Simple Perineal Prostatectomy

Currently, adenomectomy for the treatment of BPH is rarely performed by means of the perineal route. Previously, this approach was associated with significantly lower mortality than the abdominal route. However, this latter advantage has disappeared in the modern era as the mortality from all forms of prostatectomy has decreased to exceedingly low levels (18).

Resurgence of interest in the radical perineal prostatectomy has resulted in an increasing number of urologists becoming familiar with the perineal approach. This, in addition to a more precise understanding of anatomic relationships of the prostate (sphincter mechanism, neu-rovascular bundles), may encourage reevaluation of the perineal approach for the management of BPH in selected cases. In any event, knowledge that a perineal adenomectomy is a feasible procedure that has been performed with satisfactory results is important to maintain (1).

Proper establishment of the exaggerated lithotomy position is critical in establishing optimal perineal exposure and obviating positioning-related morbidity. The desirable flat perineum lying parallel to the floor can be achieved by elevating the buttocks or by marked flexion of the thighs. This requires avoiding pressure on the legs and the shoulders by using proper padding and careful placement of supports. The arms should be kept as close to the body as possible. In many instances, this can be accomplished by simply taping the hands (properly padded) to the knees.

Following the establishment of optimal positioning, the perineum is shaved, prepared, and draped in sterile standard fashion. A curved Lowsley tractor is placed into the bladder and then carefully withdrawn into the prostatic fossa. A semicircular skin incision between the ischial

Rectourethralis Muscle Cleavage

Fig. 14. Transection of the central tendon. Before doing this maneuver, the superficial perineal fascia must be entered and the ischiorectal fossa developed on both sides of the midline. If the central tendon is not easily identified and undermined, the index fingers should be inserted most posteriorly. It is important to stay behind the transverse muscles and the bulbar urethra. (Reprinted with permission from ref. 19.)

Fig. 14. Transection of the central tendon. Before doing this maneuver, the superficial perineal fascia must be entered and the ischiorectal fossa developed on both sides of the midline. If the central tendon is not easily identified and undermined, the index fingers should be inserted most posteriorly. It is important to stay behind the transverse muscles and the bulbar urethra. (Reprinted with permission from ref. 19.)

tuberosities is placed just above the mucocutaneous junction. The incised skin and subcutaneous tissues are then anchored with sutures or clips to an inferiorly placed drape or towel. Posteroinferior pressure applied to the Lowsley tractor helps push the prostate toward the perineum. The superficial fascial layers are incised carefully, preserving the central tendon. Each ischiorectal fossa is developed superiorly and posteriorly, with the handle of the knife working on the superior aspect of the infe-riorly placed index finger until the posterior aspect of the prostate is felt. The index fingers of each hand should encounter very little resistance as they are then used in a gentle seesaw motion ventral to the rectum and behind the central tendon to isolate this structure. The central tendon is then sharply divided (Fig. 14; 14).

Following transection of the central tendon, the whitish longitudinal muscle fibers of the rectum should become readily apparent. That structure constitutes an important regional landmark. At this point, it can be helpful to place an extra glove on the nondominant hand. Once done, an index finger can be placed in the rectum to better define that structure. It is also helpful to use a moist 4 x 4 gauze pad under the left thumb to

Simple Prostatectomy

Fig. 15. Incision of the rectourethralis. Once the rectourethralis is identified, gentle but deliberate spreading of the levator ani muscles in this area will often reveal the distinctive white surface covering the prostate on either side near the apex. It is important to recall that the rectum is still tented and can be entered. (Reprinted with permission from ref. 19.)

Fig. 15. Incision of the rectourethralis. Once the rectourethralis is identified, gentle but deliberate spreading of the levator ani muscles in this area will often reveal the distinctive white surface covering the prostate on either side near the apex. It is important to recall that the rectum is still tented and can be entered. (Reprinted with permission from ref. 19.)

draw the rectal wall taut. With the knife handle, the external rectal sphincter can be lifted away from the rectal lamina propria if this approach is desired. At this point it is useful to insert specially designed right-angle (often designated lateral) retractors to help achieve the exposure desired and to use a pediatric or perineal Omni retractor to maintain exposure.

The fibers of the levator ani muscle covering Dnomvilliers' fascia should be readily apparent. These fibers often fuse in the midline, thus constituting the so-called rectourethralis muscle. Once identified, it is helpful to insert a Lowsley or similar tractor into the bladder and open the blades. The assistant can then use the properly positioned tractor to elevate the prostate into the wound for better definition of the prostatic apex. The rectourethralis can then be sharply divided, avoiding the rectal wall (Fig. 15) but keeping in mind the relative safety of a limited misadventure into the surgical capsule of the prostate (19).

The assistant should then raise and tilt the Lowsley tractor to move the prostate into the wound. By doing so, the pubic symphysis acts as a fulcrum. Blunt dissection should now permit definition of the apical portion of the ventral rectal fascia (also referred to as the posterior layer of Dnomvilliers fascia). This is best done with the knife handle.

Cavernous Nerves Prostatectomy

Fig. 16. Exposure and incision into the posterior layer of Denonvilliers fascia. A vertical incision in the posterior lamella protects the cavernous nerves, which are located in a lateral position. This figure also depicts the levator ani muscles standing in relief lateral adjacent to the respective borders of the prostate. (Reprinted with permission from ref. 19.)

Fig. 16. Exposure and incision into the posterior layer of Denonvilliers fascia. A vertical incision in the posterior lamella protects the cavernous nerves, which are located in a lateral position. This figure also depicts the levator ani muscles standing in relief lateral adjacent to the respective borders of the prostate. (Reprinted with permission from ref. 19.)

This layer is also designated the pearly white gates of Young. By making a superficial vertical incision in the posterior lamella below the apex, the cavernous nerves (which are located laterally) can be avoided (Fig. 16; 19). The rectal fascia should then be bluntly dissected laterally over the body of the prostate to preserve the neurovascular bundles (Fig. 17); again, the knife handle is often useful in this maneuver (19).

Following exposure of the prostatic capsule, an inverted U-shaped or V-shaped incision should be made in the surgical capsule of the prostate. The apex of this incision should be slightly proximal to the verumon-

Fascia Rectalis
Fig. 17. Dissection of the rectal fascia. Using blunt and sharp dissection, the rectal fascia should be mobilized laterally over the body of the prostate. By doing so, the neurovascular bundles can be preserved. (Reprinted with permission from ref. 19.)

tanum. The latter is often demonstrable as a soft spot in the capsule. The incision into the surgical capsule should be deep enough to expose the cleavage plain of the adenoma (Fig. 18; 19). An Allis clamp can be used to grasp the apex of the U-flap and turn it downward (Fig. 19; 19). Both sharp and blunt dissection should be used to define the lateral border of the adenoma and its interface with the surgical capsule (Fig. 20; 20). Digital dissection can be used to further mobilize the adenoma in its apical aspect and better outline the urethra. The dorsal wall of the urethra should be divided to free the apical extent of the adenoma. Once accomplished, the remainder of the urethra can be divided at the apex to avoid injudicious tension placed on the sphincters (Fig. 21; 19). Before completing digital enucleation, it is prudent to remove the long tractor and the lateral and posterior retractors to avoid injury and tearing during the process of enucleation. The digital enucleation should stop when the adenoma has been completely mobilized except for its attachment to the bladder neck. The bladder wall should be grasped with an Allis clamp and the adenomectomy completed with sharp transection of this remain-

Prostate Adenoma Enucleation

Fig. 18. Inverted U-shaped capsulotomy. An inverted U-shaped or V-shaped incision provides optimal exposure for enucleation of the adenoma. The apex should be slightly proximal to the verumontanum. The incision through the capsule should be deep enough to define the cleavage plain between surgical capsule and adenoma. (Reprinted with permission from ref. 19.)

Fig. 18. Inverted U-shaped capsulotomy. An inverted U-shaped or V-shaped incision provides optimal exposure for enucleation of the adenoma. The apex should be slightly proximal to the verumontanum. The incision through the capsule should be deep enough to define the cleavage plain between surgical capsule and adenoma. (Reprinted with permission from ref. 19.)

Simple Prostatectomy

Fig. 19. Development of the U-shaped flap and exposure of the underlying adenoma. This figure depicts optimal retraction of the rectum inferiorly and the levator muscles laterally and superiorly. The U-shaped flap is grasped with an Allis clamp and turned downward. This exposes the underlying adenoma. (Reprinted with permission from ref. 19.)

Fig. 19. Development of the U-shaped flap and exposure of the underlying adenoma. This figure depicts optimal retraction of the rectum inferiorly and the levator muscles laterally and superiorly. The U-shaped flap is grasped with an Allis clamp and turned downward. This exposes the underlying adenoma. (Reprinted with permission from ref. 19.)

Simple Prostatectomy

Fig. 20. Separation of the adenoma from the prostatic capsule. In this figure, sharp dissection is used to initiate the plane of cleavage between the adenoma and the surgical capsule. This is facilitated by a Young's tractor that is positioned into the bladder and permits mobilization of the adenoma and ultimately amputation of the urethral apex. (Reprinted with permission from ref. 20.)

Fig. 20. Separation of the adenoma from the prostatic capsule. In this figure, sharp dissection is used to initiate the plane of cleavage between the adenoma and the surgical capsule. This is facilitated by a Young's tractor that is positioned into the bladder and permits mobilization of the adenoma and ultimately amputation of the urethral apex. (Reprinted with permission from ref. 20.)

Perineal Adenomectomy

Fig. 21. Division of the prostatic urethra. Before this point, the adenoma has been freed in both lateral aspects. Once transection of the urethral apex occurs, an index finger can be inserted into the cleavage plain and completion of the enucleation can take place. (Reprinted with permission from ref. 19.)

Fig. 21. Division of the prostatic urethra. Before this point, the adenoma has been freed in both lateral aspects. Once transection of the urethral apex occurs, an index finger can be inserted into the cleavage plain and completion of the enucleation can take place. (Reprinted with permission from ref. 19.)

What Suprapubic Prostatectomy
Fig. 22. Detachment of the adenoma. In this figure the adenoma has been grasped with a thyroid clamp. The Allis clamp has engaged the bladder neck. The tether point is being transected to free the adenoma from the bladder neck. (Reprinted with permission from ref. 19.)

ing tether point (Fig. 22; 19). As is the case with suprapubic prostatectomy, it is important to remove all significant subtrigonal and subcervical lobes. In the case of a large middle lobe, it may be necessary to dilate the bladder neck digitally and pop this component of the adenoma into the surgical field. Removal of a posteriorly placed V-shaped wedge of tissue will usually allow a fibrotic constricted bladder neck to spring open.

Bleeding can be controlled by spot fulguration or by carefully placed hemostatic mattress sutures of 2-O chromic catgut at the 5 o'clock and 7 o'clock positions. These sutures can also be used to anchor the bladder neck to the prostatic fossa (Fig. 23; 19). Dead space within the evacuated prostatic fossa can be obliterated (and hemostasis optimized) by leaving the hemostatic figure-eight sutures attached to the bladder neck long, with the ultimate intention of passing them through the

Lowsley Suprapubic Tractors

Fig. 23. Reconfiguration of the bladder neck. Allis clamps are used to grasp the 2 and 10 o'clock positions of the bladder neck. Hemostatic figure-eight sutures of 2-O chromic catgut have been placed in the 5 and 7 o'clock positions. Those sutures are intentionally kept long for later use. Posteriorly oriented sutures engage the bladder neck and posterior capsular flap. This maneuver helps to draw the posterior bladder neck into the prostatic fossa. (Reprinted with permission from ref. 19.)

Fig. 23. Reconfiguration of the bladder neck. Allis clamps are used to grasp the 2 and 10 o'clock positions of the bladder neck. Hemostatic figure-eight sutures of 2-O chromic catgut have been placed in the 5 and 7 o'clock positions. Those sutures are intentionally kept long for later use. Posteriorly oriented sutures engage the bladder neck and posterior capsular flap. This maneuver helps to draw the posterior bladder neck into the prostatic fossa. (Reprinted with permission from ref. 19.)

prostatic capsule and tying them snuggly. A 24-Fr 30-mL balloon catheter should be inserted into the wound and directed into the bladder using a curved clamp. The balloon can be hyperinflated to 60-70 mL if necessary. The catheter should be irrigated to evacuate any clots that may have accumulated and to validate optimal positioning (Fig. 24; 19). Currently, a perineal drainage tube is almost never placed in the bladder.

The U-shaped flap is closed using interrupted 2-O chromic catgut suture. A Penrose drain is placed in the perineum and brought out through one corner of the perineal wound. The Levator fibers are approximated with interrupted 2-O or 3-O chromic catgut sutures; the subcutaneous tissues are approximated with interrupted 3-O plain catgut; and the skin with a subcuticular closure.

Rectal Tube

Fig. 24. Foley catheter insertion. A 24-Fr 30-mL catheter is inserted into the urethra and directed into the bladder utilizing a curved clamp. The balloon is then hyperinflated to 60-70 mL. This figure also depicts the placement of previously inserted hemostatic sutures through the prostatic capsule. These sutures are then snuggly tied to further obliterate dead space and optimize hemostasis. (Reprinted with permission from ref. 19.)

Fig. 24. Foley catheter insertion. A 24-Fr 30-mL catheter is inserted into the urethra and directed into the bladder utilizing a curved clamp. The balloon is then hyperinflated to 60-70 mL. This figure also depicts the placement of previously inserted hemostatic sutures through the prostatic capsule. These sutures are then snuggly tied to further obliterate dead space and optimize hemostasis. (Reprinted with permission from ref. 19.)

A perineal binder should hold a fluffed-gauze dressing in place. In general, the Penrose drain can be removed in 1-2 d and the catheter in approx 1 wk (Fig. 25; 19).

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  • BERARDO CALABRESE
    How to seesaw a penrose drain?
    6 years ago
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    What is a lowsley prostatic retractor?
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