Campbell-Walsh Urology, 11th Edition

PART XIV

Prostate

114

Open Radical Prostatectomy

Edward M. Schaeffer; Alan W. Partin; Herbert Lepor

Questions

  1. What is the arterial blood supply to the prostate?
  2. The pudendal artery
  3. The superior vesical artery
  4. The inferior vesical artery
  5. The external iliac artery
  6. The obturator artery
  7. What vessels are located in the neurovascular bundle?
  8. Capsular arteries and veins
  9. Pudendal artery and vein
  10. Hemorrhoidal artery and vein
  11. Santorini plexus
  12. Accessory pudendal artery
  13. A radical prostatectomy may compromise the arterial blood supply to the penis by injuring the aberrant blood supply from which artery?
  14. The obturator artery
  15. The inferior vesical artery
  16. The superior vesical artery
  17. The penile artery
  18. All of the above
  19. The main parasympathetic efferent innervation to the pelvic plexus arises from:
  20. S1.
  21. S2-S4.
  22. T11-L2.
  23. L3-S1.
  24. T5-T8.
  25. What is the relationship of the neurovascular bundle to the prostatic fascia?
  26. Inside Denonvilliers fascia
  27. Outside the lateral pelvic fascia
  28. Inside the prostatic fascia
  29. Between the layers of the prostatic fascia and the levator fascia
  30. Both inside and outside the prostatic fascia
  31. Why is there less blood loss during radical perineal prostatectomy?
  32. It is easier to ligate the dorsal vein complex through the perineal approach than through the retropubic approach.
  33. There is no need to divide the puboprostatic ligaments.
  34. The dorsal vein complex is not divided because the dissection occurs beneath the lateral fascia and anterior pelvic fascia.
  35. Because the perineum is elevated, there is lower venous pressure.
  36. The arterial supply to the prostate is ligated early.
  37. Which anatomic structure is responsible for the maintenance of passive urinary control after radical prostatectomy?
  38. Bladder neck
  39. Levator ani musculature
  40. Preprostatic sphincter
  41. Striated urethral sphincter
  42. Bulbar urethra
  43. What is the major nerve supply to the striated sphincter and levator ani?
  44. The neurovascular bundle
  45. The sympathetic fibers from T11 to L2
  46. The pudendal nerve
  47. The obturator nerve
  48. The accessory pudendal nerve
  49. What is the posterior extent of the pelvic lymph node dissection?
  50. The hypogastric vein
  51. The obturator nerve
  52. The obturator vessels
  53. The sacral foramen
  54. The pelvic side wall musculature
  55. In opening the endopelvic fascia, there are often small branches traveling from the prostate to the pelvic sidewall. These branches are tributaries from the:
  56. obturator artery.
  57. external iliac artery.
  58. inferior vesical artery.
  59. pudendal artery and veins.
  60. neurovascular bundle.
  61. How extensively should the puboprostatic ligaments be divided?
  62. Superficially, with just enough incised to expose the junction between the anterior apex of the prostate and the dorsal vein complex
  63. Extensively, down to the pelvic floor, including the pubourethral component
  64. Not at all; the puboprostatic ligaments should be left intact
  65. Widely enough to permit a right angle to be placed around the dorsal vein complex
  66. Not at all; the puboprostatic ligaments do not need to be divided to perform a radical prostatectomy
  67. When the dorsal vein complex is divided anteriorly, what is the most common major structure that can be damaged, and what is the most common adverse outcome?
  68. Aberrant pudendal arteries; impotence
  69. Neurovascular bundle; impotence
  70. Striated urethral sphincter; incontinence
  71. Levator ani musculature; incontinence
  72. Both a and b
  73. What is the most common site for a positive surgical margin and when does this occur?
  74. Posterolateral; during release of the neurovascular bundle
  75. Posterior; when the prostate is dissected from the rectum
  76. Apex; during division of the striated urethral sphincter–dorsal vein complex
  77. Bladder neck; during separation of the prostate from the bladder
  78. Seminal vesicles
  79. How should the back-bleeders from the dorsal vein complex on the anterior surface of the prostate be oversewn and why?
  80. The edges should be pulled together in the midline to avoid bleeding.
  81. Bunching sutures should be used to avoid excising too much striated sphincter.
  82. The edges should be oversewn in the shape of a V to avoid advancing the neurovascular bundles too far anteriorly on the prostate.
  83. They should be oversewn horizontally to avoid a positive surgical margin.
  84. Oversewing the proximal dorsal vein complex is not required.
  85. After the dorsal vein complex has been ligated and the urethra has been divided, what posterior structure, other than the neurovascular bundles, attaches the prostate to the pelvic floor?
  86. Rectourethralis
  87. Denonvilliers fascia
  88. Rectal fascia
  89. Posterior portion of the striated sphincter complex
  90. Neurovascular bundles
  91. What are the advantages of releasing the levator fascia higher at the apex (more than one answer may be correct)?
  92. More soft tissue on the prostate
  93. Less traction on the neurovascular bundles as they are released
  94. Preservation of anterior nerve fibers
  95. Less blood loss
  96. Better visualization of the location of the cancer
  97. Once the apex of the prostate has been released, what is the best way to retract the prostate for exposure of the neurovascular bundle?
  98. Traction on the catheter, producing upward rotation of the apex of the prostate
  99. Use of a sponge stick to roll the prostate on its side
  100. Downward displacement of the prostate with a sponge stick
  101. Use of finger dissection to release the prostate posteriorly
  102. Dissection with the sucker
  103. To avoid a positive surgical margin, what is the best way to release the neurovascular bundle?
  104. Right-angle dissection beginning on the posterior surface of the prostate and dissecting anterolaterally
  105. With sharp dissection, laterally dissecting toward the rectum
  106. With finger dissection to fracture the neurovascular bundle from the prostate
  107. With electrocautery to separate the neurovascular bundle from the prostate
  108. Elevation of the prostate with traction on the Foley catheter
  109. What is the latest point at which a decision can be made regarding preservation or excision of the neurovascular bundle?
  110. When perineural invasion is identified on the needle biopsy specimen
  111. When the neurovascular bundle is being released from the prostate and fixation is identified
  112. When the prostate has been removed and tissue covering the posterolateral surface of the prostate is thought to be inadequate
  113. When the patient is found to have a positive biopsy result at the apex
  114. When the Partin tables indicate a greater than 50% chance of extraprostatic extension
  115. Before the lateral pedicles are divided, what is the last major branch of the neurovascular bundle that must be identified and released?
  116. Apical branch
  117. Posterior branch
  118. Capsular branch
  119. Bladder neck branch
  120. Seminal branch
  121. When the vesicourethral anastomosis sutures are being tied, if tension is found, what is the best way to release it?
  122. Creating an anterior bladder neck flap
  123. Placing the Foley catheter on traction postoperatively
  124. Releasing attachments of the bladder to the peritoneum
  125. Using vest sutures
  126. Releasing the urethra from the pelvic floor
  127. If there is excessive bleeding from the dorsal vein complex while it is being divided, what should be done?
  128. Abandon the operation and close the incision.
  129. Ligate the hypogastric arteries.
  130. Inflate a Foley balloon and place traction on it.
  131. Divide the dorsal vein complex completely over the urethra and oversew the end.
  132. Deflate the Foley catheter.
  133. If a rectal injury occurs during the operation, the most appropriate next step is:
  134. to create a loop colostomy.
  135. to create an end colostomy.
  136. to create a Hartman pouch.
  137. to ensure interposition of the omentum following repair of the injury.
  138. to repair the rectal injury in two layers.
  139. In postoperative patients who require transfusions of blood for hypotension, the best approach is to:
  140. avoid re-exploration because it might damage the anastomosis.
  141. perform re-exploration.
  142. place the Foley catheter on traction.
  143. administer fresh frozen plasma.
  144. serially monitor the patient in an intensive care unit setting.
  145. What is the best way to ensure good coaptation of the anastomotic mucosal surfaces to avoid a bladder neck contracture?
  146. Hold the catheter on traction while tying the sutures.
  147. Use a sponge stick in the perineum.
  148. Use a Babcock clamp to hold the bladder down.
  149. Use vest sutures.
  150. Evert the bladder mucosa.
  151. What is the most common cause of incontinence after radical prostatectomy?
  152. Intrinsic sphincter deficiency
  153. Detrusor instability
  154. Failure to reconstruct the bladder neck
  155. Injury to the neurovascular bundles
  156. Bladder neck contracture
  157. Preservation of the seminal vesicles during radical prostatectomy has demonstrated:
  158. improved erectile function in the majority of men.
  159. no increase in biochemical recurrence.
  160. improved early and late urinary control.
  161. increased rate of pelvic abscess.
  162. none of the above.
  163. Preservation of the bladder neck during radical prostatectomy has demonstrated:
  164. improved erectile function.
  165. improved long-term urinary control.
  166. decreased surgical margins.
  167. improved anastomotic stricture rate.
  168. none of the above.
  169. What percentage of men who had bilateral sural nerve grafting demonstrated full erections sufficient for penetration?
  170. 9%
  171. 13%
  172. 26%
  173. 38%
  174. 57%
  175. Sural nerve grafts are placed:
  176. end to end on the ipsilateral side from the tumor.
  177. above the bladder neck and below the pubic arch.
  178. in reverse to the natural position (proximal to distal and distal to proximal).
  179. in a circle to enhance nerve growth factor release.
  180. next to the prostatectomy specimen in the pelvis until it is time for anastomosis.
  181. Which complication has changed dramatically with experience with salvage prostatectomy?
  182. Overall urinary incontinence
  183. Potency
  184. Blood loss
  185. Rectal injury
  186. Stricture rate
  187. Which of the following statements about perineal prostatectomy is FALSE?
  188. The pathologic outcomes are similar to those of radical retropubic prostatectomy and proven over considerable time.
  189. It has experienced a resurgence of interest as a result of its low morbidity and rapid convalescence.
  190. It fell out of favor as the principal technique in the 1970s, secondary to high intraoperative blood loss.
  191. Nerve-sparing techniques have been applied to the approach, allowing for postoperative potency.
  192. Partin tables allow for relatively accurate predictions of pathologic stage, forfeiting the need for staging lymphadenectomy in many patients.
  193. With regard to postoperative neurapraxia, which of the following statements is TRUE?
  194. The literature supports that it is almost always transient.
  195. It usually results in a motor deficit that is transient.
  196. Most studies show that a self-limited neurapraxia occurs in approximately 25% of patients.
  197. The same rates of neurapraxia tend to occur in retropubic prostatectomy as well.
  198. This is a major source of morbidity and the reason many surgeons do not use this approach.
  199. Which of the following statements with regard to rectal injury associated with perineal prostatectomy is FALSE?
  200. If unrecognized, it may result in the occurrence of a rectocutaneous or urethrocutaneous fistula.
  201. Despite the close proximity of the rectum in the initial dissection, the incidence is fairly low.
  202. It can be avoided when an assistant places gentle downward pressure on the Lowsley tractor while the rectourethralis muscle is divided.
  203. If repaired with a two-layer closure, most clinical sequelae are avoided.
  204. After repair with a two-layer closure, the operation can continue without a problem.
  205. When selecting a patient for radical perineal prostatectomy, which of the following must always be considered?
  206. Gleason score of biopsy specimen
  207. Preoperative serum prostatic-specific antigen (PSA)
  208. Mild degenerative lumbar disk disease
  209. a and b only
  210. All of the above
  211. Which of the following statements is TRUE regarding the radical perineal prostatectomy?
  212. Patients who require lymph node sampling for staging purposes should undergo a radical retropubic prostatectomy because the radical perineal prostatectomy, when combined with a laparoscopic lymph node dissection, yields much higher morbidity and is not cost effective.
  213. Patients with ankylosis of the hips or spine may not tolerate a radical perineal prostatectomy.
  214. Patients with a prior history of renal transplant surgery with the allograft in the right iliac fossa are not candidates for a radical perineal prostatectomy.
  215. Morbid obesity is becoming a common contraindication to a radical perineal prostatectomy.
  216. None of the above.
  217. Which of the following statements regarding blood loss during radical perineal prostatectomy is TRUE?
  218. Because transfusion rates are low, a blood type and crossmatch are not recommended before starting the case.
  219. Unlike a radical retropubic prostatectomy, the dorsal venous complex is not usually encountered and blood loss is significantly reduced.
  220. Transfusion rate in most reports is approximately 15%.
  221. The dorsal venous complex is ligated early, resulting in reduced blood loss.
  222. Rates of transfusion are generally greater than those in the retropubic literature.
  223. Which of the following statements concerning postoperative care is TRUE?
  224. The diet is rapidly advanced to a regular diet.
  225. Most patients are discharged from the hospital by postoperative day 2.
  226. A rectal suppository is administered on a scheduled basis while in the hospital to minimize Foley catheter discomfort except in cases of intraoperative rectal injury.
  227. a and b only
  228. All of the above
  229. Which of the following statements is TRUE with regard to potency outcomes of the radical perineal prostatectomy?
  230. Using a nerve-sparing technique, potency is shown to return in up to 70% of men.
  231. Older patients are as likely to be as potent as younger patients if a nerve-sparing technique is used.
  232. Pharmacotherapy is demonstrated to improve postoperative potency status.
  233. All of the above
  234. a and c only
  235. In a perineal prostatectomy, exposure of the urethra is facilitated by:
  236. encircling the urethra with umbilical tape.
  237. the Lowsley retractor.
  238. division of the puboprostatic ligaments.
  239. division of the dorsal venous complex.
  240. retraction of the neurovascular bundles medially.
  241. Which of the following statements concerning the technique of urethral anastomosis is TRUE?
  242. The presence of the Lowsley retractor assists in identifying the membranous urethral stump for the initial placement of interrupted sutures.
  243. A running suture technique is advocated for a watertight anastomosis.
  244. The visualization of the anastomosis is difficult, one of the few disadvantages of the radical perineal prostatectomy.
  245. The sutures are interrupted in a tennis-racquet fashion.
  246. The indwelling Foley catheter is not passed until after the anterior vesicourethral anastomotic sutures are placed and tied down.

Answers

  1. c. The inferior vesical artery.The prostate receives arterial blood supply from the inferior vesical artery.
  2. a. Capsular arteries and veins. The capsular branches run along the pelvic sidewall in the lateral pelvic fascia posterolateral to the prostate, providing branches that course ventrally and dorsally to supply the outer portion of the prostate.Histologically, the capsular arteries and veins are surrounded by an extensive network of nerves. These capsular vessels provide the macroscopic landmark that aids in the identification of the microscopic branches of the pelvic plexus that innervate the corpora cavernosa.
  3. e. All of the above.The major arterial supply to the corpora cavernosa is derived from the internal pudendal artery. However, pudendal arteries can arise from the obturator, inferior vesical, and superior vesical arteries. Because these aberrant branches travel along the lower part of the bladder and anterolateral surface of the prostate, they are divided during radical prostatectomy. This may compromise arterial supply to the penis, especially in older patients with borderline penile blood flow.
  4. b. S2-S4.The autonomic innervation of the pelvic organs and external genitalia arises from the pelvic plexus, which is formed by parasympathetic visceral efferent preganglionic fibers that arise from the sacral center (S2 to S4).
  5. d. Between the layers of the prostatic fascia and the levator fascia.The neurovascular bundles are located in the lateral pelvic fascia between the prostatic and levator fasciae.
  6. c. The dorsal vein complex is not divided because the dissection occurs beneath the lateral fascia and anterior pelvic fascia.In an effort to avoid injury to the dorsal vein of the penis and Santorini plexus during radical perineal prostatectomy, the lateral fascia and anterior pelvic fascia are reflected off the prostate. This accounts for the reduced blood loss associated with radical perineal prostatectomy.
  7. d. Striated urethral sphincter.The striated sphincter contains fatigue-resistant, slow-twitch fibers that are responsible for passive urinary control.
  8. c. The pudendal nerve.The pudendal nerve provides the major nerve supply to the striated sphincter and levator ani.
  9. a. The hypogastric vein.The obturator artery and vein are skeletonized but are usually left undisturbed and are not ligated unless excessive bleeding occurs. The dissection then continues down to the pelvic floor, exposing the hypogastric veins.
  10. d. Pudendal artery and veins.The incision in the endopelvic fascia is carefully extended in an anteromedial direction toward the puboprostatic ligaments. At this point, one often encounters small arterial and venous branches from the pudendal vessels, which perforate the pelvic musculature to supply the prostate. These vessels should be ligated with clips to avoid coagulation injury to the pudendal artery and nerve, which are located just deep to this muscle as they travel along the pubic ramus.
  11. a. Superficially, with just enough incised to expose the junction between the anterior apex of the prostate and the dorsal vein complex.The dissection should continue down far enough to expose the juncture between the apex of the prostate and the anterior surface of the dorsal vein complex at the point where it will be divided. The pubourethral component of the complex must remain intact to preserve the anterior fixation of the striated urethral sphincter to the pubis.
  12. c. Striated urethral sphincter; incontinence.The goal is to divide the complex with minimal blood loss while avoiding damage to the striated sphincter.
  13. c. Apex; during division of the striated urethral sphincter–dorsal vein complex.The exact plane on the anterior surface of the prostate can be visualized, avoiding inadvertent entry into the anterior prostate and ensuring minimal excision of the striated sphincter musculature. This is the most common site for positive surgical margins because it can be difficult to identify the anterior apical surface of the prostate.
  14. c. The edges should be oversewn in the shape of ato avoid advancing the neurovascular bundles too far anteriorly on the prostate. To avoid back-bleeding from the anterior surface of the prostate, the edges of the proximal dorsal vein complex on the anterior surface of the prostate are sewn in the shape of a V with a running 2-0 absorbable suture. If one tries to pull these edges together in the midline, the neurovascular bundles can be advanced too far anteriorly on the prostate.
  15. d. Posterior portion of the striated sphincter complex.The posterior band of urethra is now divided to expose the posterior portion of the striated urethral sphincter complex. The posterior sphincter complex is composed of skeletal muscle and fibrous tissue.
  16. b. Less traction on the neurovascular bundles as they are released, and c. Preservation of anterior nerve fibers.The purpose of this technique is to speed up recovery of sexual function by reducing traction on the branches of the nerves to the cavernous bodies and striated sphincter and/or avoiding inadvertent transection of the small branches that travel anteriorly. However, because there is less soft tissue at the apex, the risk of positive margins may be increased.
  17. b. Use of a sponge stick to roll the prostate on its side.When the surgeon releases the neurovascular bundle, there should be no upward traction on the prostate. Rather, the prostate should be rolled from side to side.
  18. a. Right-angle dissection beginning on the posterior surface of the prostate and dissecting anterolaterally.After the plane between the rectum and prostate in the midline has been developed, it is possible to release the neurovascular bundle from the prostate, beginning at the apex and moving toward the base, by using the sponge stick to roll the prostate over on its side. Beginning on the rectal surface, the bundle is released from the prostate by spreading a right angle gently. With use of this plane, Denonvilliers fascia and the prostatic fascia remain on the prostate; only the residual fragments of the levator fascia are released from the prostate laterally.
  19. c. When the prostate has been removed and tissue covering the posterolateral surface of the prostate is thought to be inadequate. Clues that indicate that wide excision of the neurovascular bundle is necessary include inadequate tissue covering the posterolateral surface of the prostate once the prostate has been removed, leading to secondary wide excision of the neurovascular bundle.This last point is important to understand. The surgeon does not have to make the decision about whether to excise or preserve the neurovascular bundle until the prostate is removed, and, if there is not enough soft tissue covering the prostate, one can excise the neurovascular bundle then.
  20. b. Posterior branch.The surgeon should look for a prominent arterial branch traveling from the neurovascular bundle over the seminal vesicles to supply the base of the prostate. This posterior vessel should be ligated on each side and divided. By this method, the neurovascular bundles are no longer tethered to the prostate and fall posteriorly.
  21. c. Releasing attachments of the bladder to the peritoneum.The anterior suture is tied initially. There should be no tension. If there is, the bladder should be released from the peritoneum.
  22. d. Divide the dorsal vein complex completely over the urethra and oversew the end. If there is troublesome bleeding from the dorsal vein complex at any point, the surgeon should completely divide the dorsal vein complex over the urethra and oversew the end.This is the single best means to control bleeding from the dorsal vein complex. Any maneuver short of this will only worsen the bleeding. To gain exposure for the prostatectomy, one must put traction on the prostate. If the dorsal vein is not completely divided, traction opens the partially transected veins and usually worsens the bleeding.
  23. d. To ensure interposition of the omentum following repair of the injury.It is wise to interpose omentum between the rectal closure and the vesicourethral anastomosis to reduce the possibility of a rectourethral fistula.
  24. b. Perform re-exploration. Our findings suggest that patients requiring acute transfusions for hypotension after radical prostatectomy should undergo exploration to evacuate the pelvic hematoma in an effort to decrease the likelihood of bladder neck contracture and incontinence.
  25. c. Use a Babcock clamp to hold the bladder down.We have found that the use of a Babcock clamp to approximate the bladder neck and urethra while the anastomotic sutures are tied has virtually eliminated bladder neck contractures in our practice.
  26. a. Intrinsic sphincter deficiency.After radical prostatectomy, incontinence is usually secondary to intrinsic sphincter deficiency.
  27. e. None of the above.Sparing of the seminal vesicles has not improved incontinence, potency, or margin status, and there have been no reported cases of pelvic abscess.
  28. e. None of the above. Sparing of the bladder neck has not improved incontinence, potency, margin status, or stricture rates.
  29. c. 26%.The percentage of men who had bilateral sural nerve grafting and demonstrated full erections (sufficient for penetration) was 26%.
  30. c. In reverse to the natural position (proximal to distal and distal to proximal).Sural nerve grafts are placed in reverse to the natural position (proximal to distal and distal to proximal).
  31. d. Rectal injury.Only rectal injury rates have dramatically changed.
  32. c. It fell out of favor as the principal technique in the 1970s secondary to high intraoperative blood loss.In the 1970s, the procedure fell out of favor because the importance of pelvic lymphadenectomy was understood for the purposes of staging. However, with the advent of Partin tables, surgeons could accurately predict the chances of lymph node involvement, obviating the need for staging lymphadenectomy. Furthermore, laparoscopic lymphadenectomy has gained favor and allows for radical perineal prostatectomy and lymph node dissection in one operative setting in patients in whom it is required. Pathologic outcomes are not significantly different for either procedure. It offers shorter hospital stays and lower costs than the retropubic prostatectomy. Blood loss is significantly lower than with the retropubic approach. A nerve-sparing technique can be accomplished through the perineal approach.
  33. a. The literature supports that it is almost always transient.Sensory neurapraxia of the lower extremity is reported to occur in approximately 2% of radical perineal prostatectomy cases. However, one study did report an incidence of 25%. This is reported significantly more often than with retropubic prostatectomy. True motor deficits are rare. Because of the transient nature, this is not a major source of morbidity.
  34. c. It can be avoided when an assistant places gentle downward pressure on the Lowsley tractor while the rectourethralis muscle is divided.Traction on the Lowsley tractor during division of the rectourethralis muscle tents the rectum upward and increases the likelihood of injury. Traction should not be placed until after the rectourethralis muscle is divided. When unrecognized, a fistula may ensue. Although one report showed an incidence of rectal injury in 11% of cases, most series recognize an incidence of 1% to 5%. When the injury is recognized and repaired at the time of occurrence, the operation can continue without a problem.
  35. d. a and b only.The patient's Gleason score and PSA value help determine the likelihood of organ-confined disease and, thus, the candidacy for a radical perineal prostatectomy. A history of degenerative disk disease is not a contraindication to surgery.
  36. b. Patients with ankylosis of the hips or spine may not tolerate a radical perineal prostatectomy.Because of the necessity for either an exaggerated lithotomy or a modified exaggerated lithotomy position, ankylosis of the hips or spine may be a contraindication to the procedure. Concomitant radical perineal prostatectomy and laparoscopic lymph node dissection results in little increased morbidity and remains cost effective when compared with radical retropubic prostatectomy. Patients with prior renal transplantation or morbid obesity are often better candidates for a perineal approach than for the retropubic approach.
  37. b. Unlike a radical retropubic prostatectomy, the dorsal venous complex is not usually encountered and blood loss is significantly reduced.The dorsal venous complex is usually not encountered, resulting in relatively lower blood loss when compared with the retropubic approach. A blood type and antibody screen are performed in the days or hours before surgery, but a crossmatch is generally unnecessary. Transfusion rates are generally around 5%.
  38. d. a and b only.Postoperatively, the diet is advanced rapidly as tolerated, patients ambulate early, and the overwhelming majority of patients are discharged by the second postoperative day. However, rectal stimulation or manipulation is prohibited in the postoperative period.
  39. e. a and c only.In a series by Weldon and colleagues (1997),* up to 70% of the patients were potent postoperatively. Furthermore, pharmacotherapy has been demonstrated to improve potency outcomes. However, older age has been demonstrated to be a risk factor for postoperative impotency.
  40. b. The Lowsley retractor.The apex of the prostate and adjacent urethra can be palpated easily because of the presence of the Lowsley retractor.
  41. e. The indwelling Foley catheter is not passed until after the anterior vesicourethral anastomotic sutures are placed and tied down.During placement of the anterior vesicourethral anastomotic sutures, a red rubber catheter is placed transurethrally and used to identify the membranous urethral stump and also provide traction on the urethra to assist in placement of the sutures. The red rubber catheter is then removed, and the indwelling Foley catheter is then placed retrograde into the bladder. Simple interrupted sutures are placed for the anastomosis. A tennis-racquet technique is used for bladder neck reconstruction if necessary.

Chapter review

  1. The dorsal vein has three major branches: a superficial branch in the midline and two lateral branches that span over the lateral aspects of the prostate.
  2. The prostate is covered with three distinct fascial layers: Denonvilliers fascia, prostatic fascia, and levator fascia.
  3. Denonvilliers fascia is most prominent and dense near the base of the prostate and overlying the seminal vesicles and thins dramatically more caudad at its termination at the striated sphincter.
  4. Laterally the prostatic fascia fuses with the levator fascia.
  5. Following radical prostatectomy, 15% to 20% of men develop an inguinal hernia. It is usually an indirect inguinal hernia.
  6. The final decision whether to preserve the neurovascular bundles is made at surgery.
  7. Findings that would indicate a neurovascular bundle should be resected include palpable induration in the lateral pelvic fascia, a neurovascular bundle that appears fixed to the prostate, and insufficient tissue on the posterolateral aspect of the specimen.
  8. Thermal energy should never be used on or near the neurovascular bundles.
  9. Bladder neck contractures occur in less than 10% of patients.
  10. Factors important for recovery of erectile function include patient age, preoperative potency status, and preservation of the neurovascular bundles.
  11. Potency improves with time such that in one study 42% of patients were potent at 3 months and 73% at a year.
  12. In a randomized study using sural nerve grafting to preserve potency in patients in whom a neurovascular bundle needed to be sacrificed, there was no difference in those grafted versus those who were not.
  13. Salvage radical prostatectomy should only be considered in men who have unequivocally clinically localized prostate cancer.
  14. Complications following salvage radical prostatectomy include 50% incontinence, 24% anastomotic stricture, and nearly universal erectile dysfunction, with approximately a 45% recurrence rate at 5 years.
  15. Complete excision of the seminal vesicle during radical prostatectomy is recommended for cancer control.
  16. Surgery should be deferred for 6 to 8 weeks after biopsy and 3 months after a transurethral resection of the prostate.
  17. During pelvic lymphadenectomy, one should preserve the lymphatic tissue covering the external iliac artery, which drains the lower extremity.
  18. Accessory pudendal arteries should be preserved.
  19. The most common site of a positive margin occurs at the apex, followed by the posterior and the posterolateral prostate.
  20. The bladder mucosa should be advanced so that the urethral vesicle anastomosis opposes mucosa to mucosa, is water tight, and is tension free.
  21. If postoperative phosphodiesterase type 5 inhibitors are to be used, on demand is preferred to daily dosing.
  22. Aberrant pudendal arteries may arise from the obturator, inferior vesical, and superior vesical arteries and should be preserved so as not to compromise the blood supply to the penis.
  23. Wide excision of the neurovascular bundle should be considered when there is inadequate tissue covering the posterolateral surface of the prostate once the prostate has been removed. The surgeon does not have to make the decision about whether to excise or preserve the neurovascular bundle until the prostate is removed, and, if there is not enough soft tissue covering the prostate, one can excise the neurovascular bundle then.
  24. If there is troublesome bleeding from the dorsal vein complex at any point, the surgeon should completely divide the dorsal vein complex over the urethra and oversew the end.
  25. Patients requiring acute transfusions for hypotension after radical prostatectomy should undergo exploration to evacuate the pelvic hematoma in an effort to decrease the likelihood of bladder neck contracture and incontinence.
  26. Rectal stimulation or manipulation is prohibited in the postoperative period.

* Sources referenced can be found in Campbell-Walsh Urology, 11th Edition, on the Expert Consult website.



If you find an error or have any questions, please email us at admin@doctorlib.info. Thank you!