35

THE TREATMENT OF ACUTE RETENTIONOF URINE

With Special Reference to Immediate ProstatectomyBy J. D. FERGUSSON, M.D., F.R.C.S.

Surgeon to St. Peter's and St. Paul's Hospitals and to the Central Middlesex Hospital; Director, The Institute ofUrology (University of London)

There appears to exist in the minds of manysome confusion as to the correct procedure toadopt when confronted with a case of acute urin-ary retention. This, though mainly due todifficulty in balancing the benefit of catheterizationagainst the associated risk of introducing infection,springs also from a belief that there are certainforms of retention for which rapid decompressionby the natural channel may be dangerous, andsome in which the passage of an instrument isactually impracticable. Furthermore, even ifsuch a simple measure should suffice to. tide thepatient over his initial discomfort there remains,as will be seen, in practically every case theproblem of dealing later with an underlyingobstructive cause. An appreciation of the factthat immediate radical surgery may now be under-taken in many cases with a degree of safetyformerly unknown, also leads to a desire not toprejudice its success by the adoption of ill-advisedpreliminary procedures.The successful management of acute urinary

retention, therefore, demands a clear conceptionof its cause together with a full appraisal of thepossible methods applicable for its relief and theirconsequences. Nor is this sufficient, since in caseswith a similar aetiology treatment may sometimesrequire modification to suit the condition of thepatient, or adaptation to meet the needs ofattendant circumstances. Measures found satis-factory in straightforward cases due to prostaticobstruction lmay, for example, prove quite un-suitable when this type of retention complicatesthe progress of a patient suffering from pneumoniaor heart disease. Similarly, immediate operativetreatment, though successful in a well-equippedhospital with adequate transport facilities, may beentirely impracticable in remote rural areas. Muchmay depend also on the individual experience andadroitness of those dealing with the condition as to

how far any method is both safe and effective.This applies equally to catheterization and themore specialized operative techniques. There isno doubt that familiarity with a particular pro-cedure leads to a reduction in mortality andmorbidity which justifies its employment in awider field, but this should never invalidate theneed for careful selection. The art of surgery liesas much in an individual consideration of eachpatient's requirements as in the perfection withwhich the treatment is carried out.Nowadays the problem of selection has at once

been both simplified and complicated by theintroduction of new safeguards which permit theextension of early radical treatment to a widerrange of patients. Advances in anaesthesia, im-proved knowledge of fluid balance and bloodchemistry, and the availability of antibiotics, to saynothing of better raaiological techniques and morecomprehensive post-operative care, all combine toincrease the scope of surgery in cases of urinaryretention. While such improvements certainlydiminish the risk of surgical treatment they like-wise impose the need for team work and a thoroughunderstanding of their use and applicability. Incertain hospitals the organization of special unitshas enabled the adoption of a standard routine fordealing with a high proportion of cases of re-tention due to prostatic obstruction in whichimmediate' operation plays an integrant, if in-

dispensable, part. The results achieved by thismethod, when employed with discretion, haveshown a remarkably low mortality and a consider-able saving of time in hospital. It cannot, however,be too strongly emphasized that success is notwholly dependent on hospital organization. Thesafety ot immediate prostatectomy depends largelyon the initial preservation of asepsis, and it isclearly important that the risks oc early infectionby repeated catheterization under adverse con-

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36 POSTGRADUATE MEDICAL JOURNAL January I952

ditions in the home should be avoided. For thisreason it is well that a close liaison should beestablished between the practitioner undertakingthe initial arrangements and his neighbouringhospital, so that when it is felt that immediatesurgery may be contemplated suitably plannedaction can be undertaken from the start. It isonly in this way that a method which dependsessentially on mutual co-operation as much as onthe availability of certain technical facilities for itssuccess, can be applied with satisfactory results.Having thus indicated a trend in the surgery ofacute urinary retention it is now necessary toconsider the subject in a more general light, de-fining the condition with which we have to deal,reviewing its causes, and deciding how frequentlythese call for early operative treatment.

AetiologyAcute retention of urine implies a sudden

cessation of the ability to micturate, in consequenceof which a tense accumulation of urine occurswithin the bladder. In contrast to the relativelypainless state of the laxly distended bladder inchronic retention; the acute condition is alwayspainful, save when it follows certain forms ofspinal injury or, rarely, acute disease of the ner-vous system. Apart from such instances of traumaand neurological disease, it is generally held thatacute retention is usually precipitated by localcongestion superimposed on an organic obstruct-ing lesion of the lower urinary tract. Occasion-ally, however, it may result merely from spasm ofthe sphincter or inco-ordination of the mechanismof emptying without the presence of a previousobstructive element, as in hysterical or post-operative retention. In most cases admitted tohospital with acute retention, however, it is safe

TABLE I

ANALYSIS OF 300 CONSECUTIVE CASES ADMITTED TOHOSPITAL WITH ACUTE RETENTION

Per cent.Benign prostatic enlargement .. 193 64.3Prostatic carcinoma .. .. 39 13Urethral stricture (uncomplicated) . . 20

, , (with periurethral ab- - 7.7scess) . .. 3 J

Phimosis . .. . . 1 4 4.7Carcinoma of the bladder (clot reten-

tion) . . ... .. 5Papilloma of the bladder (clot retention) 4Impacted urethral calculus .. .. 3Acute cystitis ..... 2Acute prostatitis . .. .. 2

Rupture of urethra .. .. .. 2Papilloma of urethra .. .. .. ISpinal injury . .. ... 4Neurological disease . .. .. 4Ephedrine addiction . .. .. iMiscellaneous .. .. .. .. 3

to assume a pre-existing underlying obstruction,confirmation of which is often obtainable from ahistory of antecedent urinary difficulty. Ananalysis of 300 consecutive cases of acute urinaryretention occurring in the practice of a largegeneral hospital (Table i) amplifies this statement.The precipitating factor in acute retention is,

on the other hand, rather more indefinite. Apartfrom relatively uncommon instances in which theurinary outflow is suddenly and completely ob-structed by blood clot or the impaction of acalculus, the immediate cause is usually attributed,somewhat vaguely, to congestion. This is some-times stated to follow exposure to cold or to arisefrom alcoholic, dietetic or sexual excess, but, infact, its origin is often problematical. Carefulinterrogation of patients seldom leads to the directincrimination of these factors, but alternatively,frequently evokes a history of enforced holding ofurine for excessive periods. Thus it is not un-usual for acute retention to follow social eventswhere opportunities for micturition are restrictedthrough fear of embarrassment, or where dullingof the sensation of fullness from alcoholic in-dulgence leads to procrastination. 'At other timesthe fear of exposure to cold may deter the elderlysubject from rising at night and favour an abnormalaccumulation of urine in the bladder. It seemspossible, therefore, that in cases where an in-flammatQry cause can be excluded, local con-gestion may be mainly secondary to pressureexerted by the already full bladder combined withthe turgescent effect of straining to void. Thepractical bearing of this distinction is that, sincesuch congestive changes tend to undergo rapidresolution after relief of the acutely distendedbladder, the performance of an immediate radicaloperation can be effected in suitable cases withcomparatively little subsequent blood loss.

Factors Influencing TreatmentNo matter in what way the acute state of re-

tention finally arises the conception of a pre-disposing obstructing cause is of paramountimportance. The existence of this in almost everycase affects the problem of treatment in three ways.In the first place it emphasizes the need for carefulclinical examination to ascertain the nature of theobstruction so that appropriate treatment can beselected. Secondly, it draws attention to thepossibility of secondary structural or functionalchanges having already developed in the urinarytract and raises the question as to how far thesecall for modification of treatment by virtue of anincreased susceptibility to infection or liability torenal failure. Thirdly, it implies that the adoptionof conservative measures, such as simplecatheterization or suprapubic aspiration, can in

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yanuary 1952 FERGUSSON: The Treatiment of Acute Retention of Urine 37

most instances bring about only temporary relief.In addition to these considerations resultingdirectly from the presence of the local obstructiveprocess, it must be remembered that the choice ofspecific surgical methods may be influenced, asalready mentioned, by the general state of thepatient and the attendant circumstances. Broadlyspeaking, it may be said that while the appropriatetreatment will be determined by the character ofthe obstructive process, the optimum time for itsadoption turns on the general clinical conditionand on the facilities available. From the patient'sstandpoint, the main considerations are primarilysafety, and, secondly, speed of recovery and per-manence of result, and the success of any methodmust ultimately be judged by its fulfilment of theserequirements.The Nature of the Obstructing LesionThe clinical features of acute retention are well

known and, in the majority of cases, easily recog-nized. The painfully distended bladder presentsabdominally as a rounded swelling arising from thepelvis, dull to percussion and cystic to palpation.The presence of the full bladder distinguishes thecondition from that of urinary suppression, whileits painful nature and sudden onset help todifferentiate it from chronic retention. It will benoted, however, from ensuing remarks that thedistinction between acute and chronic retention isnot always clearly defined, and that intermediatecases occur requiring special assessment basedonthe results of investigation of the structure andfunction of the remainder of the urinary tract.The abdominal findings alone give no indication

of the cause of the condition. This can only begauged by further examination supplemented bya knowledge of the previous history and symptoms.Since early and accurate diagnosis is essential togood treatment it is important that these mattersshould be attended to expeditiously and with care.In a small number of cases a reason for the re-tention will be clear from the outset, as in in-stances following local trauma or spinal injury. Ina further number, the external appearances onclinical examination may reveal a cause, such asextreme phimosis (not infrequent in associationwith balanitis in the senile or diabetic) or im-paction of a calculus at the external meatus. Suchcases, however, represent but a small proportion ofthose admitted to hospital with acute retention,the vast majority being due to some form ofprostatic obstruction or, less commonly, urethralstricture.

Reference to Table i shows an analysis of 300consecutive cases of acute retention admitted to alarge general hospital during 3j years (I948-midI951). Of these approximately two-thirds were

found to be due to benign prostatic enlargementwhich, together with prostatic cancer and urethralstricture, accounted for over 85 per cent. of thecases. When to these are added the few alreadymentioned as due to obvious causes (trauma,phimosis, etc.) there remains only a small residueof miscellaneous conditions in which, for the mostpart, diagnosis can be readily established by thehistory and clinical signs. It transpires, therefore,in practice that, in most instances, a distinctionhas to be drawn between three conditions, namelybenign prostatic enlargement, prostatic carcinomaand urethral stricture. The need for this dis-tinction is emphasized by the fact that the treat-ment generally advocated for these conditions,when uncomplicated by retention, is essentiallydifferent. Any method, therefore, used for therelief of retention should, if possible, be capable ofcombination with the standard procedures used fordealing with these underlying causes. In mostcases differentiation can be readily established byrectal examination in conjunction with a con-sideration of the previous history. It should beobserved, however, that in acute retention fromany cause the prostate may become depressed bythe full bladder and an erroneous impression ob-tained of its size. Conversely, absence of prostaticenlargement on rectal examination does not pre-clude the existence of an intravesical projection.Where retention is due to malignant disease theextent of the neoplastic lesion is usually sufficientlymarked to leave little doubt as to its nature. Irevery instance it is most important to enquire asto any possible cause for stricture and to excludethe presence of a contributory neurological lesion.In doubtful cases where, following the applicationof these principles, no clearly defined evidence ofthe cause can be established it may be assumedwith a high degree of accuracy that the patient issuffering from benign prostatic obstruction.Whether the retention arises directly from this orfrom associated changes of the bladder neck is amatter for speculation, but the fact remains thatunder these circumstances prostatic enucleationcombined with trigonectomy produces uniformlysatisfactory results.

Secondary Changes in the Urinary TractThe assessment of secondary changes in the

urinary tract during the phase of acute retentioncannot be accurately achieved by clinical methods.Fortunately, in intravenous pyelography, we havea method by which these may be estimated with aminimum of disturbance or risk to the patient. Inacute, as opposed to chronic retention due tobenign prostatic enlargement, the previous ob-structive effect is seldom sufficient to have broughtabout serious or irreversible impairment of renal

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38 POSTGRADUATE MEDICAL JOURNAL January 1952

function, and, in a majority of cases, structuralalterations in the upper urinary tract are slight. Insome instances excretion from the kidneys may bedelayed, but in most a satisfactory outline of therenal pelves and calyces can be observed within30 minutes of injection. Dilatation of the lowerthirds of the ureters is sometimes visible, but it isunusual for marked hydronephrotic changes to beapparent. Such changes, however, may be morein evidence in acute retention due to urethralstricture, or where the condition is complicated bythe coexistence of organic nervous disease, pre-sumably due to the tardier evolution of the ob-structing process. In this respect carcinoma of theprostate occupies an intermediate position in that,where it is associated with adenomatous hyper-trophy, structural or functional changes may beslight, whereas if the malignant process has slowlyextended to involve the whole gland or infiltratearound the ureters, the resulting disturbance tothe upper tract may be considerable.The urine in cases of acute retention due to

benign prostatic enlargement is practically alwayssterile, a fact which can readily be confirmed byculture of aspirated specimens obtained during'immediate' operation. On the other hand,when due to stricture or advanced prostatic car-cinoma the urine has, in many instances, alreadybecome infected plior to the onset of acute re-tention.The foregoing .observations on the condition of

the urinary tract in cases of acute retention due tosimple prostatic enlargement refer to the majorityof cases where antecedent symptoms of obstructionhave been relatively slight. Occasionally, however,in senile subjects or those of low intelligence andslovenly habits, the inconvenience of progressivefrequency and difficult micturition may be dis-regarded and the patient, having fortuitouslyavoided an early episode of retention, ultimatelypresents with acute urinary obstruction super-imposed on an already severely damaged urinarytract. Such cases approximate more closely tothose of chronic retention in which, in addition torenal impairment and the presence of structuralchanges favouring the spread of infection, a de-trusor weakness renders prolonged drainagenecessary before adequate voluntary evacuation ofthe bladder can be restored. In this respect,however, it must be remembered that such patientsare notoriously uncooperative and that if im-mediate operation is deferred the alternative periodof preliminary catheterization may prove just astroublesome as it would have been when used forroutine post-operative drainage.

In general it may be said then, that a high pro-portion of patients admitted to hospital withacute retention due to simple prostatic enlarge-

ment are in suitable condition, as regards thestructure and function of their urinary tracts andthe character of their urine, to undergo earlyradical operative treatment. It is fully establishedfrom the results of 'immediate' prostatectomythat the sudden relief of pressure in the acutelydistended bladder entails little risk of precipitatingrenal failure provided that infection is avoided andthe condition of the upper urinary tract is reason-ably satisfactory.The Effectiveness of Conservative Measures

Excluding resort to the catheter, the diversity ofmeasures employed in the home for the attemptedalleviation of retention bears testimony to theirusual ineffectiveness. Changes of posture, con-trast bathing of the genitals, and procedures vary-ing from the passage of parsley stalks per urethramto squatting over a boiling kettle, merely em-phasize the urgency with which relief is sought.The time honoured hot bath following an in-jection of morphia may temporarily reduce thediscomfort, but is rarely successful in re-estab-lishing the urinary flow. It therefore becomesnecessary to decide at an early stage what are theprospects of obtaining safe and permanent reliefby catheterization. This is a much more difficultquestion to answer than might be supposed fromthe views expressed on predisposing obstructingcauses in preceding paragraphs. In hospitalpractice restoration of the normal ability tomicturate following catheterization alone can onlybe achieved in a very small proportion of patientsadmitted with acute retention, and many of thesereturn subsequently with further urinary symp-toms. In general practice, on the other hand, it israre to meet the practitioner who at some time oranother has not had success by this method in apatient reluctant to leave his home. It is im-possible to estimate the place of catheterization,however, from such individual experiences, nordo we know sufficient of the after-history to judgethe permanence of the result. It is certainly notunusual for cases to be admitted to hospital withadvanced prostatic disease who have been pre-viously catheterized with apparent success. It isalso clear that the method is frequently unsatis-factory from the outset, infection being introducedwhich seriously affects the suosequent treatmentand progress in hospital. Again, in a few cases,inability to distinguish acute from chronic re-tention with incipient uraemia, combined with alack of appreciation of the danger of rapid catheterdecompression in the latter, may lead to disaster.The practitioner, however, has a difficult problemsince, often unsupported by adequate facilities,he is beset by relatives of the patient urging himto relieve the condition, as seems most natural to

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January 1952 FERGUSSON: The Treatment of Acute Retention of Urine 39

them, by the passage of a catheter, even though itis agreed that the patient should then go tohospital. In adopting this course the opportunityfor immediate aseptic prostatectomy is abandonedeven though the possibility of radical cure by otheroperative methods remains. Before condemningcatheterization, however, it is necessary to indicatewhat advantages immediate aseptic prostatectomyhas to offer over alternative surgical measureswhich are, at any rate to some extent, independentof its adoption as a preliminary. With this inmind the following description is based on apersonal experience of a comparatively small seriesof immediate operations undertaken with a viewto comparing the results with those obtained bymore orthodox methods.

Immediate Aseptic ProstatectomyThe introduction of this operation by Hey of

Manchester was based on the belief that the badresults of other methods of prostatectomy for re-tention were due not to the sudden release ofpressure in the bladder, but the introduction ofinfection at preliminary catheterization. Evidenceendorsing this view is available from the fact thatthe onset of rigors-the so-called catheter fever-after urethral instrumentation, is sometimes notedeven after failed catheterization where the intra-vesical pressure has not been reduced. The mostimpressive support, however, comes from theoperative results of Hey himself and others whohave adopted the technique. Several hundredcases have now been treated by immediate opera-tion with rapid decompression of the bladder, and,although judged by ordinary standards, many ofthe patients were poor risks, the overall mortalityhas proved extremely small. The figures, in fact,compare favourably with those obtained withelective surgery in cases uncomplicated by re-tention. Since the method embodies the preserva-tion of asepsis and allows full control ofhaemorrhage, the bladder may be closed withoutdrainage, thus reducing post-operative morbidityand promoting early ambulation. For all practicalpurposes the only prerequisites for its adoption inpatients whose general condition admits of surgicaltreatment are, firstly, a reasonable assurance thatretention is due to prostatic obstruction andsecondly, that there should have been no pre-liminary attempt at urethral instrumentation.These matters have already been discussed inprevious paragraphs.

Assuming that the clinical diagnosis has beenmade, an intravenous pyelogram is carried out assoon as possible after the patient's arrival athospital. At the same time a sample of blood iswithdrawn for purposes of cross matching and, ifdesired, for estimation of the blood urea. The

object of the pyelogram is two-fold. Firstly, it isof value as an aid to diagnosis, as it will demon-strate opaque calculi either in the prostate orwithin the bladder or it may reveal the presenceof secondary malignant deposits in the bones froman unsuspected prostatic carcinoma. In somecases a large intravesical prostatic projection maybe demonstrated. Secondly, the pyelogram is anexcellent test of renal function, especially whentaken in conjunction with the blood urea value,but, in addition to showing the ability of thekidneys to excrete and concentrate the dye, it alsogives information referring to the presence orabsence of renal deformity from back pressure.

Immediately following pyelography a furtherassessment of the patient's general condition isobtained by an X-ray of the chest to exclude un-suspected pulmonary disease or gross enlargementof the cardiac shadow. Provided the results aresatisfactory and the pyelogram shows some evi-dence of renal function the patient is straightwayprepared for operation. In a well-organized unitthis should be possible within two hours of ad-mission to hospital, but where for any reason in-vestigation is delayed, an injection of morphia maybe required to supplement any previous sedationwhich the patient should have already receivedbefore leaving his home. The operation now per-formed is based on the principles enunciated byHey, but shows certain modifications suggestedlargely by the technique employed by Wells atLiverpool. Spinal anaesthesia is employed forpreference and preliminary ligation and divisionof the vasa carried out. The approach to theprostate is across the bladder through the usualmidline subumbilical incision; the bladder being,of course, already distended from the retention ofurine.The bladder is explored from within and the

diagnosis confirmed. The openings of the uretersinto the bladder are demonstrated and a markingcut made with diathermy just to the inner aspect ofeach orifice and continued around the rim of theprojecting prostate. It is usually very easy toidentify the ureteric orifices as there is a markeddiuresis following the relief of bladder tension. Asoft rubber catheter is then induced into theinternal urinary meatus and passed down theurethra. As soon as the tip of this catheter hasemerged at the external meatus a clamp is placedat each end of the catheter to prevent it beingdisplaced during the subsequent manipulations.Enucleation of the prostate from aiound thecatheter is then commenced, but not completed.As soon as the prostate has been about seven-eighths enut'l:ated a bladder retractor is insertedand the final removal of the prostate and divisionof the urethra is made by dissection, using the

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diathermy. By this means damage to the mem-branous urethra is avoided, a fact of considerableimportance in the prevention of post-operativestricture. The area of trigone between the twomarking incisions is then excised together withany tissue tending to form a shelf between thebladder and prostatic cavities. The removal ofthis tissue gives a good view of the prostaticcavity, and enables a high degree of haemostasis tobe obtained by diathermy. The relative lack ofbleeding may be remarked upon at this point,particularly when compared with that so oftenencountered in operations performed after aperiod of indwelling catheterization. All mucosaltags and minute adenomata that may remain arenow excised. A 20 F Harris or whistle-tipcatheter is then sutured tail-to-tail to the catheteralready in place, the latter being then withdrawnoutwards, thus pulling the Harris catheter intoposition. An anchoring suture is placed throughthe eye of the Harris catheter and each end isbrought out through the abdominal wall. Thebladder is then closed in two. or .more layers afterthe instillation of a few ounces of 5 per cent.sodium citrate solution to prevent the catheterbecoming blocked by clot. A small corrugatedrubber drain is inserted into the prevesical spaceand the wound closed. The catheter is thenwashed through with sodium citrate solution, 2 oz.of which are left in the bladder, and the patientreturned to the ward. The after treatment isgenerally straightforward and demands little moreattention than any other abdominal operation.The catheter is allowed to drain freely after onehour, but should it become blocked gentle irriga-tion and suction may be required. Bladderwashouts are not given. The wound drain is re-moved after 48 hours, at which time the patient isallowed out of bea. The catheter is removed afterfour to five days, the patient then usually beingable to pass urine per urethram. It is advisable toencourage frequent micturition at this stage toavoid undue strain on the bladder sutures, and ifany leakage should occur this is usually due to asmall clot blocking the urethra. The use of acatheter for a further 24 hours, a comparativelysafe procedure at this stage when granulation inthe prostatic cavity is well advanced, is generallysufficient to overcome this difficulty.

Following operation. the patients are given aseven-day course of penicillin and a suitablesulphonamide, while streptomycin is held in re-serve to combat exceptional infection. In amajority of cases the urine remains sterile for thefirst four or five days, but the mere presence of thecatheter occasionally leads to urethritis and atransient mild coliform infection later. Earlyambulation is considered important in the pre-

vention of post-operative morbidity in theseelderly patients, and in this way facilitates earlydischarge from hospital. There is no evidencethat it interferes with healing of the wound or pre-disposes to leakage. The morbidity followingoperation is, in fact, strikingly low and, asfamiliarity with the technique becomes establishedit will be found possible to extend its use to ' poorrisk ' cases. In these, it must be emphasized, theneed for careful post-operative supervision withregard to fluid balance and control of the bloodchemistry is most essential. It seems fair to saythat, handled in this manner, many will survivewho, had they been treated by preliminarycatheterization, would have succumbed from in-fection and uraemia following a delayed one- ortwo-stage operation.ResultsAt this point it may perhaps be opportune to

refer to the results observed in a personal ex-perience of 60 cases treated by immediate prostatec-tomy during the period January 1950-SeptemberI95I (Table 2). These represent slightly less thanhalf of all cases admitted with acute retention fromwhatever cause during this time, the number beingaffected by the fact that in the early days manywere catheterized before being sent to hospital,and for this reason were not subjected to immediateoperation. In this way and, since at the outsetonly those showing reasonably good pyelographicappearances were operated upon, the series mustbe regarded as selected, but with increasing ex-perience during the past year all but the hopelesslyinoperable have been included. The average ageof these patients was 68 years, the oldest being87 years. Estimation of the blood urea valueduring the phase of acute retention ranged up toI30 mgm. per cent., a level at which many woulddefer prostatectomy had previous suprapubicdrainage been performed. There were threedeaths in the series (5 per cent.), one from infectionand renal failure in an uncooperative patient whowould not tolerate the continued presence of acatheter, the others from cardiac failure underanaesthesia and pulmonary embolism respectively.The average duration of stay in hospital of the re-maining 57 patients was 23 days, the shortest beingo days and the longest 6I days in the case of apatient who developed both a post-operative re-tention, requiring additional perurethral resection,and also a deep venous thrombosis.

During the same period 36 patients were ad-mitted suffering from acute retention due toprostatic enlargement for whom it is probable,from a consideration of their general condition,that immediate operation would have been advisedhad not instrumentation previously been carried

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out. The average age of these cases was 69 years,and in most instances treatment took the form ofdeferred prostatectomy by the retropubic orFreyer technique after indwelling catheter drain-age. Five of these patients died (I3.9 per cent.)-four from infection and renal failure-while theaverage duration of stay in hospital of the re-mainder was just over six weeks. Follow-uprecords indicate a considerably greater post-operative morbidity from persistent urinary in-fection in these cases. The results in this groupcorrespond closely to those obtained from similarmethods in the years preceding I950, before theadoption of the immediate operation (see Table 2).

rn reviewing these figures it must be re-membered that the mortality rates relate not toprostatectomy as an operation, but to the operativetreatment of enlargement of the prostate com-plicated by acute retention. Even when dueallowance is made for the initial selection, alreadyreferred to, of cases submitted to immediateprostatectomy, it becomes apparent that, with theinstitution of catheter drainage, the prognosis isadversely affected. The fact that the mortalityrate of immediate prostatectomy for acute re-tention compares favourably with that of electiveprostatectomy in cases which are not severelyobstructed, indicates that acute retention per seneed not be considered a hazard demanding extra-ordinary pre-operative management. When boththe retention and its underlying obstructive causecan be dealt with effectively and expeditiously at asingle operation without increasing the risk to thepatient, the latter's criteria of safety, speed of re-covery and permanence of result are fully satisfied.

DiscussionEnough perhaps has been said of the advantages

of the immediate operation. Let us now turn tothe drawbacks inherent in the method if theprinciples described are rigidly adhered to. In thefirst place it imposes the inconvenience of notbeing able to relieve the patient's acute discomfortby catheterization prior to operation. Thisdifficulty may be surmounted by the employmentof adequate sedation and, where delay in trans-ference to hospital is inevitable, by palliativesuprapubic aspiration. It is, of course, in thisrespect necessary to establish a liaison with prac-titioners participating in the treatment by em-phasizing the advantages of immediate radicaltreatment so that the above measures can beadopted. Secondly, it may be objected that thepatient seized with sudden urinary retention maybe reluctant to undergo immediate operation.Against this the remote prospect of securing per-manent restoration of function by palliativemethods has already been referred to, and it isin fact a common experience to find such caseseager for early operative relief. Thirdly, and per-haps most seriously for the successful extension ofthe technique, the need is imposed for a full-timeurological service backed by radiological andpathological facilities for immediate investigationof cases on arrival at hospital throughout the 24hours. If the basic principles of the method arescrupulously observed there is no means ofovercoming this disadvantage, save by continuedsedation and repetition of aspilation until a con-venient moment arrives. There are, however,many hospitals in which the necessary facilities

TABLE 2

ACUTE RETENTION OF URINERESULTS OF IMMEDIATE PROSTATBCTOMY COMPARED WITH THOSE OBTAINED BY ALTERNATIVE METHODS EMBODYING

PREVIOUS CATHETERIZ XTION

Immediate prostatectomyJanuary I95o-September 1951 Prostatectomy following previous catheterization

(21 months) January 95o-September 1951(Partial selection of cases during early months. (21 months)See text)

Cases .. ..... ... 60 Cases . .. .. .. 36Average age . .. 68 years Average age . ... 69 yearsAverage duration of stay in hospital .. 23 days Average duration of stay in hospital .. 45 daysDeaths .. 3 (5%) Deaths . ........ .. 5 (I3.9%)

Prostatectomy following previous catheterizationJanuary I949-January 1950

(2z months)(Prior to adoption of' immediate' technique)

Cases .. .. .. .. .. 48Average age .. .. . 68 yearsAverage duration of stay in hospital . 49 daysDeaths .. .. .... 7 (14%)

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January 1952 FERGUSSON: The Treatment of Acute Retention of Urine 43

already exist for dealing with general emergencies,and the organization of a urological team trainedin the performance of what is really a com-paratively simple operation should present nooutstanding difficulty. Fourthly, it may beobjected that in the performance of immediate' blind' prostatectomy an unsuspected cause forthe retention may be encountered which, hadpreliminary catheterization or cystoscopy beenperformed, would have been brought to light. Inthis respect it must be admitted that such a chanceexists, but with capable pre-operative clinical andradiological assessment the prospect is remote.From an analysis of the causes of retention(Table i), the chance of acute retention of obscureorigin being due to prostatic obstruction is over-whelmingly great, and if by mischance at opera-tion a stricture should be detected the establish-ment of temporary suprapubic drainage may wellprove beneficial. In a single case, additional tothose in the personal series quoted above, anuratic calculus was found impacted at the internalmeatus and removed. This was the only case inwhich an unforeseen cause for obstruction wasencountered at immediate operation.

Finally, it may be asked whether immediateoperative treatment necessarily restricts the sur-geon to the transvesical route. Here the im-portance of being able to visualize the interior ofthe bladder at some time, either before or duringthe performance of the operation, is at issue.There is no question but that this is desirable inorder that additional lesions may be detected anddealt with, if possible at the same time asprostatectomy. However, unless the principle ofstrict avoidance of urethral instrumentation is dis-regarded exploration can only be conducted byopening the bladder. There is some evidence, onthe other hand, that cystoscopy carried out withfull asepsis immediately prior to operation may

not be grossly harmful, and that, if this is doneand the bladder found clear, immediate operationby the retropubic technique may then be per-formed with good results. One is somewhathesitant in view of the success of the true asepticmethod, however, to allow any further relaxationof the embargo on urethral instrumentation. Itcertainly seems best that, if pre-operative cysto-scopy be regarded as essential to the performanceof an alternative operative technique, cases ofacute retention should be considered in the samelight as those of suspected rupture of the urethrain which instrumentation is only countenancedwith strict regard to asepsis as a pre-operativemeasure in the theatre. The time may possiblycome when improvements in antibiotic therapymay allow the earlier introduction of a catheterwithout the attendant risk of infection, and thismay modify our views on the value of the im-mediate operation. The fact remains, however,that this would probably only lead to the de-ferment of radical treatment which the aseptictechnique, outlined above, has demonstrated asboth effective and safe.

AcknowledgmentsIn being able to present the results of a small

series of cases of acute urinary retention treated byimmediate prostatectomy I am very greatly in-debted by my Senior Registrar, Mr. J. W. P.Gummer, whose assistance in the organization ofinvestigations and in the performance of many ofthe operations has been of the greatest value. Iwish also to express my thanks to the staff of theradiological and pathological departments at theCentral Middlesex Hospital, whose co-operationallowed the formation of a team without which theadoption of the method could not have beenundertaken.

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