BJU International (1999), 83, 776–782

REVIEW
A century of prostatic surgery
D. SHACK LEY
Department of Genome Damage and Repair (ERO), Paterson Institute for Cancer Research, Christies’ Hospital, Manchester, UK

haemorrhage and were largely abandoned. In 1876,

Introduction
Bottini used electric current to destroy prostate tissue
The syndrome of bladder neck obstruction has been transurethrally with ‘galvanocautery’, but excess hyper-
described for many centuries. The ancient Ebers Egyptian thermia caused serious complications [7].
papyrus from the 15th century bc alludes to diBculty
with passing urine and Hippocrates suggested that acute
Orchidectomy and other operative techniques
retention should be treated by purging [1,2]. The devel-
opment of the urinary metal catheter is credited to the John Hunter in the 18th century discussed the sequelae
Romans Celsus and Galen in the first century ad [3], of prostatic obstruction, including bladder hypertrophy
and the flexible catheter by Avicenna of Arabia in 1036 and upper tract dilation. His specimens supporting these
[4]. Since then, the catheter in all its forms, from the observations are displayed in the Museum of the Royal
hollow leaves of Allium fistulosum used by the ancient
Chinese [5] to the metal, rubber and gum elastic com-
pounds of today, has been the mainstay of treatment for
prostatic obstruction for 2000 years (Fig. 1). Despite this,
there was great anatomical confusion about the male
genitourinary tract and only in 1538 was the prostate
first represented diagrammatically, although unlabelled,
in Table 1 of Vesalius’ Tabula Anatomicae Sex. In 1611
Casper Bartholin named the gland ‘prostate’ and in the
ensuing two centuries a succession of practitioners
proved the association between prostate hypertrophy
and obstructive uropathy [6]. However, successful pros-
tatic surgery has evolved only in the last hundred years
and this article celebrates its first century (Table 1).

The Dark Ages (before 1895)

Transurethral procedures
Along with the catheter, various treatments and tech-
niques were tried to alleviate prostatic obstruction.
Ambroise Pare of France was the first to use a modified
catheter as a transurethral instrument to remove ‘car-
nosities’ of the bladder neck, in the 16th century. He
was far ahead of his time, this technique failing to gain
any popularity until the 19th century. The Frenchmen
d’Etoilles, Civiale and Mercier, and the Englishman
Guthrie, all designed and used various snares, excisors
and incisors of the prostate to create a channel transur-
ethrally. These blind techniques often caused dramatic
Fig. 1. Catheterization was the only realistic treatment for prostate
disease until the turn of the century (by kind permission of the
Accepted for publication 24 November 1998 British Library MS 197 d2, fol 19v).

776 © 1999 BJU International


College of Surgeons of England. He also proved the
association between the prostate and the testicle [8],
work which later merited a Nobel Prize for Charles
Huggins in 1940. Everard Home, Hunter’s brother-in-
law, published these findings in his textbook of 1811 [9].
The turn of the century marked a growing interest in
orchidectomy as a treatment for the enlarged prostate
although then the particular association with prostate
cancer was not known. William White reported in two
papers of 1895 and 1904 [10,11] the symptomatic
improvement in over a half of patients with an enlarged
prostate treated by castration. This was supported by
Cabot, a fellow surgeon, in 1896 [12]. However, despite
these seminal works orchidectomy never found favour
with practitioners of the day. August Bier in 1893
ligated both internal iliac arteries in the hope of causing
ischaemic atrophy of the prostate, but in his series of 11
patients, three died. Other operative techniques were
attempted, including vasectomy, with little success [7].
Towards the close of the 19th century, surgeons
became more ambitious after the fall in mortality associ-
ated with the major developments of general anaesthesia
(William Morton 1846) and aseptic techniques (Ignaz
Semmelweis 1861 and Sir Joseph Lister 1867) [13]. In
addition, the first direct-light endoscope was invented by
Table 1 Major surgical developments in prostatic surgery
Date Event
1846 General anaesthesia introduced (W. Morton, USA)
1867 Joseph Lister (UK) published two landmark papers
on asepsis
1880 Max Nitze (Germany) invents first cystoscope
1891 Goodfellow (USA) performs first blind perineal
prostatectomy
1895 Fuller (USA) publishes report of first total
suprapubic enucleation
1900 Freyer (Ireland) lectures on his original ‘new’
suprapubic technique
1901 First descriptions of visualized perineal
prostatectomy by Proust (France)
1905 First published case of perineal prostatectomy
performed for malignancy (Young, USA)
1908 Electrosurgery first used in urology by Beer (USA)
1911 Cold punch described (Young)
1915 Lewisohn (USA) introduces citrated blood
transfusion
1926 Resectoscope designed by Maximillian Stern (USA)
1941 Hormone manipulation of prostatic cancer noted
1944 Penicillin introduced
1945 Millin (UK) presents his retropubic technique
1954 Hopkins (UK) invents rod lens ‘fibrescope’
1975 TRUS developed
1989 PSA declared as useful serological test for prostate
cancer
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A C ENTU RY OF PROSTATIC S URGER Y 777
Maximillian Nitze of Berlin, allowing urologists to
develop a real appreciation of prostatic intraurethral
narrowing [7]. A period of huge urological advance was
ushered in, together with the first descriptions of
prostatectomy.
The period of enlightenment (1890–1950)
Suprapubic prostatectomy
Hippocrates taught that injuries to the bladder were fatal
and in the long history of bladder stone surgery, the
vesical suprapubic approach was neglected in favour of
others, most notably the perineal. The first suprapubic
approach to the bladder was by Nicholas Franco of
Lausanne in 1556 for stone extraction, but this was
only done in desperation after the failure of the perineal
technique. Prostatic obstructive disease treated by supra-
pubic cystotomy in the 18th and 19th centuries led to
the production of a persistent urinary fistula which often
strictured [14].
The earliest record of suprapubic prostatectomy is in
1827 by Jean Amussat, who used scissors to cut away
the obstructing prominent middle lobe. Various surgeons
during the late 19th century, including Bilroth, von
Dittel and Trendelenberg, described varying techniques
of suprapubic prostatectomy, but it was not performed
with any frequency until the close of the century [15].
William Belfield of Chicago reviewed all the published
cases of prostatectomy in 1890, finding 133 operations
of which 88 were suprapubic, the rest being perineal or
combinations of techniques [16]. Together with Arthur
McGill of Leeds, these two pioneering urologists were the
first real advocates of suprapubic prostatectomy in 1886
and 1887, respectively, they being the first to report any
series of operations [17]. The suprapubic prostatectomy
was initially known eponymously within the UK after
the Leeds surgeon. The mortality of suprapubic prostatec-
tomy in 1892 was #20% [15].
At that time there was much resistance to prostatec-
tomy. The concept that bladder atony could not be cured
by relieving the obstruction was supported by the most
famous ‘urologist’ of his day, Sir Henry Thompson of
London; his views were supported by others, including
Buckston-Browne [18].
It seems likely that the first operations before 1895
were only partial prostatectomies and credit for the first
deliberate suprapubic enucleation of the whole prostate
gland goes to Eugene Fuller of New York. He used
scissors to cut the bladder lining near the prostate and
then to blindly enucleate the gland with a finger [19].
He described using counter-pressure supplied by a fist
pushed against the perineum. His boxing sparring part-
ner and fellow professor, Ramon Guiteras, developed this
778 D . SHACKLEY
Fig. 2. Sir Peter Freyer (by kind permission of BAUS).
technique into intrarectal counter-pressure with two
digits of the left hand [20].
Sir Peter Freyer (Fig. 2) of Galway, Ireland, who was
‘headhunted’ to the newly formed specialist urological
St Peter’s Hospital in London, after pioneering bladder
stone ‘litholopaxy’ work, declared in 1900 that he was
the originator of the first total suprapubic prostatectomy
[21]. He described a technique very similar to Fuller’s,
except that he scored the urothelium with his fingernail
rather than scissors and left behind a large suprapubic
drain with no urinary catheter [22]. His first patient for
this procedure was a Mr John Thomas! Much bad feeling
existed at the time between Fuller and Freyer, with the
question of priority being hotly debated in medical circles.
Various surgeons at the time expressed their dislike of
Freyer’s claims. Berkeley Moynihan, later the President
of the Royal College of Surgeons of England, who assisted
McGill as a medical student during his early operations,
described him as ‘‘that Galway man aptly named ‘pee
freer’ ’’. It seemed to many too much of a coincidence
that Freyer had met Guiteras in London in the summer
of 1900.
Although undoubtedly Fuller was the originator of
the operation, Freyer was the first to show it could be
done safely and expeditiously, this being particularly
important before the sophisticated anaesthetic agents
and muscle relaxants of later years. He single-handedly
raised the whole profile of prostatectomy and urology.
He also laid claim to some remarkable results. In 1625
suprapubic prostatectomies, he recorded a mortality rate
of 5.3%, which compares very favourably with ‘catheter
life’ in the early 20th century, which carried an 8%
mortality within the first month of use [23].
Initially, all suprapubic operations were a one-stage
procedure, but as an understanding of the poor prog-
nosis of uraemia-associated surgery developed, some
practitioners resorted to a two-stage operation. This
followed the observations of Hugh Young of Baltimore
in 1889. He noticed that a comatosed patient in acute
renal failure treated by catheterization rapidly improved
before having an uneventful prostatectomy. The
patient was discharged home well a few weeks later.
The two-stage procedure was performed with an initial
suprapubic cystotomy, with the prostatectomy following
2 weeks later via the same incision [24]. By the 1920s,
most surgeons were using this technique. However, by
the 1930s it became apparent that the uraemic
patient represented only a small proportion of the total,
and indeed a two-stage operation worsened the
prognosis in the nonuraemic patient [25]. The pendu-
lum then swung back in favour of a single-stage
operation for most patients. Harry Fenwick of St Peter’s
in London (who was the first British urologist to use
the cystoscope) indicated further refinements. He
described using the anterior commissure of the prostate/
bladder interface as the easiest route to complete
enucleation [26]; other urologists, such as Bentley
Squire, agreed.
As the operative techniques developed, surgeons
turned to limiting morbidity, in particular, by haemo-
stasis. E.L. Keynes of America described a variety of
haemostatic techniques including cautery, stitches, tam-
ponade and pressure [27]. Hugh Young developed his
‘boomerang’ needle to place sutures deep in the prostatic
fossa and Paul Pilcher described a haemostatic bag. All
these techniques were to some extent successful. Sir
John Thompson-Walker, also of St Peter’s, suggested in
1919 that direct vision of the prostatic bed after the
enucleation would allow the surgeon to assess any
significant bleeding and treat it accordingly. To this end
he patented a bladder retractor, which he used with a
headlamp [28]. Harry Harris of Sydney, Australia,
received acclaim in the late 1920s for his mortality rates
for suprapubic prostatectomy of <4%. He argued for
complete closure of the bladder in all cases, with no
drains or dressings. He attributed his results purely to
technique, with meticulous haemostasis under direct
vision [29]. These developments, along with the
© 1999 BJU International 83, 776–782

controversy surrounding Freyer, brought the suprapubic
approach for prostatectomy to the attention of the uro-
logical world. It became the dominant operation for the
prostate in Europe until 1945.
Perineal prostatectomy
Perineal prostatectomy emanated from the operation of
perineal lithotomy. Bilroth in 1867 described the tech-
nique for what turned out to be a malignant prostate.
William Fergusson in 1870 and Langenbeck in 1876
described the same for benign disease. However, partial
prostatectomies have undoubtedly been performed
accidentally during the course of perineal lithotomy for
several centuries [30,31]. George Goodfellow of
California performed the accepted first total deliberate
perineal enucleation of the prostate in 1891. He
reported his series of 72 operations, with two deaths, in
1904 [32]. His was a ‘blind’ intraurethral technique,
and problems with limited access and counter-pressure
limited its widespread acceptance. The visualized extra-
urethral technique used today was developed almost
simultaneously on both sides of the Atlantic, by Proust
of France in 1901 and Hugh Young of America in
1903. It relied on the developments in design of suitable
perineal retractors, together with an exaggerated dorsal
lithotomy position [33–35]. The dreaded postoperative
complications of rectourethral fistula, urinary inconti-
nence and particularly impotence were reported to have
led to the killings of practising urologists by their
patients in France and the technique fell into disrepute
within Europe. The enthusiasm, superior anatomical
knowledge and persistence of Hugh Young, together
with his growing reputation, allowed the technique to
flourish. It became arguably a more widespread tech-
nique than suprapubic prostatectomy within the USA
during the early 20th century. Young described the
technique on benign (1903) and malignant (1905)
prostates. Along with Freyer, he published some aston-
ishing results; over a series of 1000 prostatectomies he
had a mortality rate of <4% [36], at a time when his
less experienced peers quoted 20–30% [37]. Young’s
success with prostatic urology led to the famous quip of
his colleague, E.L. Keynes, who said ‘the prostate makes
most men old but it made Hugh Young’.
Transurethral prostatectomy
The cold-punch technique. The invention of the endoscope
by Nitze, together with the discovery of high-frequency
current by Hertz, allowed urologists to turn their atten-
tion to the least invasive approach to the prostate. Hugh
Young was once again instrumental in the instigation
of this form of prostatectomy. In 1909 he originated the
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A C ENTU RY OF PROSTATIC S URGER Y 779
‘cold punch’ technique, which cut a channel through
the obstructing prostate transurethrally. This involved
passing a sheath with a large fenestration or hole at its
distal convex end into the bladder with a removable
obturator. The fenestration was then pressed down onto
the obstructing prostatic tissue and a blade then intro-
duced to excise this protruding tissue. This technique
was essentially performed by ‘feel’ with the help of locally
instilled cocaine only [38].
Edwin Beer was the first to show the clinical eCect of
monopolar diathermy under water in 1909 in an
experiment on bladder tumours [39]; with this, the
electrosurgical age was born. Young quickly incorpor-
ated electrocoagulation in his punch in 1911. However,
poor quality diathermy, haemostasis and consequent
poor vision initially limited the usefulness of this exciting
new technique.
In few other areas of medicine are the benefits of
improved instrumentation better shown to enhance an
operation than in TURP. In little over half a century,
this operation went from being performed with relatively
poor results solely in the USA, to becoming the accepted
‘gold standard’ for prostatectomy worldwide. Its develop-
ment is entirely to the credit of the leading American
urologists and instrument makers of the day. William
Braash, who later became a pure endoscopic urologist,
incorporated direct-vision endoscopy whilst using the
punch in 1918 [40], although lack of haemostasis
hampered the view. Kenneth Walker in 1925 developed
a Bakelite-insulated sheath with the uninsulated edge of
the fenestration acting as the electrosurgical site. This
improved coagulation and reduced unnecessary urethral
diathermy damage [41].
The resectoscope technique. The most significant develop-
ment occurred in 1926 when Maximillian Stern of New
York designed a cutting loop of tungsten through which
current could be passed, in eCect coagulating whilst
cutting [42]; thus the ‘resectoscope’ was born. Joseph
McCarthy incorporated this development into his ‘panen-
doscope’ in 1931, which therefore had direct vision, an
insulated sheath, diathermy, a cutting loop resection
and irrigation [43]. This became known as the Stern-
McCarthy resectoscope.
During this time there were improvements in optical
systems of the endoscopes, in particular by William Otis,
and developments in delivery of the electrosurgical cur-
rent by Reinhold and Friedrich Wappler, father and son,
who had moved to New York from Germany. Reed
Nesbitt in 1939 designed a spring trigger allowing one-
handed resection. The advantage of this was that the
free hand could be used to elevate the prostate rectally,
giving more of a depth impression during the prostatec-
tomy [44].
780 D . SHACKLEY
Alcock in 1932 reported 12 deaths from his first 50
cases of TURP [45] and this would seem to be typical of
the era. The technique was diBcult to learn, especially
with relatively primitive instrumentation, and the lack
of adequate training and supervision. However, by the
mid-1930s the mortality of the operations in the USA,
particularly in specialist centres like the Mayo clinic,
was significantly less than 10%.
In the UK, there developed a substantial resistance to
TURP and physicians there persevered with the supra-
pubic approach. The anti-specialist feelings then held by
the senior general surgeons meant that very few special-
ist urologists existed. Together with a lack of operative
expertise and specialist units, this meant poor results
with the transurethral technique. The electrosurgical
input was also hampered because the powerful dia-
thermy machines were being requisitioned for counter-
radar work [8]. Despite these setbacks, a few surgeons
learned the techniques from the USA. Thomas Lane of
Dublin and William Wardhill of Newcastle travelled to
Rochester to learn the ‘punch technique’ under Gershom
Thompson at the Mayo clinic. In the paper describing
his results, Wardhill emphasized the need for specialist
units and irrigation of the bladder until the urine was
clear with no clots [46].
Terence Millin, originally of Ireland, and Hamilton-
Stewart of Bradford, also tried transurethral surgery,
and in the case of the former, the ‘resectoscope’ [8].
Despite these eCorts, TURP was a rare procedure at this
time and a surgical registrar in 1960 from Great Britain
still had to travel to the USA to learn this operation
[47].
Retropubic prostatectomy
Before the introduction of antibiotics towards the close
of the Second World War, nobody dared to regularly
transgress the prevesical or retropubic space, because of
the risk of sepsis and lack of a route for dependent
drainage of infection. The introduction of first sulpho-
namides and then penicillin changed the face of prosta-
tectomy, cutting mortality and morbidity at a stroke.
Terence Millin, himself a previous transurethral resector,
turned his attention to the fourth approach to the
prostate. The retropubic approach first performed by
Millin in 1945 [48] was quickly adopted as the operation
of choice within the UK and revolutionized urological
practice worldwide. It is easy to learn, the bladder is left
intact and there is no need for sophisticated instrumen-
tation. Furthermore, it oCers an acceptable curative
operation for malignancy, something that limits the
transurethral operation, as described by other surgeons
just after Millin’s landmark paper, including Souttar,
Memmelaar and Chute [49,50].
Modern prostatectomy (1950 to the present)
Benign prostatectomy
Over the next 25 years, TURP slowly took over as the
‘gold standard’ operation for benign prostatectomy or
malignant outlet surgery. Further improvements in
instrumentation and advances in diathermy led to
increasing ease of use. This has also been coupled with
an increasing specialism of urology.
There have been three modern landmarks in TURP.
Undoubtedly the most important was Harold Hopkins’
invention of the rod-lens system [51]. This consisted of
a potentially flexible cable with a markedly improved
light transmission through coaxial light fibres and the
concept of ‘total internal reflection’. This led to much
better operative visualization during TURP. The second
advance was the change in irrigation fluid from water
to glycine. This followed work by Emmett on the dangers
of intravascular haemolysis with water [52]. The most
recent major improvement is the introduction of micro-
chip cameras in the last decade and since then TURP
has become much easier to teach and assess.
Malignant prostatectomy
Operations for malignant prostate disease continued to
some degree in the USA with the retropubic and perineal
approaches, but in Europe between the 1950s and the
1980s, the main stratagems for carcinoma of the prostate
moved to nonsurgical options.
The discovery by the Gutmans of acid phosphatase as
the first serum marker for metastatic prostate cancer in
1938 [53], followed by the discovery of endocrine
manipulation of prostate malignancy by Huggins and
Hodges [54], led to a growing belief in the eBcacy of
hormonal treatments. Oestrogen therapy [55] seemed to
hold much promise as a treatment. Castration once more
became popular and there were significant developments
in the field of chemical orchidectomy, after work by
Schally on LHRH analogues, published in 1976, which
contributed to his Nobel prize [56]. Radiotherapy seemed
to oCer another alternative, especially when surgery is
complex with marked complications. There was also a
growing realisation that most tumours had progressed
beyond the stage of surgical cure [57].
However, during the last two decades there has been
a move back to radical prostatectomy. In 1983, Patrick
Walsh described a radical retropubic prostatectomy with
a nerve-sparing approach [58]. Other workers noted that
radiotherapy may be less eCective than early surgery in
some younger patients [59]. The development of TRUS-
directed biopsies of the prostate [60] together with the
development of the PSA blood test [61] has enabled
© 1999 BJU International 83, 776–782

earlier diagnosis of prostate cancer. Further advances
include staging laparoscopy, which has allowed a
re-evaluation of the less invasive perineal radical prosta-
tectomy, currently enjoying a renaissance alongside the
more familiar retropubic approach.
Two central themes run through this celebration of
100 years of prostate surgery. First, the enthusiasm of
particular individuals to improve the techniques, notably
Fuller, Freyer, Young and Millin amongst many others,
has been pivotal in instigating changes. Second, the
importance of technological advances in instrumentation
is underlined.
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Author
D. Shackley, FRCS, Research Fellow in Urology, Flat D, 32
Lapwing Lane, Didsbury, Manchester M20 2NS, UK.
© 1999 BJU International 83, 776–782