuccessful attempts at catheterization. The 
perinseum was swollen and indurated, showing evidences of extravasa- 
tion of blood and urine. I could not pass a catheter even under 
chloroform. Suprapubic aspiration was resorted to, and about a quart 
of urine, so mixed with blood and clot that it with difficulty passed 
through the aspirating needle, was withdrawn. The patient con- 
sented to operation, and early in the morning I performed suprapubic 
prostatectomy, enucleating the gland according to the method I have 
described. The patient at the time of operation was suffering from 
shock and suppression, due to the retention of the day before. His 
pulse was feeble and his tongue dry. I operated as quickly as pos- 
sible, giving but little anaesthetic. I removed a large right lateral 
hypertrophy and the median hypertrophy, which last was moderate. 
Owing to the bad condition of the patient, I did not wait to remove a 
small left lateral hypertrophy. The patient rallied from the opera- 
tion, convalesced without any disagreeable complications, and left the 
hospital during the middle of the fourth week of his confinement. He 
can now pass his urine naturally at proper intervals, emptying his 
bladder after each act. 
Case B.—Sixty years old. When first seen, was in a state of reten- 
tion of urine, with dribbling, owing to prostatic obstruction. He had 
been in that condition some time. A catheter was passed under anti- 
septic precautions, and the attempt made to break him into catheter 
life. He was shown how to use his catheter, and apparently was able 
to use it himself at the end of a week. At the end of that time, how- 
ever, in some unaccountable way he twisted and bent upon itself in 
his urethra a gum-elastic instrument in a vain attempt to draw his 
urine, and in his effort to withdraw his bent-up instrument he pro- 8 
Original Communications. 
duced an extensive rent in the membranous urethra. Much vesical 
tenesmus followed, associated with chill and fever. Chloroform had to 
be given in order to pass a catheter, and only then a silver instrument 
could be passed, and that with great difficulty. The case being then 
one of emergency, was operated on, I made the suprapubic incision, 
and enucleated in the way described a large collarlike hypertrophy of 
the prostate. The case did finely, being confined to bed bat three 
weeks. The result is all that can be desired. He urinates naturally, 
with good stream, at proper intervals, emptying his bladder after 
each act. 
Case C.—Seventy-three years old. When first seen, was in a state 
of acute retention, with great vesical distention due to prostatic ob- 
struction. The immediate cause of the retention had been exposure to 
cold under circumstances which did not allow of his making the at- 
tempt to urinate when first called upon to do so. I succeeded with 
some difficulty in passing a gum-elastic catheter. This instrument 
was left in the urethra and tied securely. The case was then turned 
over to his regular attending physician, with directions to remove the 
catheter at the end of thirty-six hours, after which time resort to regu- 
lar catheterization was prescribed as occasion required. I was called 
again at the end of four days in a hurry. He was again in a state of 
retention. He had some fever, and had bled freely from the urethra. 
1 found he had discharged his original doctor, and that he had had 
several others besides since I had seen him. All had found great dif- 
ficulty in drawing his urine. I made an attempt and found that noth- 
ing would pass except a silver instrument with an extreme prostatic 
curve. This instrument could only be passed with the greatest diffi- 
culty. The urine drawn off was bloody and somewhat decomposed. 
There were evidences of urethral lacerations in the region of the pros- 
tatic sinus. On the next attempt even this instrument would not pass, 
and I found it necessaiy to aspirate. Up to this time the patient had 
been very obstinate, and would not listen to any proposition recom- 
mending a cutting operation. I now told him, however, that unless 
he left me free to act as I saw fit I would give up his case. He then 
consented to operation. At this time he was suffering from renal sup- 
pression and evidences of commencing sepsis. His pulse was also 
feeble. Taking into consideration his advanced age, with all these 
bad symptoms, the outlook for a favorable result from a radical opera- 
tion was certainly poor. I, however, determined upon and did a su- 
prapubic prostatectomy according to the method herein advocated. I 
found two very large lateral hypertrophies. The median lobe was not 
marked. These hypertrophies were all thoroughly enucleated without Six Successful and Successive Cases of Prostatectomy. 
9 
difficulty. One of the lateral ones was found to have been pierced to 
its center by a punctate wound of recent date, evidently made by a 
catheter. After the operation the patient convalesced slowly but 
steadily, and left the hospital in his fifth week. Five months after 
the operation he reported hale and hearty, stating that he felt ten 
years younger. His urinations were normal, natural, and complete, 
each act emptying the bladder. He stated that he had not urinated 
since boyhood with such force and satisfaction as at the present 
time. 
Case D.—Forty-eight years old. About a year and a half before 
consulting me he had noticed that at times he urinated with difficulty. 
This difficulty had gradually increased until he was seized with com- 
plete retention, which accident had occurred six months before his 
first consultation with me. Since that time he had been obliged to 
depend entirely on his catheter. Sometimes he had experienced great 
difficulty in introducing his instrument. This difficulty was becoming 
more marked, so that he felt that other and more radical measures 
should be employed for his relief. The urine was slightly purulent, 
hut of good quality. Hectal examination showed but slight enlarge- 
ment of the prostate. A good-sized steel instrument could be passed 
into the bladder provided its end was kept well up against the roof of 
the prostatic urethra during its passage, otherwise the instrument 
would be arrested by a firm obstruction in connection with the floor of 
the prostatic urethra. Owing to the age of the patient and to the 
small size of the prostate as felt per rectum, it was not thought neces- 
sary to make a suprapubic incision, the perineal route being employed. 
As the result of this operation a very hard fibrous mass, similar in 
shape to but somewhat smaller than a hen’s egg, was found lying 
transversely across the floor of the bladder just at the vesical neck. 
This mass was cut through by the knife in making the perineal in- 
cision, It was, however, so fibrous and so firmly attached to the cap- 
sule of the prostate that it was found impossible to enucleate it, and it 
consequently had to be cut away by the use both of the serrated scis- 
sors and of prostatectomy cutting forceps. This was the only case out 
of the six where it was found impossible to accomplish enucleation, 
and I am inclined to suspect that the growth may prove to be more of 
the nature of a fibroma originating in the capsule of the prostate than 
of a senile prostatic hypertrophy. The patient recovered from the 
operation without trouble, and at the end of his third week was pass- 
ing a full, forcible stream along the urethra. He went home shortly 
after with a perfect result, his urine being clear and his urinations 
being normal and complete. 10 
Original Communications. 
Case E.—Fifty-eight years old, a charity case. He gave a history 
of a sudden retention of urine four years before consulting me. At 
that time he lay in bed a week or ten days, suffering intensely without 
surgical relief, the urine dribbling passively away after the vesical dis- 
tention had become extreme. Finally, the bladder unaided regained a 
little of its expulsive force. Since that time he had continually suf- 
fered from urgent, frequent, and difficult urination day and night, with 
at times attacks of complete retention. For relief from his latter 
attacks of retention he had visited dispensaries and hospitals and been 
catheterized. After leaving these institutions, however, the use of the 
catheter had always been discontinued, on the ground that he could 
not use the instrument himself, and that it made him very sore locally 
as well as feverish. On examining him I found a distended bladder, 
the summit of which was halfway between the pubes and umbilicus. 
Rectal feel showed the prostate to be very large and hard. The urine 
was of low specific gravity, abnormally abundant in amount, slightly 
acid, and loaded with albumin together with granular and hyaline 
casts. It was also bacterial and moderately purulent. The tongue 
was dry at times, and there were stomach and bowel disturbances 
which I took to be of a uraemic nature. The patient was feeble and 
altogether an extremely bad surgical risk. Yesical drainage was, 
however, called for in order to give him relief. I decided to enucleate 
the prostate by the suprapubic operation and to establish as usual 
perineal drainage. I enucleated two large lateral hypertrophies to- 
gether with a smaller median one, the whole mass coming away in 
one piece (see Fig. 1). The operation was easy of performance and 
there were no attendant complications. There was considerable sup- 
pression after the operation, and on the third day the patient, being 
delirious tore off his dressings and pulled out the perineal and supra- 
pubic drainage tubes. These were never replaced. By careful atten- 
tion and abundant diuresis this severe uraemic attack was finally 
weathered. Owing to his wretched condition, and partly also to his 
premature removal of the drainage tubes, a slough occurred in the 
space of Retzius. All the vesical suffering was removed by the 
operation, and the urine improved in quality. Four weeks after 
the operation the patient sat up, and now, six weeks after, he walks 
about the ward with the aid of an attendant. The urine, now 
clean, still comes through the granulating suprapubic wound, which 
the slough made quite extensive. There is good expansive force 
to the bladder, and with the suprapubic wound closed I feel that urina- 
tion will be accomplished without difficulty. The uraemic symptoms 
have not all disappeared, and at times he is drowsy or excitable. It is Six Successful and Successive Cases of Prostatectomy. 
11 
probable that after a time he will succumb to his nephritis, and such is 
to be expected, especially since, owing to his poverty, comparatively 
little can be done for him. In this case double castration was sug- 
gested, but refused by the patient. 
Case F.—Sixty-three years old. When first seen by me he was 
using a catheter, being unable to void any urine naturally, owing to 
prostatic hypertrophy. He was dissatisfied with catheter life and 
wanted something radical done. He was not willing to lose his testi- 
cles. His urine was of good quality and his prostate large. I per- 
formed the suprapubic operation and enucleated two large lateral 
hypertrophies together with a collarlike median hypertrophy partially 
surrounding the prostatic urethra (see Fig. 2), He did not tolerate 
well the perineal drainage tube, since it caused much tenesmus. Con- 
sequently I removed it on the third day, letting him drain through the 
suprapubic tube. On the twentieth day after the operation the supra- 
pubic wound had so closed that he began to pass urine through the 
urethra. How, at the end of his fourth week, he is able to leave 
the hospital, passing his urine freely, easily, and completely by the 
urethra.