The Common Vein Copyright 2010
Introduction
The first prostatectomy was performed by Hugh Hampton Young in 1904, however due to the common complications of impotence and incontinence the procedure was not popular. As knowledge and technology improved so did the outcomes of surgery. This is the treatment of choice in men with organ confined disease and a life expectancy of more than 10 years.
There are four main ways to perform a radical prostatectomy.
1) Radical retropubic prostatectomy
2) laparoscopic radical prostatectomy
3) robotic assisted laparoscopic prostatectomy
4) Radical perineal prostatectomy
Aim:
To remove the prostate and acheive local control of prostate cancer, including removal of fascia and at times the neurovascular bundle. Also important, is to complete a lymph node dissection.
Procedure:
Most surgeons prefer the retropubic approach to prostatectomy as it allows access to the pelvic lymph nodes for dissection. Also it allows for the prostate to be removed with the surrounding fascia. The procedure is performed through and infraumbilical incision. First the lymph node dissection takes place in the obturator space with the lateral margin of dissection being the pelvic wall and external iliac vein, the distal margin being the node of Cloquet and the proximal margin being the hypogastric vessels. The posterior margin is the obturator nerve within the pelvis. Next, the endopelvic fascia is defined by removing any fat from this structure, and a sharp incision is made in the endopelvic fascia just lateral to the capsular veins of the prostate. Now the prostate is able to be moved laterally. Next, attention is paid to the dorsal venous complex where sutures are placed to control bleeding. Next, the fascia covering the prostate is divided sharply, including division of the puboprostatic ligaments. The dorsal vein complex is then entered and oversewn. Next, the striated urethral sphincter and urethra are then divided just distal to the apex of the prostate. Care is taken to preserve urethral spinchter length. Next, the lateral prostatic fascia is divided just above the neurovascular bundle at the posterolateral level of the prostate, and the prostate is released from the neurovascular bundle starting at the apical level. The posterior prostate is then dissected from the rectum and Denonvilliers’ fascia is then incised just medial to the neurovascular bundle, freeing the bundle from the prostate. After the prostate is mobilized laterally, Denonvilliers’ fascia is incised over the level of the seminal vesicles allowing dissection along the seminal vesicles up laterally over the bladder. Next, the bladder is entered with care taken to avoid entry into the prostate. A midline dissection is then performed to isolate the vas deferens which are clipped and divided. The prostate can then be removed. Next the bladder is attached to the urethra with circumferential sutures in a tension free anastomosis.
Complications:
The major risk of the open prostatectomy are bleeding, incontinence, and impotence. Care with ligation of the dorsal venous complex will assist in decreasing blood loss. Incontinence and impotence rely heavily on preserving the neurovascular bundle.
Preparation:
Most surgeons wait 6 weeks after prostatic biopsy to perform a prostatectomy to allow for decrease in inflammation. Patient may be asked to be on a clear liquid diet prior to surgery and perform a bowel prep the day before.
Advantages of laparoscopic or robotic prostatectomy:
The major advantages of these procedures are lower blood loss, decreased pain, and shorter hospital stay.