Beginning the procedure
The patient is placed in the supine position with the
table broken in the midline and tilted in the
Trendelenburg position. A midline lower abdominal
incision is made and a limited bilateral staging
pelvic lymphadenectomy is performed. Bull-dog
clamps are placed on the hypogastric arteries to
reduce blood loss. Next, a Hoitgrewe malleable
blade is used to displace the Foley balloon superiorly and posteriorly. Fibroadipose tissue is
teased from
the anterior surface of the prostate and the
endopelvic fascia is opened against the pelvic sidewall. Using finger dissection, the pelvic sidewall
musculature is separated from the lateral surface of
the prostate.
Click
on any step to get a detailed drawing of the procedure
Figure 1.
Division of the puboprostatic
ligaments
With a sponge stick positioned on the prostate to
place tension on the puboprostatic ligaments, the
ligaments are incised laterally; residual fragments
are fractured by finger dissection. The superficial
branch of the dorsal vein is electrocoagulated and
divided.
Figure 2.
Visualizing the field
A schematic illustration of the dorsal vein complex,
pelvic fascia, striated urethral sphincter, smooth
musculature of the urethra, and neurovascular bundles. When the right angle clamp is passed anterior
to the urethra, it transverses the fascia, some small
lateral venous branches, and the anterior one-half of
the striated sphincter.
Figure 3.
Isolating the dorsal vein complex
A McDougal clamp is used. The lateral wall of the
urethra is identified by palpating the indwelling
catheter and the lateral pelvic fascia is gently perforated by the clamp, which is then passed through
the avascular plane on the anterior surface of the
urethra. Care must be taken to avoid entering the
apex or anterior surface of the prostate.
Figure 4.
Dividing the dorsal vein complex
The McDougal clamp is positioned beneath the dorsal vein complex and surrounding striated urethral
musculature. The dorsal vein can be ligated and
divided or divided without ligation. We feel that
dividing the dorsal vein without ligation avoids injury
to the striated sphincter from the ligature and permits more
tissue to be removed on the anterior surface of the prostate. If the clamp has been placed in
the correct plane, the dorsal vein can be divided
completely with little residual bleeding.
Figure 5.
Oversewing the dorsal vein/
urethral sphincter complex
The dorsal vein/striated urethral sphincter complex
is oversewn horizontally using a running 2-0 Vicral
suture on a 5-8 circle tapered needle. Large venous
channels are often located at the posterolateral
edges and should be oversewn. This maneuver
forms an anterior hood of tissue that will be helpful
in the final anastomosis. Venous backbleeders on
the anterior surface of the prostate are oversewn
with 2-0 chromic catgut suture.
Figure 6.
Transecting the urethra
The urethra is gently separated from the lateral and
posterior portions of the striated sphincter without
mobilization. The right angle clamp is positioned
behind the urethra but anterior to the striated
sphincter. The neurovascular bundles cannot be
damaged by this maneuver because they are posterior to the striated sphincter. The anterior surface of
the urethra is divided. The Foley catheter is brought
through the incision, cross-clamped, and divided.
The balloon on the Foley catheter is released from
the malleable blade to provide proper traction on the
prostate and the posterior wall of the urethra is
divided.
Figure 7.
Visualizing the lateral and posterior components of the striated
urethral sphincter
With traction on the catheter one can visualize a
complex of skeletal muscle and fibrous tissue that
tethers the apex of the prostate to the pelvic floor
musculature. This is the residual lateral and posterior components of the striated urethral sphincter. A
right angle clamp has been passed immediately
beneath the left edge of the sphincter. The neurovascular bundle is posterior to the right angle clamp
and should not be injured during this maneuver.
Figure 8.
Dividing the superficial fascia
To prepare for preservation of the left neurovascular
bundle, the superficial lateral pelvic fascia on the
lateral surface of the prostate is released, first at the
bladder neck and then towards the apex of the
prostate. This maneuver releases the prostate,
making it more mobile, and exposes the location of
the neurovascular bundle in a groove at the posterolateral edge of the prostate.
Figure 9.
Releasing the lateral pelvic fascia
Beginning at the apex of the prostate, the lateral
pelvic fascia is gently released posteriorly from the
edge of the prostate, using a right angle clamp. This
maneuver assures that Denonvilliers' fascia is not
separated from the prostate. A small arterial branch
is clipped and divided. Having released the bundle
at the apex the dissection continues to the midprostate.
Figure 10.
Dividing the lateral pedicies
Once the neurovascular bundles have been released
on both sides, the attachment of Denonvilliers'fascia
to the rectum is divided in the midline, maintaining
all layers of Denonvilliers'fascia on the prostate.
At this point, a prominent arterial branch running
from the neurovascular bundle to the posterior surface of the prostate is identified. By dividing this
posterior branch, the neurovascular bundle falls
posteriorly, reducing the chance for injury during
division of the lateral pedicies. The lateral pedicies
are next divided on the lateral surface of the seminal
vesicles without ligation. Obvious arterial bleeders
are simply controlled with hemoclips once the lateral pedicle has been completely divided.
Figure 11.
Dividing the bladder neck
Once the bladder neck has been incised anteriorly,
the Foley catheter is deflated and used for traction.
The plane between the bladder neck and seminal
vesicles is easily identified because the lateral pedicles have already been divided.
This plane is developed and the bladder neck is divided on the anterior
surface of the seminal vesicles. An Alice clamp is
placed on the posterior bladder neck exposing the
vasa deferens in the midline. The vasa deferens are
clipped and divided. Next the seminal vesicles are
mobilized, arterial branches are clipped and divided,
and the specimen is removed.
Figure 12.
Closing the bladder neck
A tennis-racket closure of the bladder neck is preformed, using interrupted 2-0 chromic catgut suture;
4-0 chromic catgut sutures are used to evert the
mucosa of the bladder over the raw edges of the
detrusor musculature to avoid a bladder neck contracture.
Figure 13.
Catheter placement
A No. 16 French Foley catheter is placed through the
urethra and a silk suture is used to pull the tip of the
catheter through the urethral stump, exposing the
urethral mucosa.
Figure 14.
Anastomosis with distal urethra
Using 2-0 Vicral sutures on 5-8 circle tapered needles, full thickness sutures are placed at 12, 3, 6, and
9 o'clock positions through the urethral mucosa,
smooth muscle, striated urethral sphincter, and fascia. At the 6 o'clock position the suture is placed
with care to avoid injuring the neurovascular bundles, which are located posterior to the striated
sphincter. At the 12 o'clock position the suture incorporates the anterior dorsal vein/striated urethra
sphincter hood.
The patient had an uneventful postoperative recovery. Pathologically, there was
established capsular penetration, but the surgical margins of excision, seminal
vesicles, and pelvic lymph nodes were negative for tumor. One week after the
Foley catheter was removed the patient was able to have intercourse. Although
it is very unusual for a patient to have recovery of sexual function this early postoperatively,
this illustrates that it is possible to perform a radical prostatectomy
with ample soft tissue margins that preserves sexual function.
Recovery of sexual function is related to the age of the patient, the pathologic
extent of disease, and the surgical technique. Patients who are young and have
organ-confined disease are the best candidates for cure and also have the best
postoperative result. Using this anatomical approach, it is possible today to cure
prostate cancer with fewer side effects than in the past.
