ADENOMA OF THE PROSTATE (adenoma prostatae; synonym: adenoma of a cranial part of a prostate, periurethral adenoma, a knotty or adenomatous hyperplasia, an adenomatous dishormonal prostatopathy) — a high-quality new growth of a complex structure, coming from a cranial part of a prostate. The former name — a prostatauxe — does not correspond to a being and a morphological picture of process.
And. item. — disease of advanced age. It is observed at men 50 years are more senior. The greatest number of patients, according to L. I. Dunayevsky, belongs to age groups of 50 — 60 years (24,7%) and 60 — 70 years (52,2%). According to Blum and Rubritsius (V. Blum, N. Rubritius), And. item. often meets in India, Egypt, North America and England, and in Japan and China — it is extremely rare.
And. item. it is quite often observed at the father and at sons. Gyuyon and Lege (F. Guyon, F. Legueu) connect the frequency of emergence And. item. at fathers and sons with a factor of hereditary predisposition. In genesis And. item. has value and an occupation. According to L. I. Dunayevsky, nearly 60% of patients led a sedentary life.
The etiology and a pathogeny
gained the Greatest recognition the endocrine theory, or, correct, the theory of correlative dysfunction of gonads. Still E. V. Pelikan in 1872 proved that the prostate at castration before puberty but develops, and at castration after approach of puberty atrophies. In 1892 — 1893 F. I. Sinitsyn, proceeding from interrelation between development of testicles and a prostate, treated And. item. castration; B. V. Klyucharev, V. P. Konoplev and L. M. Shabad confirmed emergence of endocrine frustration at involution of gonads.
This theory received Anatomo-morfologichesky confirmation after microscopic studying of cuts of a prostate [Gilles S. Gil Vernet], embryological researches.
Anatomo-morfologichesky researches by method of a trakhiskopiya of blocks of a prostate according to M. A. Baron (back department of urethral dripped, a neck of a bladder) showed that the prostate is body of a diverse structure. In it the different ferruterous educations sensitive to hormonal influences of the unequal nature coexist.
In to a prostate (see) in the practical relation it is accepted to distinguish: upper, or a lobby — a cranial part and lower, or back — a caudal part; with age distinction of a structure of these parts comes to light more clearly (fig. 1 and 2).
Adenoma develops in a cranial part, and cancer — in caudal. Adenoma and a prostate cancer can coexist at the same patient at the same time.
The pathological anatomy
the Prostate at adenoma is increased; weight it can reach 80 — 100 g and more. Microscopically allocate the ferruterous, fibromuscular and mixed forms A. item. Adenomatous nodes are constructed of closely located branchy glands forming numerous crypts and papillary outgrowths. Glands are covered by 1 — 2 layers of cells of a high prismatic epithelium. In a gleam of glands — the condensed secret, colloid corpuscles, accumulations of leukocytes. The stroma of nodes consists of the mature fibromuscular fabric poor in cellular elements. Leukocytic and lympho-histiocytic infiltrates, abscesses, the centers of a necrosis meet.
At fibroadenomatozny structures nodes consist of seldom scattered ferruterous elements of a tubular and alveolar structure. The stroma of nodes is rich with cells like fibroblasts. Tubular adenoma meets seldom. Nodes are usually single; they are constructed of the twisting or straightened tubules covered by one number of high prismatic cells with faintly painted cytoplasm and basally the located kernels. Kernels divisions, hyperchromic without figures.
Fibromuscular nodes, spheroids, it is possible to see almost in all cases along with nodes of a ferruterous structure. These nodes, as a rule, multiple, seldom exceed 1 — 2 cm in the diameter. They consist of the fibrous fabric rich with cellular elements reminding a stroma of a prostate of an embryo; more often in them cells of muscular type prevail. In the thickness of such nodes it is possible to see primitively constructed tubules covered flat, cubic more rare a single-row high prismatic epithelium.
The clinical picture
distinguishes Most of urologists in a clinical current And. item. three stages; some — four stages (having allocated the IV stage from III); The I stage — harbingers (the initial erased symptoms), the II stage — a hyperemia (the period of a dysuria and dystonia), the III stage — an incomplete chronic ischuria (the period of a residual urine), the IV stage — an inconscience with overflow (the period of an incomplete ischuria with stretching of sphincters of a bladder).
I stage (preclinical) is observed more often at patients at the age of 50 — 60 years suffering earlier from disturbances of blood circulation of urinogenital system (because of the postponed infections). It is known that more than a third of men in a prostate and seed bubbles has over 35 years developments of stagnation and an infection [A. J. Leader]. Aged after 50 years with development And. item. there are early symptoms in the form of insignificant disturbances of the act of an urination, unpleasant feelings in a crotch, in the bottom of a stomach, in back department of an urethra. This early symptomatology speaks previous And. item. works with a phase of histiocytic infiltration in a reflexogenic zone in a vesical triangle, edge as the irritating factor.
Precursory symptom And. item. there can be a premature ejaculation, and also a hemospermia which arose after 50 years. At the last it is necessary to exclude a prostate cancer.
II stage — stage of a dysuria. There is a speeded-up urination in the beginning at night, later and in the afternoon. The symptom of an imperative desire which differs from a similar symptom at cystitis and a back urethritis in the fact that it is not followed by morbidity and opacification of urine is typical for this stage, but its intensity is very big. The imperative desire leads to not deduction of urine. Emergence of not deduction of urine after 50 years often specifies on And. item.
Periodically dysuric phenomena can weaken, even to disappear, but with growth And. item. accrue. The joining infection strengthens a dysuria. There is a complicated urination: in the beginning after a dream, long sitting, overflow of a bladder. The stagnation in venous system of a basin caused by locks, an okhlazhda niy a body and especially lower extremities, an alcohol abuse, sexual excesses strengthens difficulty of the act of an urination. The stream of urine, especially at the beginning of the act of an urination weakens, the squirt falls aweigh down (the patient urinates to himself on legs), is sprayed and soils linen. The night pollakiuria and a polyuria amplifies.
At suspicion on And. item. it is necessary to measure amount of urine and to count number of urinations since the pollakiuria in the second half of night is an important symptom And. item. The general condition of the patient in I and II stages of development And. item. remains satisfactory unless the night pollakiuria interrupts a sleep of the patient and he becomes nervous, irritable, complains of fatigue, impossibility to concentrate. The proof that the disease is in the II stage is lack of a residual urine. At the end of the II stage the hypertrophy of a muscular wall of a bladder and its trabekulyarnost as a result of reaction to the increased intravesical pressure, disturbance of a tone in a neck of a bladder and back department of an urethra appears. All these phenomena accrue in the III stage.
III stage — stage of an incomplete chronic ischuria. Transition of the II stage to III can take place hardly noticeably for the patient, but objectively is always expressed by existence of a residual urine, the quantity a cut steadily increases. In the III stage of a disease all overlying bodies of the uric device suffer: the tone of a detruzor weakens, the hypertrophy is replaced by thinning of a wall of a bubble, muscle fibers stretch and numerous small false diverticulums appear. Especially quickly there comes the decompensation of a wall of a bubble at increase in a so-called average share of gland, edges are blocked as if by a way to release of urine (fig. 3). Growing up and kzad And. item. kryuchkoobrazno raises and squeezes yukstavezikalny departments of ureters that is well visible (a symptom of «a fishing hook») on excretory Urogramum.
Insufficient bladder emptying leads to expansion of ureters and a renal pelvis; renal nipples are flattened, the renal parenchyma becomes thinner from pressure that leads to heavy renal failures, an outcome of what can be uraemia (see). In the beginning the kidney loses ability to concentrate urine and it needs for release of slags a large amount of liquid, ability of cultivation suffers later. The III stage lasts for years; the phenomena of stretching accrue so slowly that the patient gets used to the state, without feeling the increasing quantity of a residual urine. This results from the fact that together with reduction of sokratitelny ability of a bubble its sensitivity decreases. Gradually the bubble stretches and may contain 1,5 — 2 l of urine; tension of the urine which accumulated in a bladder overcomes resistance of sphincters, and urine begins to be emitted involuntarily on drops. The disease passes into the following stage.
IV stage — period of paradoxical ischurias (see), i.e. paradoxical ischuria or «detention with an incontience». In this period the renal failure with the phenomena of intoxication is expressed, and as a result of it arise went. - kish. frustration. Often make to patients wrong diagnoses: gastritis, cholecystitis, coloenteritis, carcinoma of the stomach. At the same time or slightly earlier thirst (polydipsia) which is result of an azotemia develops. Dehydration leads to sharp emaciation. Toxic oppression of function of a liver is shown by yellowness of integuments. With development of a disease oppression of the neutralizing function of a liver increases. 10 — 15 days later after cystostomy functional activity of a liver considerably improves (A. Ya. Pytel).
The factors stated above (dehydration, toxic oppression of function of a liver, frustration went. - kish. a path), and also the fastidium, cardiovascular disturbances at a certain group of patients mask symptoms of uric obstruction that induces some urologists to combine this group under the name of the hidden («mute») prostatism. At the same time early vesical symptoms remain unnoticed.
the Acute ischuria — the most frequent heavy complication at And. item., coming more often in II and III stages of a disease. It results from an acute hyperemia of pelvic bodies (at an alcohol abuse, overcooling, overfatigue, a long delay of an urination. long stay in a sitting position or lying), it is frequent at elderly people, forced it is long to be in a bed during cardiovascular crises, and also at purpose of diuretics. What it will be carried out earlier by catheterization (see), rather function of a bladder will be recovered.
The acute ischuria which arose in the II stage can not repeat a long time after catheterization, in the III stage of a disease it can be a rack and demand operational treatment.
Developments of stagnation in a bladder and overlying uric ways promote development of an infection, especially at the patients who underwent catheterization. Cystitis (see) — extremely frequent and recurrent complication. A heavy complication is pyelonephritis (see), observed almost at a half of the patients suffering And. item. Inflammatory processes in adenomatously changed gland are quite often observed — adenomit, and also epididymite (see) and deferentitis (see). For prevention of the last by the patient A. item., needing catheterization, recommend to carry out vasoresection (see).
Inspection of the patient
During the studying of the anamnesis it is necessary to get acquainted with heredity of the patient as And. item. it is quite often observed at men of one family. It is important to reveal the former sexually transmitted infections: syphilis can lead to the tabes masking the phenomena of a prostatism and demanding a special neurologic research; the gonorrhea transferred to youth can lead to formation of strictures of an urethra.
Sexual function at And. item. it is in a varying degree broken. In an early stage of a disease the raised sexual excitement can be observed. In process of increase in obstruction sexual interests and abilities fall or absolutely disappear, but can appear after an adenomectomy again.
The habit view of the patient, a condition of his skin, yellowness, dryness and rugosity confirm dehydration and existence of far come toxaemia.
Local research at And. item.: survey and a palpation of a stomach, percussion of a stomach in suprapubic area, a manual research of a prostate. Then define a residual urine, conduct X-ray inspection, a tsistoskopiya, a research of function of kidneys, a biochemical blood analysis.
In policlinic it is necessary to carry out dvukhstakanny test (see. Stakanny tests ), a clinical and bacteriological trial of urine, blood on residual nitrogen, the research per rectum, definition of a residual urine catheterization (the last research can be combined with a X-ray analysis), all types of a radiographic research (a pnevmotsistografiya, a lacunary tsistografiya, an uretrotsistografiya). Patients can make excretory urography in polyclinic conditions with the specific weight of urine not below 1,012 — 1,015, with the normal or slightly increased content of residual nitrogen, with a standard arterial atmosphere pressure. 65 years weakened patients are more senior than patients and patients in the III—IV stages of a disease should be inspected in stationary conditions. At a chronic ischuria or at an acute full ischuria in suprapubic area education — painless, a soft and elastic consistence is defined a pear-shaped form. Belonging of this education to a bladder is confirmed at catheterization. Percussion is carried out after the act of an urination; normal the bladder is reduced so that leaves deeply for symphisis pubica, and then over the last the tympanic sound is defined; the dullness indicates existence of a residual urine. It is possible to determine by percussion a bubble at contents in it 300 ml of urine.
Rectal manual research A. item. carry out in kolennoloktevy position of the patient or in situation on the right side with the hips bent in knees and densely attracted to a stomach. In the latter case the doctor costs from the sick person and facing it. The research should be conducted after an urination or catheterization of a bladder. At And. item. the sizes of its shares increase evenly or asymmetrically, the median groove can be maleficiated, the upper edge of gland at its strong increase is unavailable to a manual research; the consistence of gland happens soft and ferruterous, or plotnovato-fibrous. If a consistence very dense and the centers of consolidation differ in cartilaginous or ligneous density, assume cancer. At And. item. the mucous membrane of a rectum over a prostate is always mobile, at cancer which (especially far came) is slow-moving, the gruboskladchata also can give feeling of easy crepitation. Sensitivity of a prostate at its adenoma is small, amplifies at inflammatory changes.
X-ray inspection. Apply excretory urography, a tsistografiya and an uretrotsistografiya; the lacunary uretrotsistogramma across Knayza and Shober (fig. 4) is most rational. The oxygen entered on a catheter in number of 150 — 200 ml stretches a bladder in the form of a dome. The liquid contrast agent entered after oxygen (20% solution of Sergosinum in number of 20 ml) is located in the field of a bottom of a bladder, revealing intravesical growth And. item. Determine by this method a number of typical radiological symptoms: «beret» (fig. 5), lengthening of an urethra (fig. 6), «a blade of a saber» (fig. 7), the raised bottom.
The excretory urography, in addition to definition of function of kidneys, indicates a condition of the lower pieces of ureters which kryuchkoobrazno rise up, giving the image of «a fishing hook» (fig. 8). X-ray inspection reveals the stones and diverticulums which are also accompanying a disease.
Endoscopic methods of a research — tsistoskopiya (see), uretroskopiya (see) — it is necessary to carry out only at a hamaturia, suspicion of a tumor of a bladder or for differential diagnosis in not clear cases. Uretroskopiya is shown in an early stage of a disease and not at elderly patients. At a tsistoskopiya protrusions of a transitional fold in the form of a curtain (fig. 9) come to light, the average share in the form of a barrier is defined, existence of stones and associated diseases — cystitis, an ulcer, papilloma is specified. In II and III stages of a disease the tsistoskopiya is difficult, can be the cause of development of an infection, developing of prostatitis and epididymite. Therefore in recent years most of urologists prefers to carry out a tsistoskopiya in the operating room before operation.
Functional research kidneys it is necessary to carry out in all cases And. item. irrespective of a method of treatment (conservative or operational). Conduct a research of specific weight of urine, Zimnitsky's test (see. Zimnitsky test ), excretory urography, total indigokarminovy test with a catheter.
Coloring of urine in 6 — 8 min. after intravenous injection of indigo carmine is norm. Zimnitsky's test at patients with hron. an ischuria has the features: the residual urine shall be removed in the morning in day of a research since it does not enter the sum of a daily urine. By the end of test (in 24 hours) remove a residual urine again; the number of the last is attached to daily amount of urine.
At a full ischuria functional trials carry out in the presence of a constant catheter. Tests with cultivation and concentration are applied seldom. Fluctuations of specific weight of urine since 1,015 and are an indicator of good function of kidneys above. Constantly low specific weight of urine within 1,008 — 1,010 indicates a renal failure.
The functional condition of kidneys is estimated also but to definition at blood of residual nitrogen or urea. At the increased, accruing figures of residual nitrogen of blood (over 80 mg of %) it is necessary to recommend imposing of suprapubic fistula as the first stage of an adenomectomy.
The diagnosis is based on these above methods of a research. Diagnosis shall be local and functional. For assessment of the last it is necessary to use not one, but several methods of a functional research.
And. item. it is necessary to distinguish from cancer, acute prostatitis, tuberculosis, and also to exclude the diseases breaking outflow of urine: inflammatory or traumatic stricture of an urethra, obturation its stone, tumor of a neck of a bladder. Diseases of c can be a cause of infringement of the act of an urination. N of page; at the last are absent or desires to an urination at the crowded bladder are reduced. It is necessary to remember an opportunity And. item. at patients with neurogenic damage of a bladder. Carefully collected anamnesis, special neurologic research, and also contrast tsistografiya (tower bladder) allow to establish the correct diagnosis.
And. item. develops slowly. From time to time development of a disease as if stops, involution is in rare instances observed And. item. In I and II stages the disease does not constitute danger; conservative therapy during the long period maintains satisfactory condition of patients. In III and IV stages in the presence of a residual urine, decrease in function of kidneys and the joined infection arises opas a nost of uraemia, an urosepsis. The forecast in cases of the fulminant urosepsis which developed at patients with existence of obstruction is especially adverse. In III and IV stages of a disease the carried-out operational treatment yields satisfactory results.
Conservative therapy includes the hygienic mode, a diet, drug treatment and local physiotherapeutic procedures. Patients shall avoid the general cooling, especially cooling and a promachivaniye of legs, long sitting etc. that causes a hyperemia and developments of stagnation in bodies of a basin. It is not necessary to overdo urine also; the recystectasia can lead to a full acute ischuria. Extremely important value has a state went. - kish. path: locks strengthen a dysuria, promote an infection and an ischuria.
At locks appoint light laxatives and the corresponding diet. It is necessary to avoid purpose of the aloe and Folia sennae causing a hyperemia of a rectum. The diet can be not really strict. Completely exclude pepper, mustard, canned food and smoked products. Sodium chloride is not forbidden. Meat is limited only in cases of emergence of urates in urine or formations of urate urinary stones. Dairy products, except the milk causing swelling of intestines are very useful. Milk should be recommended with tea or coffee. Meat dishes recommend in the first half of day. After 6 hours of evening meal and liquids shall be limited, and in 2 — 3 hours prior to a dream is undesirable at all. Alkalescent mineral waters are not prohibited, but it is not recommended to direct patients to water resorts since water loadings cause weakness of a detruzor and promote an ischuria.
In the II—IV stages of a disease alcoholic beverages are completely prohibited; beer and fermentative drinks also shall be completely excluded as strengthening a pollakiuria.
Drug treatment and local procedures reduce a hyperemia and improve the general state, especially in the presence of an infection in uric bodies. At a dysuria the papaverine in candles well works: Papaverini hydrochlorici 0,02 — 0,05; Extr. Belladonnae 0,02; Butyri Cacao q. s.; M. f. supp., no to 1 candle of 1 — 2 time a day. It is possible to add to this structure amidopirip. Well warm microclysters with antipyrine affect (100 ml of warm water of 0,5 g of antipyrine). Microclysters should be applied daily within 10 — 15 days of 1 — 2 time a day.
Massage of a prostate is shown at the adenoma complicated by chronic prostatitis; light massage reduces a krovenapolneniye and stops pains.
Drug treatment by antibiotics and streptocides is applied at the accompanying cystitis and pyelonephritis. After identification of flora of urine by crops and definition of its sensitivity appoint the corresponding antibiotics (penicillin, streptomycin, biomycin), soluble streptocides (Sulfapyridazinum on 0,5 g of 1 — 2 time a day) or other drugs (furadonin 0,1 g 3 times a day, furagin 0,05 g of 6 times a day, Negramum, Nevigramonum on 0,5 - 1,0 g 4 times a day, 5-HOK on 0,1 g 4 times a day). Both antibiotics, and chemotherapeutic drugs should be changed, considering emergence of resistance to them.
At complicating And. item. cystitis the bladder is washed out on a catheter weak (1: 5000, 1: 10 000) solutions of silver nitrate, Furacilin, Aethacridinum (Rivanolum). At a large amount of putreform urine it is necessary to wash out carefully a bladder warm isotonic solution of sodium chloride or distilled water with the subsequent introduction of 15 — 20 ml of 1% of solution of colloid silver, 2% of solution of protargol or 20 — 25 ml of 3 — 5% of a sintomitsinovy emulsion.
Hormonal treatment of patients And. item. — palliative method.
Androgenic hormonal therapy can be applied only in initial stages And. item., when an operative measure is contraindicated or is not shown yet. After 65 — 70 years treatment by small and medium doses of estrogen more effectively can also give temporary improvement.
Good results are noted at use of Microfollinum and Chlortrianisenum by courses on 15 days with 15-day breaks (Microfollinum in tablets on 0,05 mg 2 — Z times a day under language or Chlortrianisenum in tablets on 0,012 g 3 times a day).
High doses of estrogen can cause an aggravation of cardiovascular frustration.
Only surgical treatment is radical. Indications to operation depend on a stage of a disease: emergence of a residual urine, a persistent infection, recurrent attacks of an ischuria, a hamaturia, multiple stones of zaprostatichesky space, sharp increase of the night urination interrupting a sleep — all these symptoms specify a pas need of operation.
Contraindications to a single-step adenomectomy are severe forms renal (an azotemia, a hypoisosthenuria) or heart failure, an aortic aneurysm, far come forms of atherosclerosis of brain vessels, a pulmonary heart.
A contraindication is also the exacerbation of chronic pyelonephritis and cystitis. Many of these contraindications are temporary, and the patient can be prepared for operation by the corresponding treatment, for the purpose of the prevention of a postoperative embolism it is necessary to reveal and treat a phlebectasia of the lower extremities; in the presence of those it is recommended in the preoperative period, during operation and in the postoperative period to bandage elastic bandage the lower extremities.
Apply the following types of operational treatment.
1. Double-stage transcystic operation on Holtsov. This operation is shown to the weakened patients with bad renal function when long drainage of uric ways is required. The first stage — imposing of suprapubic fistula for the term necessary for improvement of function of kidneys (of 3 weeks up to 6 months). The second stage — transcystic enucleation of adenoma. A lack of it like operation — need of leaving of a drainage on a long term.
2. A single-step transcystic adenomectomy according to Fedorov — to Freyer (fig. 10). This operation differs in simplicity of approach; a lethality at it about 2,0%. It is added a number of the receptions aimed at providing a hemostasis by suture on edges of a prostatic bed or its sewing up. The hemostasis at this operation is provided also with use of a catheter with the Pomerantsev — cylinder of Foley (fig. 11). Reduction of blood loss leads to reduction of such postoperative complications as sepsis or a renal failure.
3. Operation on Harris's method — Grinchaka (fig. 12) consists in sewing up of a prostatic bed after an adenomectomy under control of an eye around previously entered catheter: having removed the fabrics which remained after enucleation on edges of a prostatic bed put stitches a boomerang needle or usual considerable a curved needle on the long needle holder. If bleeding is completely stopped, the bubble can be taken in tightly; for 2 days enter into a bottom corner of a wound the small rubber or gauze graduate. The constant catheter provides evacuation of urine within 10 days. This method yields good results at careful postoperative leaving, especially in the first 2 days after operation: each 2 hours wash out a bubble warm isotonic solution of sodium chloride or 3,8% solution of sodium citrate for prevention of formation of blood clots.
4. Pozadilobkovy adenomectomy (fig. 13) it is for the first time offered by A. T. Lidsky and developed by Millin. Operation this a long time competed with Harris's operation.
In a crust. time it is applied less often because of the observed complications - to 15%. The patient is stacked in the provision of Trendelenburga with divorced legs; approach to a prostate is carried out through a vertical or cross suprapubic section. The peritoneal transitional fold is taken away up; pozadilobkovy cellulose is carefully taken away down and lateralno, avoiding an exposure of a back surface of a pubic joint. The big veins lying in a fascia on front side of a prostate gland are cut between ligatures. Own capsule of prostatic is opened with cross section of a bladder 1 cm lower than a neck.
A.p.zh. delete from the capsule with partially long curve scissors, partially a finger, allocating it up to a wall of a bladder, delete with crossing of the central part of an urethra at the neck of a bladder a tumor.
For the prevention of obstruction after an adenomectomy excise a cuff of a mucous membrane from a back arch of a neck of a bladder. The hemostasis is provided with a diathermy, and also imposing of a constant seam on a wound in the prostatic capsule; the last is very important. After a careful hemostasis through mocheis the puskatelyiy channel enter a catheter No. 18 into a bladder — 22 (on Sharryera) with big openings on the end. Over a catheter layer-by-layer take in a wound, on 48 hours enter into its bottom corner the rubber graduate.
The bubble is washed out hot normal saline solution and fill for 1 hour 3,8% with solution of sodium citrate.
5. A perineal adenomectomy according to Young (fig. 14) in a crust. time is almost not applied because of danger of emergence of complications: incontiences of urine, perineal fistulas, impotences. Emergence of these complications at perineal approach is quite explainable since adenoma is deleted through the caudal zone of a prostate which is closely connected with fabrics of an outside sphincter.
6. Transuretralpy resection carry more often out by an electrosurgical method; apply it at the disturbances of outflow of urine from a bladder caused by adenoma or a prostate cancer, a sclerosis or a tumor of a neck of a bladder. Contraindications: the urethrostenosis excluding an opportunity to carry out the tool to a bladder, the insufficient capacity of a bladder, the expressed renal failure.
The transurethral electroresection can be carried out under a local infiltration anesthesia according to A. V. Vishnevsky, an intravenous or inhalation anesthesia. Operation consists in excision of the fabrics narrowing a neck of a bladder; it is made the special tool — the resectoscope. It represents the endoscopic device supplied with a mobile loop-shaped electrode, with the help to-rogo cut off semi-cylindrical pieces of pathological fabric. The electroresection is carried out under continuous current of liquid through washing system. It is for this purpose recommended to use isotonic solutions of glucose, urea [A. M. Nyankovsky, Madsen (R. of Madsen)].
Technology of operation: the resectoscope with the obturator is entered into a bladder; the obturator is deleted, and on its place after partial filling of a bubble enter an electrode and optical system; attach inputs of lighting and coagulating current, and also washing system; current of high frequency is included (the operator or the assistant) by means of a foot pedal at the time of back motion of an electrode. The cut-off fabric cylinders delete with a reversed current of liquid. At considerable bleeding the bleeding sites coagulate by means of a special electrode roller. For achievement of a positive take do from 10 to 50 cuts. After an electroresection enter into a bladder for 3 — 7 days a constant catheter cylinder through which 3 — 4 times a day wash out a bladder.
The most frequent complication of a transurethral resection is bleeding. In addition to electrothermic coagulation, for the purpose of a hemostasis apply hemotransfusions, in more hard cases there can be a need of an epicystostomy with a tamponade of a neck or an adenomectomy.
It is recommended to apply a local hypothermia by cooling of wash liquid to prevention of bleeding (to t ° +2 °) with addition to it of vasoconstrictive substances (adrenaline, noradrenaline). During the use for filling and washing of a bladder of the distilled or boiled water disturbances of electrolytic balance, an intravascular hemolysis can be observed. Cases of an oliguria and an anury are described.
Errors in technology of operation can lead to perforation of a wall of a bladder; at the same time discrepancy of amount of the entered and following liquid is observed during washing of a bladder. If operation is performed under local anesthesia, the patient at perforation of a wall of a bubble feels an acute pain in the bottom of a stomach. Treatment of this complication: urgent imposing of suprapubic fistula with drainage of paravesical space. At suspicion on intra belly perforation audit of an abdominal cavity is shown.
After a transurethral electro-resection in case of damage of an outside sphincter of a bladder sometimes there is an incontience of urine that can demand difficult plastic surgeries.
Since 1964 considerable distribution is gained by a method of a cryosurgery of a prostate. By means of the special tool freeze the prostate containing adenomatous or cancer nodes (fig. 15).
The cryothermal cryosurgery system SE-4 Linde device is most widely used. The main part it is the special cryoprobe mounted in the form of a catheter No. 25 on Sharryera in Krom liquid nitrogen circulates. The working freezing surface corresponds to a prostatic part of an urethra, and non-working is isolated in such a way that danger of freezing of other departments of an urethra and bladder is reliably eliminated. The cryolysis usually occurs at t ° from — 120 to — 190 ° within 2 — 5 min.
After use of cold during 2 days the stage of acute hypostasis develops. Then within a week — a stage of a coagulative necrosis with an autolysis of cells, and then a stage of healing — from 3 to 6 months.
Considering that to the main shortcomings of cryoprobes the impossibility of their use under control of sight is, the Reuters (N. of J. Reuter) suggested to carry out direct vision by means of the special cystoscope trocar entered into a bladder by a suprapubic puncture.
Cryosurgical operation is shown to seriously ill patients, the Crimea the adenomectomy or a transurethral resection (about 5 — 10% of cases) is contraindicated. At a cryosurgery of a prostate there can be complications: late bleedings, pyelonephritis, urethral fistulas, osteit pubic bones.
In the postoperative period at all types of operative measures there can be complications. The embolism of a pulmonary artery is especially dangerous. - The early rising is prevention of this complication. Secondary septic bleeding from a prostatic bed is a terrible postoperative complication. It arises usually for the 7-10th day after operation. On 2 — the 3rd days after an adenomectomy urine is purified of impurity of blood. If it does not occur and impurity of blood remains on 4 — the 5th days, then it indicates inflammatory process in a bed; the last can be the cause of septic bleeding. If washings of a bladder hot isotonic solution of sodium chloride or solution of silver nitrate do not stop bleeding, the tamponade of a bed, a hemotransfusion is shown.
Feverish states in the first days after operation quite often accompany an adenomectomy. Long temperature increase to 38 — 39 °, tremendous oznoba testify to pyelonephritis or thrombophlebitis of periprostatic space. In these cases treatment by antibiotics and himiopreparata is necessary. The stricture of back department urethral dripped develops in 3 — 6% of cases. It is quickly liquidated by bougieurage. The incontience of urine at correctly carried out transcystic adenomectomy does not meet. Development of this complication indicates damage of caudal department of a prostate and fibers of an outside sphincter; prolonged treatment by bougieurage, washing of a bladder as soon as possible after operation, later — massage of a prostate, physical therapy is required. It is long not healing suprapubic uric fistulas demand excision with layer-by-layer sewing up of fabrics. Emergence of a pubic osteit (an osteochondritis, an aseptic osteonecrosis, a panosteitis) — the localized osteoporosis of pubic bones — is connected with the combined influence of an injury, neurotrophic frustration in the haunch bones leading to their demineralization. Osteit it is shown by rare morbidity in a pubic joint, upper parts of hips.
In the postoperative period at a pubic osteit the bed rest, prolonged use of corticosteroids (Prednisolonum on 0,005 g 2 — 4 times a day, dexamethasone on 0,001 g 2 — 3 times a day) in combination with antibiotics is recommended.
Results of treatment of adenoma of a prostate in recent years considerably improved. The suprapubic adenomectomy is the main and most widespread method of operation. Many urologists and surgeons recommend to expand indications to single-step operation. A lethality at it — 3%. The Pozadilobkovy adenomectomy gained insignificant distribution because of complications in our country: thromboses, fistulas and a pubic osteit who is observed at 0,5 — 2% operated. The lethality at this operation fluctuates from 3% (E. Sh. Savich) to 6% [Borkher]. Transurethral electroresection — significant progress of surgical treatment And. N., however the limited number of patients can apply it with small intravesical and vnutriuretralyyuy adenoma. At this intervention there are complications, especially bleedings and inflammatory processes. A low lethality at this operation (0 — 2%) and an opportunity to apply it at the weakened old men and persons having cardiovascular diseases induce to recommend broader use of this method.
Considerably the reasons of a lethality at all methods of an adenomectomy changed: if during the period from 1931 to 1948 the uric infection and its complications was the main reason for lethal outcomes, then for the last 10 — 15 years thrombosis and an embolism of brain and pulmonary vessels, and also cardiovascular insufficiency is the main reason of a postoperative lethality. The over-all mortality at all methods of an adenomectomy considerably decreased in comparison with the first decades of 20 century and continues to decrease.
The progressing decrease in a lethality speaks not only successful fight against an infection, but also thorough training to operation of patients with cardiovascular and other diseases, a right choice of time and a method of operation, prevention of a thromboembolism and careful postoperative leaving.
See also Prostate .
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Ya. V. Gudynsky.