Abraham Leo Wolbarst Georges Luys.

A treatise of cystoscopy and urethroscopy online

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benign tumors of the bladder, of small size and not very numerous; also for the frequent
recurrences of these tumors. In the female, Luys' method must certainly be given prefer-
ence because of the excellent results obtained. 1 am happy to be able to assist in making it
better known, having been the first to cure a case in Switzerland with this method. '*

In addition to these very characteristic histories, we may cite also
the interesting work upon the same subject by Tixier and Oauthier, of
Lyons.** There are also two interesting reports by de Keersmaecker, of
Antwerp,* on the extirpation of bladder polypi through the cystoscope.

CONTRAINDICATIOI^S TO THE EnDOVESICAL TREATMENT OF BLADDER

Tumors

If endovesical cauterization is the method of choice for all small
tumors of the bladder, and especially papillomata, I must say it can
not be considered a radical treatment in the large an<l malignant tumors
with wide and infiltrated bases; also in obese patients in whom the dis-
tention of the bladder can not be ol)tained on account of the consider-
able abdominal plethora. In these cases, Nitze's operating cystoscope
should be used.

In conclusion, the endovesical treatment of bladder tumors with my
direct vision cystoscope is to be recommended, for its remarkable effici-
ency and benign character.'' Up to the present time, I have made over
fifty applications of this method in men and women, in some cases often
repeated, without a single untoward incident.

REFERENCES

iLuys: 2d Conj»;ress, German Uroloj^ieal Society, Berlin, 1909, p. 4.35.

-Communication to the Vaudoise Medical Society, meeting of Dec. 4, 1909, also La Clinique,

1910, p. 25.
sTixier and Gauthior: Society des Sciences medicales, June, 1911.
4Dc Keersmaecker: Soci^t6 beige d'Urologie, June, 1905.
•'•Caspar! : Traitement des tumeurs de la vessie, La Clinique, 1910, p. 25.

Treatment of Bladder Tumors With the Cold or Hot Snare

This method of treatment A\as employed by Nitze, as previously
stated ; but he used this method only as a preliminary step in the gal-
vanocauterization of bladder tumors; he snared the tumor first and
then he cauterized the pedicle.

The method of Blum, of Vienna,' is entirely different. This author



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TREATMENT OF BI^VDDER TUMORS



343



Ims publisliod a series of interesting reports on liis nietliod, wliidi has
f?iven splendid results.^ Nitze's instrument consisted essentially of a
riftid system, whielr differs completely from tlie flexible system pro-
posed by Blum.

Other authors, preceding Blum, like Schlagintweit, Frank, and
Bohme,'* had conceived the idea of using the catheterizing cystoscope
as an operating instrument, but Blum was the first to devise a prac-
tical api)aratus, which thus opened a new pathway to endovesical opera-
tions.

Blum's instrument can be introduced into the catheterizing cysto-
scope in the same way as a ureteral catheter. To point the snare to-
ward different portions of the bladder, he utilizes Albanian's deflector.
The essential element of Blum's instrument is a snare enveloped by a




Fig. 202. — ^Blum's operating cystoscope.

flexible metallic sheet, which can be introduced in its entirety into the
channel provided for the ureteral catheter in the catheterizing cysto-
scope.

Blum's operating instrmnent (Fig. 202) is composed of a steel
spring 1.8 mm. wide, corresponding in caliber to a No. 6 Charriere. This
is the conducting channel for all the instruments. This spring of steel,
very flexible and free, has a solid, straight end that is strong enough
to resist pressure upon any part of the vesical mucosa, as for instance,
the base of the tumor. The spring has an eye at its vesical end, to
which a bronze aluminum wire is attached; the other extremity is at-
tached to the end of the obturator which can l)e inserted or withdrawn
within the lumen of the spiral in order to enlarge or diminish the snare.



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PLATE XXIII

Fig. 1. — Edematous aspect of a ureteral orifice; undoubtedly indicating a
diseased condition of the ureter or of the corresponding kidney.

Fig. 2. — Edema of the uretiral orifice observed in connection with a ureteral
calculus.



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Fig. 2.

PLATE XXIII



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TREATMENT OF BLADDER TUMORS 345

The caliber of the external extremity of the spring is sufficient to
allow the steel obturator to completely close its lumen. The internal
extremity has a semilunar groove in which the snare is fully lodged
when reduced to its minimum size.

The manipulation of this instrument is facilitated by the use of
Leiter's drum handle; this has a flat spring, over the external extrem-
ity of which the obturator is rolled. The plain snare can be replaced by
a forceps which is operated by the obturator and the drum handle.
Zuckerkandl, of Vienna, has devised a special cautery which can be
attached to this instrument; it aids in the cauterization of the base of
the tumors.

Preparation of the Patient. — Blum anesthetizes the anterior ana
posterior portions of the urethra with three or four c.c. of a 5 per cent
solution of novocaine. Sometimes in sensitive patients he injects hypo-
dermatically two c.c. of morphine, or he gives the patient an antipyrin
irrigation. After the bladder is emptied, he instills five c.c. of a 1 :1000
solution of adrenalin, to prevent bleeding. (This dose of adrenalin
seems quite strong and dangerous.) Finally, to obtain the clearest pos-
sible vision, the bladder is filled with 250 to e300 c.c. of sterile water.

The quantity of water to be injected varies according to the indi-
vidual. Blum has noticed that in tumors on the roof of the bladder
or on the anterior wall, it is advisable to inject a smaller quantity of
water, so as to bring the cystoscope to a more convenient distance.
Thus in a man eighty years old, with a papilloma on the roof of the
bladder, he employed the following procedure: AVith 150 c.c. of water
in the bladder, the tumor was so far away that he could not grasp it
with the snare. He then opened the snare so widely that the largest
circumference of the tumor could easily be enclosed by it. Then he
gradually emptied the bladder till thirty or forty c.c. remained. In
this way, the vesical tumor descended spontaneously into the snare
and was thus extirpated.

Preparation of the Instrument. — The operating instruments are
attached to Nitze's catheterizing cystoscope. The bronze aluminum
wire constituting the snare is pulled so that it assumes the shape of
the letter TJ, one centimeter in length ; this is completely hidden in the
concavity of Albarran's deflector. The instrument is now introduceil
into the bladder.

Operating Technic. — ^A\nien the tumor appears in the visual field,
the spiral spring is pushed inward until its extremity is seen; then the
loop is foraied in a circle, the diameter of which should be a little
larger than the greatest circumference of the tumor. The spring is so
manipulated that the loop is perpendicular to the length of the tumor.



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346 CYSTOSCOPY AND URETHROSCOPY

With tlie aid of All)arran's deflector, the loop is brouglit around the
tumor and tlie spring is pushed toward tlie vesical wall so that it
presses upon tlie normal vesical mucosa.

AVhen the loop is at the base of the growth, the obturator is pulled
forcibly. During this maneuver a sensation of crackling of the de-
stroyed tissues is often felt. It is important to make sure that the
loop is firmly attached to the pedicle, for then the tumor will follow
all the movements of the spiral.

After fixation is thus secured, the cystoscope is withdrawn leaving
the spiral and the snare in the same manner that a ureteral catheter is
left in the ureter. The snare is left in this position for 24, 36, or 48
hours, when it usually comes out spontaneously. Shortly thereafter the
patient generally passes the entire tumor with the first micturition.

It is well not to cystoscope the patient for eight to fourteen days
after this operation, on account of possible hemorrhages. But if it is
done, an ulceration will be seen at the site of the former growth, in the
form of a crescent covered by necrotic tissue. Fifteen days after opera-
tion the eschar usually comes out spontaneously, accompanied by a
slight hemorrhage. In this way, the destruction of the tumor is at-
tained at one sitting without the loss of a drop of blood. This is cer-
tainly an ideal technic for a simple operation ; but often certain difficul-
ties are encountered.

The operative difficulties, are the following: First the tumor can
not be grasped as above described. In this case the double catheter-
izing cystoscope should be used. The sj)iral and snare are passed into
one of the channels, and a toothed-forceps into the other. The forceps
grasps the tumor and the snare is worked around the growth as close
to the base as is possible.

Other difficulties are due to the indirect cystoscope itself, the
principal being tluit the vesical ihiid becomes cloudy. Finally, serious
hemorrhages are always to be feared, particularly when the eschar
separates and comes away.

Operative Results. — Blum has operated on 44 bladder tumors of
which 37 were papillomata. In one case he was compelled to resort
to suprapubic cystotomy because of a very dangerous hemorrhage
which followed the separation of the eschar. (This occurred eight or
fifteen days after the endovesical operation, while the operator was
cystoscoping the patient in order to verify the residt.) In all the
other cases the endovesical operation was successful. Two cases
recun-ed and were again operated on in the same way. Blum prefers
the cold snare because the hot snare might burn and perforate the blad-
der wall.



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TnEATMKNT OF BLADDER TUMORS 347



REFERENCES



iRluni, Victor: Kin noiios iiitiavesikales Operations verfaliroii, Ztsclir. f. Urol., 11)09, iii, 116.
2Blum: Ztsehr. f. Urol., 1911, p. 834.

sBohmc, Fritz: Zur Tochnik dor iiitravesikalon Operation von niasentumoren, Ztsehr. f. Urol.,
1909, iii, 340.

P]lectrocoagui^tion of Tumors of the Bladder

Tlie treatment of bladder tumors by eleetrocoagulation 1ms l)eeii
utilized because of tlie splendid results obtained with this method in
tumors on accessible parts of the body, by Doyen* in France, Berndt,
in Austria, and Nagelschmidt- in Germany. Doyen"* first makes a supra-
pubic incision and through this opening in the bladder he appli(»s elec-
trocoagulation to the tumor.

Edwin Beer* of New York, in 1910, conceived the idea of applying
electrocoagulation to bladder tumors through the natural channels,
lie used tlie indirect cystoscope. A number of Americans shortly after-
ward published cases confirming the value of this method.

Among the most noted publications may be mentioned those of
Buerger and AVoll)arst,' (lardner,"* Sinclair,^ McCarthy,^ Judd,^ Harps-
ter,*" Binney,'' AVatson,'^ Pilcher,'^ and Barney.'* Reports have also
l)een published by Bachrach,'' in Austria, Kuttner," Bucky and
Frank,^^ in fJermany, and in France by Legueu,'** ifeitz-Boyer and Cot-
tenot,'" Andre'*' and Lepoutre and d'Halluin.-^

Electrocoagulation is produced by high-frequency currents of low
tension; while the spark produced by the high-frequency current and
high tension which constitutes ^^fulguration," exerts but a superficial
action, and no effect deeper than three or four nun. Doyen has demon-
strated that with the high-frequency spark and loir tension, electro-
coagulation can be obtained in the substance of the tissues to a depth
of fifteen to twenty nun.

The current necessary for electrocoagulation is secured through
a special current transformer (Fig. 208). This apparatus is composed
of a transformer which changes the street current with its high voltage
running up to several million volts. This current passes into Oudin's
resonator; a third part regulates the intensity of the current.

Sparking is not absolutely essential for electrocoagulation. If
instead of leaving a gap between the electrode and the tumor, the two
are brought into direct contact, coagulation will be produced without
carbonization, because its action is not due to the heat alone.

AVlien the electric current is not very strong, and it is used with
very large electrodes having equal surfaces, 'Miathermia" or ^* thermo-
penetration" is produced; this simply produces a sensation of heat.



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348 CYSTOSCOPY AND ITRETIIROSCOPY

When a stronger current is used and tlie electrodes Imve a very much
smaller surface, the albununoid matter is coagulated and we have ** elec-
trocoagulation."

To produce the maximum effect two electrodes are required, one
being very large and wide and the other very small. A sensation
of heat will be produced near the large electrode, because the heat is
spread over a large surface ; on the other hand, the maximum electro-
coagulation will be obtained near the small electrode. In practice,
the wide indifferent electrode consists of a sheet of tinfoil placed under
the buttocks of the patient, and the small active electrode is introduced
into the bladder in direct contact with the tumor.

The small electrode consists of a perfectly insulated copper wire



BnESL4UER - LOWENSTEIN - PAWS
Fig. 203. — Current transformer for electrocoagulation.

having a copper tip at its end, which comes into contact with the
growth. Its caliber is not quite that of a ureteral catheter, being easily
passed into a catheterizing cystoscope and much more easily into a
direct vision cystoscope.

REFERENCES

iDoyen: L 'electrocoagulation, Tliird International Congress of Physiotherapy, reports and

communications, pp. 556-560.
sNagelschmidt : Eifets thermiques produits par les courants de haut frequence, Archives

d '61ectricit6 mM., March 10, 1910, pp. 161-173.
aDoyen: Th^rap. chir., Paris, 1910, iii, 71.

•*Beer: Jour. Am. Med. Assn., May, 1910; also Med. Rec, New York, Feb. S, 1913, p. 242.
sBuerger and Wolbarst: New York Med. Jour., Oct. 29, 1910.
eGardner: Am. Jour. Dermat. and Genito-urin. Dis., January, 1912.
^Sinclair: Am. Jour. Urol., March, 1912.
sMcCarthy: New York Med. Jour., Sept., 1912.



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TREATMENT OF BLADDER TUMORS 349

oJudd: Jour. Am. Med. Assn., November, 1912.
loHarpster: Am. Jour. Surg., Jan., 1913.
iiBinney: Boston Med. and Surg. Jour., Feb., 1913.
i2Wat8on: Urol, and Cutan. Rev., Feb., 1913.
ispilcher: Am. Jour. Surg., April, 1913.
"Barney: Boston Med. and Surg. Jour., July, 1913.
isBachrach: Folia Urologica, July, 1913. *

iBKuttner: Internat. Cong. med. Sc, London, Aug., 1913.
i7Bucky and Frank: Miinch. med. Wchnschr., Feb., 1913.
i«Legueu: Arch. urol. de la clinique de Necker, Paris, 1913, i.
i»Heitz-Boyer and Cottenot: Assn. d'urol., 1911, p. 774.
20Andr6: Assn. fran^. d'urol., Oct., 1913, p. 736.
2iLepoutre ^nd d'Halluin: Rev. clin. d'urol., Jan., 1914, p. 35.

Operative Technic. — The teelinic will vary according to whether
the indirect or direct cystoscope is used.

1. With the Indirect Method. — The patient is placed in the usual
position for indirect cystoscopy. The hladder is filled with 200 c.c. of
sterile w^ater and the electrode is introduced in the same manner as a
ureteral catheter, under control of the eye, and brought into direct
contact with the tumor. The current is turned on for fifteen to thirty
seconds, at each application; the changes produce<l by the action of the
current are kept under close w^atch all the time. At first gas bubbles
will appear, then the tumor will show^ a black central zone surrounded
by a whitish coagulated area.

Generally the treatment must be interrupted because the vesical
fluid soon becomes cloudy. In this case the cystoscope is w^ithdrawn
and the patient is instructed to urinate; considerable broken-down
debris of the coagulated tumor will be found in the urine thus passed.
[In the improved American cystoscopes, cleansing of the bladder is
accomplished by merely removing the telescope and irrigating the
bladder through the cystoscopic tube, wiiich remains undisturbed
throughout the treatment. — Editor.]

2. AViTH THE Direct Method. — ^In general, the technic is the same
as that in direct vision cystoscopy. The patient is placed in the in-
clined position, a large indiffei-ent electrode is placed under the but-
tocks, the cystoscopic tube and the lamp are introduced and the small
electrode is directed upon the tumor.

There is a decided difference in the application of electrocoagula-
tion between the two instruments, the direct vision method having
distinct advantages. The fluid distending the bladder will offer greater
resistance to the current than that offered by the air, as in the direct
vision method. Furthermore, the electricity will produce a certain
amount of decomposition of the water, which is made evident by the
escape of gas bubbles and by numerous small explosions during the



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350 CYSTOSCOPY AND URETHROSCOPY

coagulation. According to some antliors, tliese explosions are of no
consequence; nevertheless, although the patient is not a\vare of them,
they impair the clear vie\v of the operator to some extent at least.

With the direct cystoscope, the technic is therefore nmch more
simplified because these water inconveniences are not present in the air
medium. AVitli this instrument, a tumor of the bladder may be con-
sidered outside of the body, and can therefore be treated like any other
tumor of the cutaneous surface.

Certain precautions are necessary, however, when this instrument
is used. First, the tumor surface must be thoroughly anesthetized,
by the application of tampons soaked in a 10 per cent solution of
stovaine. After a few moments the active electrode may be safely ap-
plied, providing, however, that only weak currents are employed.
AVhen the current is too strong, the patient will suffer pain and moves
about uneasily, so that the operation can not be continued.

On the other hand, wluni the anesthesia is thorough and the cur-
I'ent weak, electrocoagulation can be done painlessly, but the opera-
tion progresses slowly and the sittings nuist be lengthy, with little to
be done at each sitting. AVith patience, however, the results obtained
are worth while. In particular, there is no bleeding. The electro-
coagulation produces a very white eschar which penetrates deeply,
and the base of the tumor can be attacked safely without fear of in-
jury to the bladder wall.

It can thus be seen that a large tumor can not be destroyed in one
sitting. It is better by far to employ repeated sittings to insure its
complete destruction.

Recently I used this method in a female patient at Broca Hospital,
in the service of Jeanselme. She complained of cloudy urine. Cystos-
copy revealed a tumor (Fig. 204). p]lectrocoagulation was performed
with my direct vision cystoscope, under most favorable conditions.
The changes and final results of the treatment are well shown in Figs.
205, 206, 207, and 208.

Comparative Value of Electrocoagulation and
Galvanocauterization

Unfortunately the comparative tlierapeutic value of these two
methods has not yet been sufficiently studied, and it is interesting to
consider which procedure is to be preferred.

Advantages of Galvanocauterization. — 1. It is simple. The use
of the cautery is very simple. A galvanic current can be provided
easily in any surgical equii)ment. The manipulation of the current is



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TREATMENT OF BLADDER TUMORS 351



Fig. 204. — View of a bladder tumor situated in median line of the trigone, — before treatment.

SO simple, so convenient, tliat it constitutes an ideally simple therapeu-
tic agent.

2. It is safe. The galvanocautery is so thoroughly under con-



Fig. 205. — Same as Fig. 204. First application of electrocoagulation. With the direct vision cystoscope,
the excavation made by the burning at the base of the tumor is easily seen.



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352 CYSTOSCOPY AND URETHROSCOPY



Fig, 206. — Same as Fig. 204. View of the same tumor eight days after the first application of electro-
coagulation. The apex of the tumor is lower and much smaller in front.

trol that it is impossible to cause injury to the bladder mucosa. Neither
perforation of the bladder nor subsequent hemorrhage has ever been
observed in my experience.



Fig. 207. — Same as Fig. 204. Second application of electrocoagulation. The base of the tumor is com-
pletely burned; its apex presents a white eschar.



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TREATMENT OF BIjVDDER TUMORS 353

3. It is painless. Galvanocauterization of bladder tumors is re-
markably painless. Pain is felt only when the cautery burns the
healthy mucous membrane. When pain is complained of, it is an ex-
cellent indication that the cauterization has reached the base of the
tumor.

4. Its final results are perfect. Scars examined years after cau-
terization have always appeared smooth, soft, and regular.

5. Kecurrence in situ has never been observed when the cauteriza-
tion has been done thoroughly. The cicatrix always remains white,
soft, and well defined.



Fig. 208. — Same as Fig. 204. View of the bladder fifteen days after the application of electrocoagulation.
The tumor has completely disappeared; the vesical floor shows nothing but edema.

Disadvantages of Galvanocauterization. — 1. The length of the treat-
ment. It is out of the question to believe that a tumor of considerable
size can be destroyed in a single sitting; repeated sessions are often
necessary. But this applies just as well to electrocoagulation.

2. The action is superficial. Galvanocauterization does not pene-
trate deeply into the tissues. It is a **blade of fire" which destroys
only that which it touches. However, this disadvantage applies
only when w^e are dealing with a malignant tumor of the bladder.
In point of fact, papillomata are superficial tumors and in the vast ma-
jority of cases galvanocauterization is perfectly able to destroy them
completely and prevent their recurrence. In cancer of the bladder.



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354 CYSTOSCOPY AND xtrethhoscopy

the galvanocautery is manifestly insufficient; on the other hand, the
most enthusiastic supporters of electrocoagulation do not employ this
method in vesical cancer.

Advantages of Electrocoagulation. — 1. Electrocoagulation has a
decidedly more powerful action than the cautery; it penetrates more
deeply and is mucli more intense.

2. Electrocoagulation causes destruction of bladder tumors almost
bloodlessly. During the operation not a drop of blood is seen; it seems
to have a most perfect and certain hemostatic action.

Disadvantages of Electrocoagulation. — 1. It requires comi)licated
and highly expensive instruments.

2. The dangers are many; e.g., perforation of the bladder has oc-
curred in many cases.

3. Hemorrhage is not produced at the time of operation, but eight
or ten days thereafter, when elimination of the eschar takes place;
this accident has also been reported.

4. Electrocoagulation seems to me more painful than galvanocau-
terization. Whichever method is employed, one thing is certain: The
operation is nmch simpler with the direct cystoscope than with the
indirect.

Endovesical Treatment of Bladder Tumors by Electrolysis

Rudolph Oppenheimer, of Frankfort,^ has proposed that papillo-
mata of the bladder be treated by electrolysis.

Operative Technic. — The positive pole connected with a wide elec-
trode is placed on the patient's thigh. The negative pole is introduced
into the bladder by means of a No. 6 Charriere catheter, which is easily
admitted by any catheterizing cystoscope. The bladder is filled with
oxycyanide of mercury solution, the cystoscope is introduced, and the
vesical extremity of the negative electrode is applied to the villi of
the tumor down to its base. The current is then applied, care being
taken not to use more than 25 to 45 milliamperes. By moving the cysto-
scope about in different positions, the electrode will attack various
parts of the tumor.

During the operation numerous gas bubbles will be seen; these are
due to the electrolysis of the vesical fluid. These air bubbles are aften
so numerous as to impair the operator's view. To correct this mishap
the author recommends emptying the bladder and then refilling it.
After the operation the patient voids fragments of the tumor of a whit-
ish color for about ten days.

Advantages. — The principal advantages which the author claims



Online LibraryAbraham Leo Wolbarst Georges LuysA treatise of cystoscopy and urethroscopy → online text (page 29 of 33)