TREATMENT OF PROSTATIC CALCULI

By MILES Fox, Ch.M., F.R.C.S.l

Senior Registrar, St Peter’s Hospital for Stone, London

CALCULI form in every prostate during the normal process of ageing (Thompson, 1861). They usually remain very small, consisting merely of calcified corpora amylacea, give rise to no symptoms, and do not require treatment. Under certain conditions, however, marked enlargement and increase in number and size occur, either of the stones already present or as an entirely new formation. An underlying pathological process is present in the majority of these

FIG. 1 FIG. 2

Fig. 1.-Multiple prostatic calculi present in the prostate. Fig. 2.-X-ray of the same patient as shown in Fig. 1 , but taken five years later. One of the stones originally

seen in the prostate is now in the bladder.

cases (Fox, 1960 a). Once formed, the calculi are often responsible for aggravating and perpetuating the condition which caused them, and, if recurrence is to be avoided, their removal together with the diseased tissue is imperative.

In order to study the clinical course and treatment of patients with prostatic calculi, pelvic X-rays of all men attending St Peter’s Hospital over a five-year period 1954-59 were examined. Prostatic stones were found in 484 cases out of 3,510 (13.8 per cent.). These obviously did not represent all the patients who had prostatic calculi, but only that significant proportion whose stones were sufficiently enlarged to be seen on X-ray examination of the pelvis. The majority suffered from benign prostatic enlargement ; the other cases were associated with prostatic carcinoma, prostatitis, urethral stricture, pyogenic and tuberculous infection, and stones in the urinary tract (Fox, 1960 b).

Indications for Operation.-The presence of stones was not by itself an indication for intervention. Operation was carried out for the relief of obstruction at the bladder neck, recurrent prostatic and urinary infection, and occasionally pain which was sometimes severe. Associated conditions such as tight urethral strictures and vesical stones were treated initially, for they were frequently responsible for a large part of the symptoms.

i Present address : Department of Urology, General Infirmary, Leeds. 93

94 B R I T I S H J O U R N A L O F U R O L O G Y

Indications for operation in benign prostatic enlargement were not influenced by the presence of stones in the prostate. In a number of cases there was initial difficulty in differentiating between a hard irregular prostate containing stones and a superadded carcinoma. Careful observation and assessment of the size and consistence of the prostate before and after a therapeutic trial with estrogens, and biopsy, clarified the diagnosis ; when confirmed, the carcinoma was treated on the usual lines.

Recurrent bladder stones formed in several patients with prostatic calculi ; an increased incidence of bladder stones in association with prostatic calculi was noted by Joly (1929) and Fox (1960 a). Figs. 1 and 2 illustrate one case ; they are X-rays of the same patient taken over an interval of five years. The prostate contained a large number of stones and was the seat of chronic prostatitis. The patient reattended on the second occasion because of an exacerbation of his symptoms which included perineal and suprapubic pain. A stone was found in the bladder ; its origin in the prostate is demonstrated in the X-rays.

The number and nature of operations performed in this series of 484 patients in relation to the number and size of the stones are shown in the Table.

Type of Treatment.

Retropubic and transvesical prostatectomy . Perurethral resection-

Carcinoma of prostate . Fibroadenomatous prostate and bladder-neck

' fibrosis . . 1 Prostatitis .

I N o treatment . Subtotal prostatectomy . .

TABLE

Under Ten Stones.

Small Large Stones. Stones.

-~ -~

36 31

6

5 2

... . . . I25 76

Large Number More of Densely

Numerous Packed and Stones. Confluent Masses

of Stones.

44 10

5 I 5 2

... 3 I14 19

N o operative treatment was carried out in 334 patients (71 per cent. of the total seen). The majority had benign prostatic enlargement but not sufficient indications for operation at the time of attendance. Nineteen patients had numerous stones ; the majority suffered from long-standing urinary infection and chronic prostatitis. Their symptoms were not severe enough to warrant operative intervention, the infection being kept in check by antibacterial drugs as necessary.

TYPE OF OPERATION

The nature of the operation depended on the condition with which the patient presented : as a rule this was the underlying process responsible for the formation of the stones.

1 . Enucleation of the Prostatic Adenoma.-The majority of patients requiring operation fell into this category. The stones were situated in the line of cleavage between the adenoma and the false capsule. Enucleation was usually carried out by the retropubic method, but transvesical prostatectomy was also employed on a number of occasions. The adenoma was frequently adherent posteriorly and sharp dissection was required to separate it from the capsule. The adenomatous tissue was removed, including as many as possible of the prostatic ducts and acini

T R E A T M E N T OF P R O S T A T I C C A L C U L I 95

bearing the calculi. The prostatic cavity was inspected and carefully palpated, and, if necessary, further blunt or sharp dissection was performed. The aim was to leave the prostatic cavity clean, smooth, and soft. Subsequent treatment was the same as for uncomplicated enucleation prostatectomy. In the small prostates in particular, the adhesions tended to be numerous, and in these cases perurethral resection proved to be the more satisfactory treatment.

2. Resection of the Prostate and Removal of Stones.--(a) Suprapubic 0perafion.-Five patients were treated by this method. As the number of stones and inflammatory changes in the prostate increased, so it was necessary to employ more sharp dissection to remove the obstructing or infected prostatic tissue. The internal urethral meatus tended to be hard and rigid and in some cases had to be dilated or even incised as a first step to removing the gland. By a combination of separation with the finger and sharp dissection, the diseased portions of the gland were removed, frequently in a piecemeal fashion, and the stones were liberated. Exposure frequently left much to be desired and the field was further obscured by considerable oozing of blood. Some infected prostatic tissue and stones were not infrequently left behind, infection tended to persist, and bladder-neck obstruction was only partially relieved. Two patients required further bladder-neck resection subsequently.

(b) The perineal approach was not carried out in this series. (c) Retropubic Operation.-The mode of treatment was analogous to that employed by the

suprapubic route, the capsule being opened and as much as possible of the infected glandular tissue and stones removed by sharp dissection and curettage. This was carried out on three occasions. The exposure was better and more direct, allowing more complete clearance of prostatic tissue. A longitudinal incision was helpful in these cases, and it was possible to combine it with Y-V plasty of the bladder neck to avoid any tendency to bladder-neck stenosis.

One patient continued to have persistent urinary infection and subsequently required further treatment because of bladder-neck obstruction. The other two made satisfactory recoveries ; Y-V plasty of the bladder neck was carried out in one.

(d) Perurethraf resection was performed in seven patients suffering from chronic prostatitis and multiple prostatic stones, in six patients with carcinoma of the prostate, and in thirteen patients with small fibrous prostates and bladder-neck stenosis accompanied by stones.

By this method of resection it was possible to remove much of the diseased gland and most of the stones. Total eradication of the disease was, however, not always accomplished, because some infected tissue and stones tended to remain. Chronic urinary infection continued in three out of seven patients following perurethral resection. Two, however, had long-standing urethral strictures. One patient developed retention of urine one month later, when a prostatic stone became impacted in the distal part of the urethra.

3. Subtotal Prostatectomy.-In order to remove all infected prostatic tissue and stones, i t is necessary to excise the prostate together with the capsule. A small cuff of prostatic capsule can be left near the apex of the prostate and the bladder sutured to it. This step prevents the occurrence of urinary incontinence which is sometimes seen after total prostatectomy, without interfering with the ultimate cure of the condition.

Three patients were treated by subtotal prostatectomy, using the retropubic approach.

Case 1.-W. L., aged 39 years, gave a six-months’ history of recurrent prostatic infection following an attack Each attack of prostatitis was accompanied by a considerable amount of pain, tenesmus,

When seen in February 1958 he had had three courses of His prostate was a little tender and urine after

Straight X-ray examination I.V.P. examination was normal.

Subtotal prostatectomy was performed in September 1958. He made an uneventful recovery and was

of acute prostatitis. frequency of micturition, dysuria, and strangury. chloramphenicol, and sulphonamides for prolonged periods. prostatic massage contained a considerable amount of pus, cultures yielding E. coli. of the renal tract showed large numbers of prostatic calculi.

96 B R I T I S H J O U R N A L O F U R O L O G Y

discharged home sixteen days after the operation. The tissue removed weighed 34 g., and histological examination confirmed the diagnosis of acute on chronic prostatitis with stones.

Micturition control was normal and he

had no frequency ( F: ). Sexual intercourse and orgasm were satisfactory, but he produced no

ejaculate. His urine was crystal clear, without pus or growth on culture.

When reviewed five months later he was well and symptom-free. ‘ D 6 .

N ‘ 0 -1 )

Case 2.-H. W., aged 26 years, was referred to St Peter’s Hospital in 1956 with a six-years’ history of frequency of micturition, dysuria, and hsmaturia. Left nephro-ureterectomy had been performed in I952 for renal tuberculosis which involved the ureter. The bladder was also affected and healing with antituberculous therapy had been slow. Stones in the prostate were noted on X-ray examination in 1956 and a calculus was also found in

FIG. 3

and there is a calculus in the bladder. Case 2 . Multiple stones are present in the prostate

the bladder, which was crushed and evacuated. A further vesical calculus was crushed in 1957. He continued to have symptoms of frequency, dysuria, and perineal pain, and from time to time passed small stones. The urine was constantly infected (with Staph. aureus), symptoms became more severe, and in 1958 a further vesical stone formed. The prostatic calculi were then large, very numerous, and distributed through the prostate (Fig. 3) .

He regained normal control of micturition two weeks after the operation and was discharged home several days later. The excised gland weighed 25 g. Histological examination showed chronic inflammation of the prostatic ducts with stones, and many tuberculous follicles deep to the epithelial lining.

When reviewed two years later the patient was fit and well, passing a clear sterile urine without frequency. Orgasm was normal but produced no ejaculate.

Case 3.--5. A. M., aged 69 years, attended in November 1957, complaining of frequency, dysuria, and poor stream of micturition of two years’ duration. Wide-spectrum antibiotics had been administered for three attacks of acute prostatitis and cystitis, but the urinary infection was never eradicated. The urine contained many pus cells, and cultures yielded B. aerogenes. Numerous stones were seen distributed throughout the prostate. A large amount of residual urine was present in the bladder and this was confirmed on cystoscopy. It was noted that the instrument was gripped by the prostate during the examination.

Subtotal prostatectomy was performed in November 1958.

I.V.P. examination showed a normal upper urinary tract.

T R E A T M E N T OF P R O S T A T I C C A L C U L I 97

Recovery was uneventful and he was discharged from hospital seventeen days after the operation. The tissue removed weighed 37 g., and histological examination showed focal acute and chronic inflammatory changes throughout the gland with numerous calculi in the ducts and acini.

Some difficulty in micturition control occurred for three months, but when seen again five months after the operation he had normal control and was passing a clear urine at three-hourly intervals.

Subtotal prostatectomy was performed later in November 1957.

DISCUSSION

Prostatic stones are a very common finding in men over middle age. In the majority they produce no symptoms and do not require treatment. In a small proportion of patients, however, the stones enlarge and may give rise to symptoms which can be severe. They include recurrent attacks of cystitis and prostatitis and pain. Although the stones usually reflect the condition that caused them, they afterwards aggravate and perpetuate that process, acting as foci of infection which encourage fkther production of stones. It is important, therefore, to remove the stones together with all the diseased prostatic tissue in order to eradicate the disease. This may not be difficult to accomplish where the stones are associated with benign prostatic hyperplasia and the adenoma shells out easily, liberating the stones from the line of cleavage. In many cases, however, adhesions are present especially posteriorly, and if numerous and dense, dissection can be very difficult.

Retropubic prostatectomy was the operation most frequently employed in St Peter’s Hospital. In most cases satisfactory exposure of the prostatic bed was obtained, the stones were removed, and good hremostasis accomplished.

When adhesions were more marked, especially in the smaller fibromuscular prostates and in cases associated with chronic prostatitis, the problem of treatment became more difficult.

The suprapubic, transvesical operation was usually unsatisfactory. Riches and Muir (1933) remarked on the poor results of this operation. Exposure and adequate removal of diseased tissue and stones were frequently inadequate. Tnfection tended to persist (two out of five patients treated required further bladder-neck resection). Other techniques were therefore usually employed.

The perineal approach to the prostate is rarely employed in this country and was not used in this series. Young ( 1 934), however, reported good results from perineal prostatolithotomy, but, as in the suprapubic operation, it was usually impossible to excise all the affected prostatic tissue without removing the prostatic capsule as well. Henline (1940) was not satisfied with the results of this operation and therefore performed perineal subtotal prostatectomy in order to eradicate the disease (see below).

Similar criticism can be levelled at the retropubic approach. It allows more direct exposure, but the removal of prostatic tissue is just as difficult. A vertical incision into the prostatic capsule may improve the operative field and can afterwards be combined with advantage with Y-V plasty of the bladder neck.

Perurethral resection of the prostate was frequently the operation of choice in these cases. Resection was more satisfactory than obtained by open methods. It was simpler than the more radical operations, frequently adequate, and unlikely to interfere with urinary continence and sexual potency.

Perurethral prostatotomy was described by Heitz Boyer (1933) and Thompson and Cook (1935). Ward (1951) used this method, laying open the stone-bearing ducts by means of a Colling’s knife introduced through a panendoscope. Although evacuation of the stones was adequate, complete drainage of the ducts could not be accomplished and the diseased prostatic tissue was left behind. This method of treatment was not employed in any of the cases reviewed.

Henline (1940) first advocated subtotal prostatectomy by the perineal route and described five patients treated in this manner. Millin (1947) performed the operation through a retropubic approach in preference to the perineal exposure which he formerly utilised. He found it easier,

I G

98 B R I T I S H J O U R N A L O F U R O L O G Y

there was less danger of injuring the rectum and compressor urethrre, and hzmostasis of the bladder neck and suturing were comparatively simple. Henline reported that sexual impotence was an almost invariable sequel to perineal subtotal prostatectomy. This is one of the reasons why the more conservative operative methods have usually been selected in younger patients, although they were not as certain to cure the condition. Neither of the younger two patients reported in this paper became impotent-possibly another advantage of the retropubic over the perineal approach to subtotal prostatectomy. All the three patients had prolonged symptoms of urinary infection and prostatitis, and were extremely grateful for the prompt and complete relief of their symptoms. The average stay in hospital was two and a half weeks. The urinary infection cleared completely and normal micturition control was regained by all three, the two younger patients in two weeks and the oldest (who was 69 years old) in three months from the time of the operation. Perineal subtotal prostatectomy in these cases proved to be a curative, expeditious, and safe technique for the treatment of calculous prostatitis.

1 am indebted to the Consultant Staff of St Peter’s Hospital, London, for permission to I wish to thank investigate patients under their care and for their helpful criticism and advice.

Mr R. Bartholomew for the photographic prints.

REFERENCES

Fox, M. (1960 a). ~ (1960 h). HEITZ BOYER, M. (1933). HEKLINE, R. (1940). JOLY, J. S. (1929). “ Stone and Calculous Disease of the Urinary Organs,” p. 519. (London :

MILLIN, T. (1947). *‘ Retropubic Urinary Surgery,” p. 140. (Edinburgh : E. & S. Livingstone

RICHES, E. W., and MUIR, E. G. (1933). THOMPSON, G. J., and COOK, E. N. (1935). THOMPSON, H. (1861). “ The Diseases of the Prostate,” p. 312. (London : J. Churchill.) WARD, R. 0. (1951). YOUNG, H. H. (1934).

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