Editing Open Radical Prostatectomy (section)

== Surgical technique of open radical retropubic prostatectomy ==

* '''Timing'''
** '''Deferred for 6-8 weeks after needle biopsy of the prostate and 12 weeks after transurethral resection of the prostate'''
* '''The anesthesiologist is encouraged to maintain relative hypotension with systolic blood pressure of ≤ 100 mm Hg and to limit the replacement of crystalloid to 1500 mL until the prostate is removed'''
* Summary of steps:
** See BJUI Surgical Atlas and Video
** Position: supine; table can be flexed in obese men to increase the distance between the umbilicus and pubis.
** Preparation: the skin is prepared and draped in the usual way. A No. 16 Silastic Foley catheter is passed into the bladder, inflated with 20 mL of saline, and connected to sterile, closed, continuous drainage. The use of a 16-Fr catheter facilitates placement of sutures in the mucosa of the urethra.
** Incision: An extraperitoneal, lower abdominal incision is made extending from the pubis toward the umbilicus. The anterior fascia is incised down to the pubis, the rectus muscles are separated in the midline, and the transversalis fascia is opened sharply to expose the Retzius space.
** Laterally, the peritoneum is mobilized off the external iliac vessels to the bifurcation of the common iliac artery. Care is taken to preserve the soft tissue covering the external iliac artery that contains the lymphatics draining the lower extremity. Interruption of these lymphatics may lead to lower extremity edema and lymphocele formation. This maneuver is accomplished without dividing the vas deferens.
** Next, a self-retaining Balfour retractor is placed. Exposure for the lymph node dissection is facilitated by placement of a narrow, malleable blade attached to the Balfour retractor beneath the mobilized vas deferens to displace the peritoneum superiorly and a deep Deaver retractor to retract the bladder medially
** '''Pelvic lymph node dissection''' is performed before the radical prostatectomy.
*** '''Internal iliac lymph nodes (hypogastric) have the highest risk of being positive for metastasis.'''§
*** '''The lymphatics overlying the external iliac artery are preserved; the dissection proceeds beneath the external iliac vein'''
*** '''Limits of dissection:'''
**** '''Inferiorly: femoral canal or circumflex vein'''
**** '''Superiorly: ureter/bifurcation of the common iliac artery'''
**** '''Medially: bladder'''
**** '''Laterally to the pelvic side wall'''
**** '''Posteriorly: obturator nerve (internal iliac vein in extended PLND)'''
***** '''The obturator lymph nodes are removed with care to avoid injury to the obturator nerve.'''
***** '''The obturator artery and vein are skeletonized but usually are left undisturbed and not ligated unless excessive bleeding occurs.'''
** If the patient has a well-differentiated to moderately well-differentiated tumor (Gleason grade < 8) and the lymph nodes are normal to palpation, frozen-section analysis is not performed
** To expose the anterior surface of the prostate, it is necessary to '''displace the peritoneum superiorly'''. A malleable blade is used to retract the peritoneum superiorly and to gently displace the bladder posteriorly.
** The fibroadipose tissue covering the prostate is carefully dissected away to expose the pelvic fascia, puboprostatic ligaments, and superficial branch of the dorsal vein.
** The '''endopelvic fascia is entered''' where it reflects over the pelvic sidewall, well away from its attachments to the bladder and prostate. '''The point of incision is where the fascia is transparent, revealing the underlying levator ani musculature. Incision more medially can lead to entry into the lateral venous plexus of Santorini running alongside the prostate, resulting in persistent venous bleeding. Beneath this venous complex lie the prostatic arteries and the branches of the pelvic plexus that course toward the prostate, urethra, and corpora cavernosa.'''
** '''The''' '''incision in the endopelvic fascia is then extended''' in an anteromedial direction toward the puboprostatic ligaments. This allows the surgeon to palpate the lateral surface of the prostate. '''At this point, small arterial and venous branches from the pudendal vessels are encountered that perforate the pelvic musculature to supply the prostate'''. These vessels should be ligated with clips to avoid coagulation injury to the pudendal artery and nerve, which are located just deep to this muscle as they travel along the pubic ramus.
** The fibrofatty tissue covering the superficial branch of the dorsal vein and puboprostatic ligaments is gently teased away to prepare for '''division of the puboprostatic ligaments''' without injury to the superficial branch of the dorsal vein. After the superficial branch has been dissected away from the medial edge of the ligaments, it is coagulated and divided. After all fibrofatty tissue has been removed, a sponge stick is used to gently displace the prostate posteriorly and scissors are used to divide each ligament superficially, just enough to expose the juncture between the apex of the prostate and the anterior surface of the dorsal vein complex at the point where it will be divided. The pubourethral component of the complex should be spared to preserve the anterior fixation of the striated urethral sphincter to the pubis
** The goal is to divide the dorsal vein complex with minimal blood loss while avoiding damage to the striated sphincter and inadvertent entry into the anterior apex of the prostate. With use of the sponge stick to push the prostate posteriorly, a 3-0 Monocryl suture is passed through to '''ligate the dorsal vein complex''' just distal to the apex of the prostate
** The '''apical dissection''' is the most complex and important step in the operation. The striated sphincter and the surrounding dorsa vein must be divided with care to avoid inadvertent incision into the apex of the prostate, the '''most common site for positive margins.'''
*** '''Most patients with positive surgical margins are cured by the radical prostatectomy'''
** With the application of gentle downward pressure on the anterior surface of the prostate with a sponge stick, Metzenbaum scissors or a No. 15 blade is used to '''divide the dorsal vein complex'''
*** See Figure for representation of DVC in relationship to other surrounding veins
*** When the dorsal vein complex is divided anteriorly, the striated sphincter complex is the most common major structure that can be damaged, increasing the risk of incontinence
** '''To avoid back-bleeding from the anterior surface of the prostate, the edges of the proximal dorsal vein complex on the anterior surface of the prostate are sewn in the shape of a V with a running 2-0 absorbable suture. If one tries to pull these edges together in the midline, the neurovascular bundles can be advanced too far anteriorly on the prostate.'''
** With scissors, '''the anterior two thirds of the urethra is divided''' with care to avoid damage to the Foley catheter. This provides excellent exposure for '''placement of six sutures in the distal urethral segment''' at the 1-, 3-, 5, 7-, 9- and 11-o’clock positions. With 3-0 Monocryl on a 5 8 circle tapered needle, the needle should incorporate just the urethral mucosa and submucosa but not the smooth muscle.
** The '''posterior band of the urethra is now divided''' '''to expose the posterior portion of the striated urethral sphincter complex'''
** To '''divide the posterior portion of the sphincter''' safely, a right-angled clamp is passed immediately beneath the left edge of this complex. The clamp should pass midway between the apex of the prostate and the urethra
** '''The neurovascular bundle is outside the prostate between the prostatic and endopelvic/levator fascia.''' '''If nerve sparing is performed correctly, the prostatic fascia must remain on the prostate. This is called an interfascial dissection.  '''
*** '''In performing nerve-sparing surgery, the neurovascular bundles are identified at the apex of the prostate, and the bundles are dissected free of the posterolateral surface of the prostate gland.''' When the neurovascular bundle is released, there should be no upward traction on the prostate. Rather, the prostate should be rolled from side to side.
*** Preoperatively, no definite decision is made as to when and where to excise the NVB. Consideration is given to the status of sexual function, but in impotent patients, there is evidence that the bundles provide both somatic and autonomic innervation to the continence mechanism and that patients who undergo excision of both NVBs have more incontinence than do patients in whom the NVBs are preserved. However, no final decision is made until the time of surgery.
*** When the endopelvic fascia is opened, if induration is palpable, the NVB on that side is widely excised. If there is no induration but the NVB appears to be fixed to the prostate at the time it is being released, it is also excised. However, the final decision about preservation or wide excision of the NVB does not need to be made until the prostate is removed. If there appears to be inadequate tissue over the posterolateral surface after the prostate has been removed, the NVB can then be widely excised.
*** '''The advantages of releasing the levator fascia higher at the apex is to speed up recovery of sexual function by reducing traction on the branches of the nerves to the cavernous bodies and striated sphincter and/or avoiding inadvertent transection of the small branches that travel anteriorly.''' However, because there is less soft tissue at the apex, the risk of positive margins may be increased.
** The vascular branches to the NVBs are best controlled by small hemoclips placed parallel to the bundle. Thermal energy of any form (unipolar, bipolar, or harmonic scissors) should never be used on the NVB or its branches
** Once the NVBs have been either preserved at the apex or widely excised and the prostate has been mobilized to the level of the seminal vesicles, the catheter is replaced and, with light upward traction on the catheter, '''the attachment between the rectum and Denonvilliers fascia is divided in the midline posteriorly'''
** After the plane between the rectum and prostate in the midline has been developed, it is possible to release the neurovascular bundle from the prostate, beginning at the apex and moving toward the base, by using the sponge stick to roll the prostate over on its side. Beginning on the rectal surface, the bundle is released from the prostate by spreading a right angle gently. With use of this plane, Denonvilliers fascia and the prostatic fascia remain on the prostate; only the residual fragments of the levator fascia are released from the prostate laterally.
*** The surgeon does not have to make the decision about whether to excise or preserve the neurovascular bundle until the prostate is removed, and, if there is not enough soft tissue covering the prostate, one can excise the neurovascular bundle then.
** '''Before the lateral pedicles are divided, the posterior branch of the NVB that must be identified and released.''' At this point the '''lateral pedicle can be divided''' safely on the lateral surface of the seminal vesicles without injury to the NVB
** The prostate has now been mobilized almost completely. The '''bladder neck is incised anteriorly''' at the prostatovesicular junction. The incision is carried down to the mucosa, the mucosa is incised, the Foley balloon is deflated, and the two ends of the catheter are clamped together to provide traction.
** After the posterior bladder wall is divided, the bladder neck is retracted with an Allis clamp, and the vasa deferentia are ligated with hemoclips and divided. '''The seminal vesicles''' are dissected free from surrounding structures. Recall that the pelvic plexus is located on the lateral surface of the seminal vesicles.
*** '''Sparing of the seminal vesicles has not improved incontinence, potency, or margin status, and there have been no reported cases of pelvic abscess.'''
*** '''Sparing of the bladder neck has not improved incontinence, potency, margin status, or stricture rates.'''
** During placement of the anterior vesicourethral anastomotic sutures, a red rubber catheter is placed transurethrally and used to identify the membranous urethral stump and also provide traction on the urethra to assist in placement of the sutures. The red rubber catheter is then removed, and the indwelling Foley catheter is then placed retrograde into the bladder. Simple interrupted sutures are placed for the anastomosis.
** A tennis-racquet technique with a running suture or interrupted 2-0 absorbable sutures to approximate full-thickness muscularis and mucosa is used for bladder neck reconstruction if necessary.