Tuesday, March 25, 2014

Historical Contribution: HH Young, Perineal Prostatectomy for Benign and Malignant Disease, 1905


Simple perineal prostatectomy for benign disease.  Conservative Perineal Prostatectomy: The Results of Two Years' Experience and Report of Seventy Five Cases.  Young H.H. VIII. Ann Surg. 1905;41:549-57.     

Radical Prostatectomy for the cure of cancer: The early diagnosis and radical cure of carcinoma of the prostate.  Being a study of 40 cases and presentation of a radical operation which was carried out in 4 cases.  Young H.H. Bull. Johns Hopkins Hosp. 1905:16:315

In these two manuscripts, the father of modern urology, Hugh Hampton Young, describes his outcomes with perineal prostatectomy for both benign disease and cancer.  He originally described the operation in 1904 and presents his outcomes in 1905.

In the first manuscript, HH Young describes his technique for treating benign prostatic disease in 75 patients.  Dr. Young created many instruments for the manipulation of the urinary system and demontrates a tractor to be inserted into the urethra and manipulate the prostate for enucleation.  He discusses management of large median lobes, bladder stones and the difficult median bar (or high-riding bladder neck as commonly discussed in current times).  More importantly, Dr. Young clearly detailed his outcomes for urinary continence, erectile dysfunction and mortality.  The vast majority of patients had volitional voiding restored with low post-void residuals.  Many of the men suffered erectile dysfunction; however, HH Young clearly demonstrated that younger men fared better than older.  Finally, four men died of causes unrelated to surgery during short follow-up.

In the second manuscript, HH Young describes
the radical perineal prostatectomy as the proposed, routine operation for cases of cancer of the prostate.  As background he details cases of early carcinoma and partial resection was performed erroneously.  He then reviews clinical and pathological study of 40 cases of prostate cancer, compares early cases in the literature in which
operations for carcinoma of the prostate were performed and finally draws conclusions from his work and the work of others regarding the practicability of early diagnosis and the radical cure of the disease.

Major insights from this manuscript include:

  • prostate cancer occurs in approximately 10% of cases of benign prostatic enlargement
  • marked induration in any man greater than 50 years of age should be considered suspicious for cancer
  • advocating frozen analysis of prostatic tissue if the diagnosis of cancer is uncertain
  • the definition of pathways of local (along the ejaculatory ducts, between the prostate and seminal vesicles) and metastatic spread (out through the lymphatics near the trigone of the bladder to the pelvic lymph nodes and osseous sites)
  • radical prostatectomy (removal of the prostate, vasa and seminal vesicles) as the only means of cure for men with prostate cancer
Follow the links above to read these manuscripts in their entirety.


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