This Antique Resectoscope demonstrates the incandescent bulb system a ratchet loop mechanism and filiform obturator.

A review of the symposium on Transurethral Surgery in 1932 demonstrated that Dr. Alcock was a pioneer in the surgical technique even thought he didn't feel that he could teach technique, that it needed to be experienced according to Alcock's precepts. He received laudatory congratulations on his work by none other than Hugh Hampton Young. Quickly thereafter, in 1933, Dr. Alcock reported to the AMA in Milwaukee on his first 500 transurethral resections of the prostate. By his own acknowledged indebtedness, Alcock built his reputation on the shoulders of Drs. T. M. Davis and Joseph Stern, who developed the early technology. All urologists of the period were influenced by the classic text by Alexander Randall at Pennsylvania who demonstrated the autopsy findings of gross pathology of prostatic obstruction. Dr. Alcock had observed the salutatory values of transurethral resection in 1931 and produced a singular experience in the technique publishing his results over the following four years. His articles published in the Journal of Urology and JAMA are classic in their content. Alcock presents his work in the first-person, describing his successes and failures, including those patients who died related to resection technique. Alcock clearly demonstrated by his segregation of operations that there was a steep learning curve in perfecting the surgical technique.

Resection room; note Alcock stirrups hanging on the wall.

His statistics demonstrated that he succeeding in perfecting the operation, reducing morbidity and mortality over succeeding cases. In 1932 Alcock sums up the discussion at the Toronto Meeting with the following comments: "In closing let me say that I appreciate very, very much your many comments. There have been many remarks in relation to my honesty which naturally have ticked my vanity but frankly I see no reason why a man in medicine should be complimented for being honest."

Alcock's cost-savings analysis sounds most modern to us today even if the dollar amounts are cheap by modern standards. He estimated a hospital stay of 71 days for suprapubic prostatectomy patients vs. 17.5 days for transurethral resection patients. Hospitals costs were $5.00 so that hospitalization costs decreased from $355 to $87.50 and his surgical fee was $100. He estimates a cost savings of $267.50 per patient and suggested that this savings would be significant when estimated for his 500 resection patients ($43,750) and a cost of $177,500 for 500 suprapubic prostatectomies. He suggested a savings of $133,750 dollars from doing resections just from hospital stay costs. His initial report lists the economic gains from decrease in nursing care, stores of surgical gauze ($7,200), and Pezzar catheters ($600) which were saved by doing transurethral surgery as opposed to an open suprapubic prostatectomy. It is amazing to note that an operating room charge was $25 in 1932.

Dr. Alcock would receive a "fill-in" resident in 1932, Dr. Rubin Flocks, recommended from Johns Hopkins University. Dr. Flocks contributed two significant papers to the development of transurethral resection. He opened to door to the studies of his disciple, Rubin Flocks, who would describe the blood supply to the prostate and bring the issues of operative and postoperative hemorrhage into perspective. The first paper on the blood supply to the prostate was published in 1937. This autopsy study clearly demonstrated the urethral and capsular blood supply of the enlarging prostate, which had to be controlled by the operating surgeon. The surgical principle of electro-desiccation at the 5 and 7 o'clock positions just below the bladder neck, allowed Dr. Flocks to minimize urethral bleeding from the enlarged adenoma of the prostate. He could then resect to the base of the adenomatous tissue, completing his resection when he noted that his capsular vessels were bleeding perpendicular to the prostatic capsular fibers. Alcock recognized that separation of capsular fibers and evidence of glistening fat tissue demonstrated capsular perforation. They admonished resident resectionists to terminate the procedure if these findings were noted.

Dr. Alcock and Dr. Flocks were always proud of their ability to remove tissue by transurethral means and the knowledge of anatomy facilitated these technical skills. The autopsy postoperative surgical specimens had a natural transition to his follow-up paper demonstrate the effects of surgery.

Dr. Flocks wrote what the incomplete resection could lead to postoperative bleeding and alluded to the issues of incomplete resection that would be the subject of his second paper on the healing of the prostatic fossa in 1938. This priceless paper demonstrates autopsy postoperative bladder and prostate specimens and tragacanth injecting urethrograms that demonstrated the postoperative findings in completed and incomplete resections. The important correlation of incomplete resection and pyuria was observed in this study performed in the pre-antibiotic era. Today, antibiotics provide a margin of safety not available to early resectionists. While Corbus had described the acute response of the McCarthy diathermy unit, he did not have the longitudinal data about prostatic wound healing described by Flocks. Clearly, the autopsy specimens indicated that tissue injury for electrocautery would be only 3-4 mm in depth towards the capsule of the prostate. Flocks could report that the surgical experience reported was based on 2,000 resections performed over the 7-year period when Dr. Alcock began his pioneering work.

During this same time, Dr. Alcock would influence another of his residents, Dr. Milo Ellik to develop his evacuator, which remains a mainstay of urologic practice. Dr. Alcock was not happy with the Davis evacuator that is similar to the present day Toomy syringe. He suggested to Dr. Ellik that he cross the Iowa River to the Chemistry Department glass blowing shop and develops a better evacuator. The result was the Ellik evacuator, reported in the Journal of Urology in 1937.

     
Ellik's tissue and blood clot evacuator consisted of a double bowl chamber with a rubber flexible adaptor to the resectoscope and a hard rubber ball pump. When filled with water, the evacuator would collect prostatic chips or clot in the lower chamber which kept them from being returned to the bladder cavity. At Iowa the evacuators were produced in the chemistry department for many years. Dr. Ellik never had a patent on his device that was ultimately patented by the Bard surgical supply company in the 1940s.

Other technical offshoots of the operation included Harry Whitver's tissue strainer and separator basket used to remove tissue from the Ellik evacuators, the Alcock stirrups which suspended the patient's legs with the foot and calf elevated above the thigh allowing collapse of venous return from the legs and avoiding deep venous thrombo-phlebitis. Although Dr. Alcock never had a resectoscope named after him, he did develop a grasping forceps, which was used to retrieve large pieces of prostatic tissue from the bladder. Rubber (demonstrated in the cartoon above), then plastic aprons were created to protect the resectionist from a "bath" of irrigating fluid during the resection. The Whitver basket was used to interrupt the urine stream so tissue did not fly in the face of the resectionist.

Transurethral resection was a skill, which was acquired with experience. In the pre-Medicare environment, residents apprenticed themselves to senior colleagues who taught them by demonstrating bleeding from adenoma vs. prostatic capsule. The extended experience with panendoscopy demonstrating the bladder neck landmarks, anterior commissure, verumontanum, and "Alcock's lobes" provided the basic anatomy for resections. For modern resectionists, one must remember that these skills were gained with incandescent #51 lamp bulbs in a 28 Fr. resectoscope and battery light sources producing 100-foot candles of light energy at 1/2 inch and perhaps 60-foot candles at 1 inch from the surface. For comparison a fiber optic source might produce as much as 1600-foot candles at 1/2 inch and 1520-foot candles of light at one inch. Clearly, the operating surgeon in Alcock's day had to reconstruct in the mind the anatomic configuration of the prostate and apply that to the two dimensional image projected dimly through his lens system. When blood was added to this visual equation either from venous or arterial sources, careful control by controlling the spark gap energy was essential for a good surgical outcome.

Inevitably, "tricks of the trade" were developed, including the preoperative placement of 20-22 Fr. urethral catheters to prepare the patient for the passage of the resectoscope. Occasional patients would have urethral strictures or tortuous prostatic urethras. A modified red rubber coude catheter was present on the resection table, which had a long string adaptor on the distal end. If the coude catheter could be advance into the bladder as evidenced by urine drainage, the Alcock grasping forceps could draw the string adaptor through the resectoscope sheath. The sheath could then be passed over the red-rubber catheter into the bladder. Resection could then be accomplished by removing the irregular prostatic adenoma or carcinoma. These observations suggest the debt of gratitude which we moderns owe to our fathers and grandfathers in urology. For the last two decades of Dr. Alcock's career and the first two of Dr. Flock's career, the modification and development of transurethral resection would be a focus of the Department of Urology.

Innovative black and white photography of resection technique would be developed to demonstrate transurethral resection of the prostate and bladder tumors. These innovative films were used by faculty and residents for teaching purposes and demonstrated the efficacy of the transurethral technique.