MALIGNANT PROSTATE SURGERY I RETROPUBIC
Prostate cancer is the second leading cause of death from cancer in U.S. men. The definitive treatment of clinically localized prostate cancer with radical retropubic prostatectomy has been a popular treatment for 100 years. Although a technically formidable procedure, it remains the “gold standard,” as hormone treatment and chemotherapy are not curative and radiation therapy may not eradicate all cancer cells. The advantage of radical prostatectomy is that it offers cure with minimal collateral damage, provides more accurate pathologic staging, and treatment failure is easily identified. The ideal candidate for the procedure is healthy, less than 75 years old, has a life expectancy of at least 10 years, and has a biologically “significant” tumor.
Radical retropubic prostatectomy involves the complete removal of the
prostate gland and seminal vesicles and may include a pelvic lymph node
dissection. The goals of surgery are cancer control and preservation of urinary
control and sexual function. A spinal, epidural, or general anesthetic is
generally used with the patient in the supine or relaxed dorsal lithotomy
position. A midline, extraperitoneal lower abdominal incision from the pubis
halfway to the umbilicus is made after a Foley catheter is placed in the
bladder. The rectus muscles are separated in the midline, the transversalis
fascia opened sharply, and the space of Retzius developed. Laterally, the
peritoneum is mobilized off of the external iliac vessels (see Plate 2-6) to
the bifurcation of the common iliac artery. A self-retaining Balfour retractor
is then placed, and a narrow malleable blade provides excellent exposure for
lymph node dissection. The lymph node dissection, if done, is first undertaken
on the side ipsilateral to the prostate tumor and proceeds by dividing the
tissue over the external iliac vein. The lymphatic tissue is excised to the
lateral pelvic wall, inferiorly to the femoral canal, and superiorly to the
bifurcation of the common iliac artery. The obturator lymph nodes are also
removed by skeletonizing the obturator vein and artery and sparing the
obturator nerve. Frozen section is then per- formed on the excised nodes before
prostatectomy.
Exposure for retropubic prostatectomy involves displacing the peritoneum
superiorly and removing the fibroadipose tissue covering the anterior prostate.
These maneuvers expose the pelvic fascia, puboprostatic ligaments, and
superficial dorsal vein. The endopelvic fascia is then entered where it reflects
over the pelvic side wall, allowing palpation of the lateral prostate. By finger
dis- section, the levatorani muscles are released from the lateral prostate
and, with sharp dissection, the puboprostatic ligaments are taken down
anteriorly. The dorsal vein complex is then ligated with care to avoid damage
to the striated urethral sphincter. These maneuvers help to optimally expose
the prostatic apex for dissection.
The apical dissection is the most complex and critical step in the
operation, as the striated urethral sphincter and the neurovascular bundles
that control erections are nearby and the prostatic apex is the most common
site for positive surgical margins. With gentle posterior displacement of the
prostate, the prostatourethral junction is visualized. A right angle clamp is
passed around the smooth muscle of the urethra anterior to the neurovascular
bundles near the prostatic apex and the urethra is transected sharply. Six
interrupted absorbable sutures are then placed in the distal urethra while the
exposure is optimized and the Foley catheter is removed. The posterior aspect
of the prostate is now exposed, allowing its dissection off the anterior rectal
wall superiorly. Denonvilliers fascia is included with
the prostate. In nerve-sparing procedures, the levator fascia is incised on the
lateral prostate but the prostatic fascia must be left intact during the
superior dissection, as the neurovascular bundle is located between the levator
fascia and prostatic fascia.
For the remainder of the posterior dissection, the Foley catheter is
replaced. After the prostate has been mobilized completely, the bladder neck is
incised completely at the prostatovesicular junction. After the posterior
bladder wall is divided, the bladder neck is retracted and the medially located
vasa deferentia are ligated. The paired seminal vesicles are then dissected free, staying close to these organs to avoid damage to the pelvic plexus
laterally. After the specimen is removed, the operative site is inspected for
bleeding and residual tumor. The bladder opening is closed with absorbable
suture in a “tennis racket” manner to a diameter that approximates the urethra,
and a rosette of mucosa is created to line the bladder neck opening for a
better anastomotic seal. Finally the bladder neck is sutured to the distal
urethra using the preplaced sutures, a new Foley catheter is placed, and the
incision closed. The patient is allowed to ambulate the day after the procedure
and is discharged on hospital day 1 or 2. Excellent cancer control is achieved with this operation.
