In view of the extent of surgery, the length of the operative time, and often advanced patient age, a thorough medical evaluation and anesthetic consultation are required.

Bowel preparation is necessary before surgery. If it is planned to use the small bowel, oral neomycin and a lowresidue diet are all that are needed. More rigorous preparation with full bowel prep is required if the colon is utilized.

Patients with histories of thromboembolic disease or varicose veins should receive a prophylactic dose of heparin (5,000 U subcutaneously) the night before the operation and every 12 hours thereafter until ambulation. A parenteral broad-spectrum antibiotic is given just before induction of anesthesia and continued postoperatively for 3 days. The region extending from the midchest to the midthigh should be cleaned and prepared on the night before surgery.

Full relaxation of the abdominal muscles by an appropriate anesthetic is necessary throughout the entire procedure. Hypotensive anesthesia would provide an additional advantage and would reduce blood loss.

The choice of instruments depends mainly on the surgeon’s preference. Standard retractors of various sizes and curves as well as long curved and angled scissors are needed. Long curved clamps should also be available.

The patient is put in the supine position with a Trendelenburg tilt. Slight bending of the knees would further help in the relaxation of the abdominal muscles, facilitate retraction, and provide a wider exposure. If a total urethrectomy is planned, the patient is put in a slight lithotomy position for access to the perineum.

The surgical area to be sterilized and draped extends from the lower chest down to the root of the penis. A self-retaining catheter is introduced into the bladder and kept indwelling for its evacuation throughout the procedure.

A long, vertical, right paramedian incision extending from the symphysis pubis inferiorly to a point halfway between the umbilicus and xiphoid process of the sternum superiorly is generally employed. Alternatively, a midline incision encircling the umbilicus can also be utilized. For obese patients, a lower abdominal muscle-cutting transverse incision is preferred. Under such circumstances, it provides a wide and direct exposure of the pelvis.

Initially, the abdominal and pelvic cavities are explored. The growth is palpated, its degree of mobility determined, and its relation to the adjacent structures assessed. The endopelvic and aortic lymph nodes are palpated and frozen sections are taken if necessary. The general peritoneal cavity, omentum, intestinal tract, kidney, spleen, and liver are thoroughly examined. If the decision is to proceed with the radical operation, the intestines are packed out of the pelvis, and the retropubic space is opened by blunt dissection. Any small bleeders are coagulated. This dissection is extended inferiorly and laterally until the ventral surface of the bladder and prostate are exposed. The peritoneal incision is extended inferiorly on either side of the urachal remnant. The urachal remnant is dissected off its attachment with the umbilicus and clamped. In this manner, a triangular peritoneal flap with its apex pointing superiorly is raised and will be removed later en bloc with the bladder.

The peritoneal incision, on either side, is extended posterolaterally along the lateral border of the external iliac and common iliac vessels up to the aortic bifurcation. The vas deferens is identified and ligated near the internal ring. The fascia on the iliopsoas is incised and reflected medially. The triangle of Marseille is exposed by retracting the common and external iliac arteries medially and dissecting the space between these vessels and the medial border of the psoas muscle (4). Dissection of the fibrolymphatic tissues in this space will expose the obturator nerve as it emerges from the medial border of the psoas muscle (Fig. 19.1). The fibrofascial sheath covering the distal half of the common iliac and the external iliac vessels is then opened and stripped medially to remove the perivascular lymphatics and lymph nodes (Fig. 19.2A). The vessels are gently retracted laterally and immediately below and medial to the cleaned external iliac vein, and the obturator space is entered (Fig. 19.2B). By working right on the psoas and obturator muscles, one can strip all the pelvic fascia medially without difficulty. The obturator neurovascular bundle is included in the stripped mass. The obturator nerve is identified and separated
from its vessels, which are ligated and divided as they leave the pelvis through the obturator foramen. Dissection is facilitated and the operating time reduced by the use of electrocoagulation to control lymphatic and small blood vessels throughout the lymphadenectomy. The fibrolymphatic mass is now reflected medially, and the internal iliac artery and its branches are identified (Fig. 19.2C), and its anterior division is divided and ligated. This completes the lateral dissection (Fig. 19.3A and B).

The ureter is identified where it crosses the common iliac bifurcation, dissected free for 3 to 4 cm, divided, and its distal end ligated. While traction is applied on the ligated ureteric stump of the ureter, finger dissection along its posteromedial border opens the space of Denonvilliers laterally. The step greatly helps in the definition of the plane between the bladder and rectum, which will be required at a later stage in the operation.

The endopelvic fascia on either side on the prostate is then opened by the tip of a blunt pair of scissors (Fig. 19.4). The optimal site for the creation of this opening is a white line marking the fusion of the parietal fascia lining the pelvic surface of the levator ani with the visceral fascia covering the lateral surface of the prostate. A right-angle clamp is used to lift the fascia from the underlying venous plexus, and it is further incised medially until the prostatic ligaments are reached. By blunt dissection, this plane is further developed posteriorly on either side of the prostate. Further anterior dissection is deferred to the final stages of the procedure to minimize the possibility of sudden blood losses from inadvertent injury of the prostatic venous plexus.

The specimen is now lifted ventrally by applying traction on the median umbilical ligament (urachus). The two planes developed along the posteromedial borders of the ureter on either side are easily joined together by blunt dissection. As a result, the peritoneal reflection from the anterior surface of the rectum to the back of the bladder could be stretched and safely incised by diathermy. The potential space between the rectum posteriorly and the bladder, seminal vesicles, and prostate anteriorly is opened by blunt dissection (Fig. 19.5). As the prostatic apex is reached, this space becomes obliterated as a result of fusion of the two layers of the fascia of Denonvilliers. This cul-de-sac is opened by the blunt tip of long angled scissors. Once this is completed, the tip of the surgeon’s forefinger would readily feel the apex of the prostate as well as the catheter in the urethra in the midline. Alternatively, if it is directed laterally, it will appear through the previously created openings on either side of the prostate (Fig. 19.6).