- Email: [email protected]
ANATOMICAL RADICAL RETROPUBIC PROSTATECTOMY: DETAILED DESCRIPTION OF THE SURGICAL TECHNIQUE
0022-5347/04/1716-2114/0 THE JOURNAL OF UROLOGY® Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 171, 2114, June 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000119822.43396.0c
Foreword to DVD ANATOMICAL RADICAL RETROPUBIC PROSTATECTOMY: DETAILED DESCRIPTION OF THE SURGICAL TECHNIQUE Mailed with this issue of The Journal of Urology威 is a video presentation of the anatomical approach to radical retropubic prostatectomy. This 1 hour and 45 minute DVD provides a detailed description, including illustrations and video footage, of a surgical technique that has been continuously modified and improved during the last 20 years in operations performed on more than 3,000 patients. In this Foreword I will comment on some of the important principles. PELVIC LYMPHADENECTOMY
Although I had always believed that the major value of pelvic lymphadenectomy was accurate staging of the lesion, I have come to understand that a more complete pelvic lymph node dissection may have therapeutic benefit because 13% of the patients with positive lymph nodes in this series who underwent radical prostatectomy had an undetectable prostate specific antigen at 10 years and may be cured. The technique for complete lymphadenectomy down to the pelvic floor skeletonizing the internal iliac veins is illustrated. CONTROL OF THE DORSAL VEIN COMPLEX
This major step in the procedure accomplishes many goals. First and foremost, it makes the operation safer and provides a bloodless field in which the remainder of the procedure can be performed with improved visualization. The striated urethral sphincter is intimately entwined in the tributaries of the dorsal vein complex, and during control of the venous tributaries care must be taken to preserve as much of the striated sphincter as possible without inadvertent entry into the apex of the prostate. This is the most common cause of positive surgical margins. At termination of this step in the procedure the posterior shelf of the striated sphincter is divided under direct vision to facilitate preservation of the neurovascular bundles. I realize that many surgeons believe that the neurovascular bundles should be released prior to ligation and division of the dorsal vein complex. However, I have found that if the dorsal vein complex has been completely divided it is easier to determine the status of the neurovascular bundle and make an informed decision about whether it can be preserved or sacrificed. PRESERVATION OF THE NEUROVASCULAR BUNDLE
Today, it is safe to preserve both neurovascular bundles in most men who are candidates for radical prostatectomy. The neurovascular bundle is outside the capsule and prostatic fascia, and can usually be preserved even when there is capsular penetration in this region if the prostatic fascia remains on the prostate. Indeed, in our experience negative margins can be obtained using this technique in 95% of such patients. I do not believe that it is wise or necessary to perform an intrafascial dissection (inside the prostatic fascia) because this carries the dissection immediately adjacent to the prostatic parenchyma and risks positive margins even in patients with organ confined cancer. Four scenarios of nerve-sparing are illustrated to demonstrate the technique used in various circumstances. RECONSTRUCTION OF THE BLADDER NECK AND VESICOURETHRAL ANASTOMOSIS
The technique for wide excision of the bladder neck with tennis racket reconstruction and intussusception of the bladder neck is illustrated. When performing the vesicourethral anastomosis, if there is any tension when pulling down the bladder, a Babcock clamp is used to hold the reconstructed bladder neck in place while the sutures are tied. Robert Myers from the Mayo Clinic suggested this to me some time ago and I have found that one can be more certain that the sutures are accurately approximated than if one tries to tie around the Foley catheter balloon while it is held on traction. This technique has markedly reduced the number of my patients in whom bladder neck contracture has developed. INGUINAL HERNIA REPAIR
Approximately 15% of patients have an inguinal hernia within 1 or 2 years following surgery. I believe that many of them had incipient hernias that could have been repaired during radical prostatectomy. The technique for identification and intraoperative repair of direct and indirect inguinal is illustrated. Patrick C. Walsh The James Buchanan Brady Urological Institute Johns Hopkins Medical Institutions Baltimore, Maryland Correspondence: Department of Urology, Marburg 134, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, Maryland 21287-2101 (telephone: 410-614-3377; FAX: 410-955-0833; e-mail: [email protected]. The video presentation was made possible through the generosity of the Mr. & Mrs. Robert C. Baker Foundation. This work is free for use for educational purposes without copyright restrictions. Any commercial use, such as sale or rental, is strictly prohibited. The anatomical figures and a transcript of the narration are included separately on the data portion of the disk. This should facilitate translation into other languages and use of the illustrations for educational purposes. This work would not have been possible without the support and contributions from patients at the James Buchanan Brady Urological Institute. For more information contact http://urology.jhu.edu/ 2114
Vol. 171, 2114, June 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000119822.43396.0c
Foreword to DVD ANATOMICAL RADICAL RETROPUBIC PROSTATECTOMY: DETAILED DESCRIPTION OF THE SURGICAL TECHNIQUE Mailed with this issue of The Journal of Urology威 is a video presentation of the anatomical approach to radical retropubic prostatectomy. This 1 hour and 45 minute DVD provides a detailed description, including illustrations and video footage, of a surgical technique that has been continuously modified and improved during the last 20 years in operations performed on more than 3,000 patients. In this Foreword I will comment on some of the important principles. PELVIC LYMPHADENECTOMY
Although I had always believed that the major value of pelvic lymphadenectomy was accurate staging of the lesion, I have come to understand that a more complete pelvic lymph node dissection may have therapeutic benefit because 13% of the patients with positive lymph nodes in this series who underwent radical prostatectomy had an undetectable prostate specific antigen at 10 years and may be cured. The technique for complete lymphadenectomy down to the pelvic floor skeletonizing the internal iliac veins is illustrated. CONTROL OF THE DORSAL VEIN COMPLEX
This major step in the procedure accomplishes many goals. First and foremost, it makes the operation safer and provides a bloodless field in which the remainder of the procedure can be performed with improved visualization. The striated urethral sphincter is intimately entwined in the tributaries of the dorsal vein complex, and during control of the venous tributaries care must be taken to preserve as much of the striated sphincter as possible without inadvertent entry into the apex of the prostate. This is the most common cause of positive surgical margins. At termination of this step in the procedure the posterior shelf of the striated sphincter is divided under direct vision to facilitate preservation of the neurovascular bundles. I realize that many surgeons believe that the neurovascular bundles should be released prior to ligation and division of the dorsal vein complex. However, I have found that if the dorsal vein complex has been completely divided it is easier to determine the status of the neurovascular bundle and make an informed decision about whether it can be preserved or sacrificed. PRESERVATION OF THE NEUROVASCULAR BUNDLE
Today, it is safe to preserve both neurovascular bundles in most men who are candidates for radical prostatectomy. The neurovascular bundle is outside the capsule and prostatic fascia, and can usually be preserved even when there is capsular penetration in this region if the prostatic fascia remains on the prostate. Indeed, in our experience negative margins can be obtained using this technique in 95% of such patients. I do not believe that it is wise or necessary to perform an intrafascial dissection (inside the prostatic fascia) because this carries the dissection immediately adjacent to the prostatic parenchyma and risks positive margins even in patients with organ confined cancer. Four scenarios of nerve-sparing are illustrated to demonstrate the technique used in various circumstances. RECONSTRUCTION OF THE BLADDER NECK AND VESICOURETHRAL ANASTOMOSIS
The technique for wide excision of the bladder neck with tennis racket reconstruction and intussusception of the bladder neck is illustrated. When performing the vesicourethral anastomosis, if there is any tension when pulling down the bladder, a Babcock clamp is used to hold the reconstructed bladder neck in place while the sutures are tied. Robert Myers from the Mayo Clinic suggested this to me some time ago and I have found that one can be more certain that the sutures are accurately approximated than if one tries to tie around the Foley catheter balloon while it is held on traction. This technique has markedly reduced the number of my patients in whom bladder neck contracture has developed. INGUINAL HERNIA REPAIR
Approximately 15% of patients have an inguinal hernia within 1 or 2 years following surgery. I believe that many of them had incipient hernias that could have been repaired during radical prostatectomy. The technique for identification and intraoperative repair of direct and indirect inguinal is illustrated. Patrick C. Walsh The James Buchanan Brady Urological Institute Johns Hopkins Medical Institutions Baltimore, Maryland Correspondence: Department of Urology, Marburg 134, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, Maryland 21287-2101 (telephone: 410-614-3377; FAX: 410-955-0833; e-mail: [email protected]. The video presentation was made possible through the generosity of the Mr. & Mrs. Robert C. Baker Foundation. This work is free for use for educational purposes without copyright restrictions. Any commercial use, such as sale or rental, is strictly prohibited. The anatomical figures and a transcript of the narration are included separately on the data portion of the disk. This should facilitate translation into other languages and use of the illustrations for educational purposes. This work would not have been possible without the support and contributions from patients at the James Buchanan Brady Urological Institute. For more information contact http://urology.jhu.edu/ 2114