Instruments
Include a basic set, genitourinary (GU) long and GU vascular sets, prostatectomy specials including a McDougal clamp, medium and large clip appliers, long forceps, Russian forceps, long Allis and Babcock clamps including one with a 45-degree angled end, long Metzenbaum scissors, and long needle holders. In addition, it is helpful to have available a 24-French Roth Greenwald suture guide, two Yankauer suctions, including one pediatric suction tip, a hand-controlled electrosurgery unit, 18-French Foley catheter with a 5-mL balloon, water-soluble lubricant, and one or two 15-mm rounded or 10-flat Jackson-Pratt drains. A Bookwalter retractor is useful for facilitating exposure, and in most circumstances the entire operation can be performed using only four Richardson 1.5-inch retractor blades. The lower two blades are used to retract the body wall and the upper two blades are useful for retracting both the superior body wall and allowing for cephalad retraction of the bladder and peritoneum. In obese patients, the upper two blades may need to be longer (2.5 inches deep). A malleable blade or ribbon may be useful for retracting the bladder medially during the pelvic lymph node dissection. Alternatively, a Balfour retractor may also be used and provides excellent extraperitoneal pelvic exposure with cephalad retraction of the bladder. Vision in the pelvis is aided by the use of 2.5× surgical loupes and head lamps that may be worn by both the surgeon and the first assistant.
Position
Place the patient in the supine position with his pubis centered over the break in the table ( Fig. 76.1 ). Next, slightly hyperextend the patient by raising the kidney rest and reflexing or breaking the table, placing the patient in an approximately 20-degree Trendelenburg position to elevate the pelvis and facilitate exposure. Care must be taken not to over-flex the table with obese patients, as they are at higher risk of postoperative nerve palsies. Alternatively, when there is concern with regard to accessing the perineum or rectum, the legs may either be frog-legged, with the knees properly supported using blankets or gel rolls, or placed in the lithotomy position in stirrups. In the latter position, place the perineum at the edge of the table to allow an assistant access for applying compression during the urethral anastomosis or inspecting the rectum. A sterile preparation is performed of the abdomen, pelvis, and genitalia, and the drapes are placed. Empty the bladder with a 16-French Foley catheter and inflate the balloon with 20–25 mL of water. Slight overinflation of the balloon facilitates cephalad retraction of the bladder using the U-shaped blade of either the Bookwalter or Balfour retractors. The Foley catheter is left in place for manipulation of the prostatic apex later in the case.
Operative Technique
Incision
A vertical midline incision is made extending from just above the symphysis to approximately halfway below the umbilicus. In general, excellent exposure is achieved through an incision that is only 6–8 cm ( Fig. 76.2 ). Split the rectus muscles in the midline. Lift the semilunar line, and dissect the peritoneum and fascia off the posterior abdominal wall and remain in the extraperitoneal space. Be sure to carry the dissection beneath the transversalis fascia to avoid injury to the inferior epigastric vessels.
Exposure
Lift up the rectus abdominis gently with a handheld Richardson retractor while sweeping the bladder and lateral edge of the prostatic fascia medially with a sponge stick to expose the space of Retzius. Free the peritoneum from the internal inguinal rings. Sweep the spermatic cord cephalad to expose the lateral edge of the external iliac artery. This creates a pocket in the retroperitoneum that allows for the spermatic cord and peritoneum to be retracted cephalad without risk of injury to the iliac vessels or genitofemoral nerve.
Retractor Placement
Insert a self-retaining surgical retractor. Before securing the oval ring to the fixed bar of the Bookwalter retractor, ensure that it is properly positioned to allow for cephalad exposure and to allow for enough room for placement of a Roth Greenwald suture guide. Generally, the upper edge of the oval ring is 1–2 inches above the umbilicus. Next, place four right-angled Richardson blades to allow for lateral sidewall and cephalad bladder retraction. The two lower retractor blades are used to separate the rectus muscles whereas the two upper blades not only separate the rectus muscles but also facilitate exposure by applying traction to the lateral edges of the bladder and peritoneum cephalad. In obese patients, the two cephalad retractor blades may need to be deeper to allow for adequate exposure. Of note, if placed correctly at the beginning of the operation, these four retractor blades will not require adjusting during the operation.
The Balfour retractor may also be used throughout the operation, and the standard blades are usually appropriate. In obese patients, the deeper sidewall blades may be needed. The malleable blade and U-blade will also be useful in retracting the spermatic cord during the lymph node dissection and the bladder during the prostatectomy, respectively.
Pelvic Node Dissection
If indicated, proceed with pelvic lymph node dissection, tailoring the extent of the dissection (modified vs extended) based on clinical risk factors.
Endopelvic Fascia
Gently tease the retropubic fat from the anterior and lateral prostatic surface. In the midline, the superficial branch of the dorsal venous complex will be identified within this fat and should be either cauterized or tied depending on its size. This allows for direct visualization of the lateral prostatic fascia and puboprostatic ligaments. Open the endopelvic fascia near the pelvic sidewall on both sides of the prostate with cautery or scissors ( Fig. 76.3, A and B ). Before incising the endopelvic fascia, it is best to place it on gentle stretch so that the fascia is taut when initially incised to avoid bleeding from any underlying blood vessels in the lateral pelvic sidewall and the medial prostatic fascia. Keeping away from the fascial attachments to the prostate and bladder avoids potentially significant bleeding from the large venous tributaries of the lateral aspect of the Santorini plexus. The incision in the endopelvic fascia is then extended medially to the level of the puboprostatic ligaments. Once the space has been opened, further develop it close to the bellies of the levator ani muscles and well lateral to the apex of the prostate by blunt dissection with either a finger or a Kittner sponge. Small perforating vessels from the levator ani muscles may be divided between clips. During dissection on the lateral prostatic fascia and near the prostatic apex, the surgeon should be cognizant of the possible aberrant vascular anatomy in this area. In particular, accessory pudendal arteries supplying bloodflow to the penis may course parallel or obliquely in this region. If technically feasible, these accessory arteries should be preserved as they may aid in the recovery of postoperative potency.
Incising the Puboprostatic Ligaments
Once the endopelvic fascia has been incised to level of the puboprostatic ligaments, a sponge stick can be used to place gentle downward traction on the prostate to distract it away from the undersurface of the pubic bone. Care must be taken to dissect free any small tributaries of the dorsal venous complex before dividing the puboprostatic ligaments. If the branches are intimately associated with the puboprostatic ligaments, they should be directly grasped with fine tissue forceps and cauterized. The puboprostatic ligaments are then partially transected with Metzenbaum scissors to allow for visualization of the prostatic apex ( Fig. 76.4 ). Once the junction of the prostatic apex and urethra is visualized and the overlying dorsal venous complex can be visualized, division of the puboprostatic ligament is discontinued. Thus the pubourethral extensions of the puboprostatic ligaments are left in place for structural support of the membranous urethra and striated urethral sphincter to aid in the recovery of continence.
Bunching of the Dorsal Venous Complex
To reduce bleeding during the division of the dorsal venous complex as well as to facilitate ligation of the complex as it courses over the prostatic apex, the dorsal venous complex may be gathered, or “bunched,” by grasping the dorsal venous complex as it courses over the junction between the bladder neck and prostatic base with a long Allis or Babcock clamp ( Fig. 76.5, A and B ). Care must be taken when grasping this complex both proximally and distally to avoid including the posterolateral tissue containing the lateral prostatic fascia and the neurovascular bundles. Place a figure-eight bunching suture of 1-0 Vicryl on a CT-1 needle on the dorsal venous complex as it courses under the clamp. Follow the dorsal venous complex distally as it courses over the prostatic urethral apex. Next, using a curved Allis to accommodate the angle of the pubic bone, the dorsal venous complex as it courses proximally over the urethra just distal to the prostatic urethral apex is grasped under the pubic bone. Using a sponge stick to gently retract the prostate away from the lateral pelvic sidewall, an absorbable suture is used to ligate the dorsal venous complex with either interrupted or figure-eight sutures ( Fig. 76.6, A and B ).
Division of the Dorsal Venous Complex
Divide the dorsal venous complex over the prostatic apex between the last bunching stitch on the proximal dorsal venous complex and the distal figure-eight dorsal venous complex stitch. This can be divided sharply or with the use of a Bovie electrocautery. Alternatively, before dividing the dorsal venous complex, a McDougall clamp may be insinuated between the undersurface of the dorsal venous complex and the anterior urethra and spread gently. The venous complex can then be divided. However, if bleeding ensues, pass a 1-0 Vicryl suture and secure the distal dorsal venous complex with an additional figure-eight suture before dividing the dorsal venous complex. If bleeding persists after dividing the dorsal vein, secure it with 2-0 Vicryl using a figure-eight stitch against the pubis, or secure it with the suture. Do not proceed with the apical prostatic dissection until hemostasis has been secured.
Apical Prostatic Dissection
Direct visualization of the prostatic apical dissection is critical to both cancer control and good functional outcomes. This is best accomplished with the use of optical magnification, use of a headlight, and maintenance of excellent hemostasis. Once the dorsal venous complex has been divided, the prostatic apex should be directly visualized with the use of some gentle cephalad retraction with a sponge stick and placement of the patient in reverse Trendelenburg position. Dissect closely around the urethra just below the apex of the prostate. The lateral extensions of the striated musculature should be cut to allow for optimal apical exposure. Care should be given to avoiding damage to neurovascular bundles through inadvertent traction or thermal injury due to cautery. At this point, some authors advocate separating the neurovascular bundles, located posterolateral, from the urethra and prostatic apex. Use scissors and then a right-angle clamp to push them off the surface of the prostate. Alternatively, the neurovascular bundles can be released after division of the urethra.
Division of the Anterior Urethra
Under direct vision, the anterior urethra is cut sharply, with care taken to preserve as much length on the striated urethral sphincter as possible. Cut the urethra obliquely with either Metzenbaum scissors or a no. 15 blade on a long handle because the apex of the prostate extends more distally on the lateral and posterior aspects of the urethra. Leave the posterior urethra intact to avoid retraction of the urethral stump. Grasp the now visible urethral Foley catheter and gently traction it cephalad. After clamping the Foley with a Kelly clamp, cut the Foley catheter at the urethral meatus and, after lubricating it, pull the now distal end through the urethra into the operative field and traction it gently cephalad. Great care should be taken to avoid aggressive pulling on the catheter that could result in damage to either the bladder neck or neurovascular bundles. Some surgeons prefer to transect the entire urethra at this point and will defer placement of the urethral stitches until after the radical prostatectomy has been completed.
Placement of the Urethral Sutures
After cutting the anterior two-thirds of the urethra, the distal anterior and lateral urethral anastomotic sutures may be placed. The advantage of placing the urethral stitches at this point is to take advantage of the fact that, with the posterior urethra still intact, the proximal urethra is easily visualized. To facilitate the anastomosis, a Roth Greenwald suture guide can be passed into the urethra. Alternatively, a urethral catheter can be used to help accentuate the urethral mucosa. Next, place five sutures of 2-0 Vicryl or 3-0 Monocryl on a curved UR-6 needle at the 12-, 2-, 5-, 7-, and 10-o’clock positions in the distal urethral stump and hold them in place with rubber-shod clamps ( Fig. 76.7 ). The urethral sutures are placed to allow for the final knots to be secured on the outside. Very carefully, these anastomotic sutures are then wrapped in a towel and protected to avoid accidental pulling or disruption. An alternative method in which the urethral stitches are placed after bladder neck reconstruction follows herein.
