Bilateral lower extremity sequential compression devices are placed and preoperative antibiotics are administered before induction of anesthesia. Following regional or general anesthesia, the doctor positions the patient so that the umbilicus lies just below the break in the table. Current preference is given to general anesthesia over epidural because of the slower effect of regional anesthesia and potentiation of postoperative ileus. The table is then flexed maximally to extend the distance from the umbilicus to the pubis. Trendelenburg positioning, so that the lower abdomen is parallel to the floor, further optimizes exposure to the pelvic organs.
A 7-8-cm vertical incision is made extending distally to the pubic bone. The rectus fascia is then divided in the midline, and the rectus muscles are separated. The transversalis fascia is then divided and the retropubic space is bluntly developed. We use the Omni-Tract system with a set of specially designed blades (Fig. 32.1), including a Y-shaped blade (Marshall), that allows the entire procedure to be performed with a single operative assistant. Bilateral pelvic lymphadenectomies are performed in 10-15 minutes as described previously.6 Briefly, the retropubic space is bluntly developed proximally to the origin of the hypogastric artery and vein. Specially designed curved Mayo blades that allow a slightly larger working radius through a smaller incision are used to move the contralateral rectus muscle laterally. Short and long Harrington blades are used to retract the bladder medially and peritoneal contents superiorly. The lymphadenectomy starts by incision of the tissue along the medial aspect of the external iliac vein. The dissection continues to the lateral pelvic side wall, proximally to the bifurcation of the common iliac vein, and distally to Coopers's ligament, where a large right-angle clip is placed on to the nodal package. In sweeping the nodal package off the pelvic side wall, the surgeon identifies the obturator nerve and vessels
on the lateral aspect of the nodal package. The nodes are resected and a large clip is placed at the base of the nodal package. The obturator fossa is dissected free from all remaining lymphatic and adipose tissue. Pelvic lymphadenectomy is primarily for staging purposes. Frozen sections are not obtained unless there are clinical suspicions or elevated PSA or high Gleason's grade.
The radical prostatectomy is commenced with the Mayo blades retracting the rectus muscles laterally and the specifically designed Marshall Y blade retracting the bladder proximally (Fig. 32.2). The surgeon clears the anterior surface of the prostate, removing fibroadipose tissue and securing the superficial branch of the dorsal vein of the penis with either ligature or cautery. The endopelvic fascia is then divided lateral to the prostate and extends down to the levator ani muscle fibers. The incision in the endopelvic fascia extends superiorly to the puboprostatic ligaments and dorsally along the lateral edge of the prostate. The puboprostatic ligaments are generally preserved but may be partially divided near their insertion on the prostate, taking care not to enter the dorsal venous complex and to preserve the portion of the puboprostatic ligament that provides support to the proximal urethra. Preservation of these fibers is likely to be important in the preservation of continence. A figure of eight 3-0 monofilament, absorbable suture is placed on the veins of the anterior aspect of the prostate to secure the divided endopelvic fascia and prevent venous back bleeding (Fig. 32.3a). The dorsal venous complex is sharply exposed above the urethra. A right-angle clamp is no longer used to encircle the dorsal venous complex at this time. We instead use a 2-0 monofilament, absorbable suture placed at the level of the pubis just underneath the dorsal venous complex in the form of a ligature (Fig. 32.3b). Care is taken to manipulate the tissue judiciously in order to prevent injury to the urethra or the external urethral sphincter. The assistant retracts the prostate in a cephalad direction with a sponge stick, and the surgeon divides the dorsal venous complex with a long-handled scalpel until the anterior aspect of the urethra is seen. The division of the dorsal venous complex should be at an angle so that the prostate is not entered at its apex (Fig. 32.4). The surgeon obtains further control of bleeding from the dorsal venous complex with the same 2-0 monofilament, absorbable suture, again taking care to avoid incorporating any significant external sphincter fibers.
The neurovascular bundles can be identified at this point posterolateral to the urethra. Dissection starts at the lateral aspect of the prostate by first releasing the fascia overlying the bundles. The assistant simplifies this maneuver, if the prostate is rolled to the contralateral side with a sponge stick. The
Mini-lap Radical Retropubic Prostatectomy
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