Prostate carinoma- surgery- Open Radical Retropubic Prostatectomy(rrp)

1. Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
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2. Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC,
Chennai. 2

3.  Radical Retropubic Prostatectomy
◦ Developed by Terence Millin-1945( All Saints
Hospital-London)
◦ Samuel Kenneth Bacon (millin’s student) university
of southern california-US
◦ Refined by Patrick C.Walsh-John Hopkins Medical
School-1982
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Dept of Urology, GRH and KMC,
Chennai.

4.  The three goals of surgery,in order of
importance are,
◦ cancer control,
◦ preservation of urinary control, and
◦ preservation of sexual function.
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

11.  Patients with intermediate risk organ
confined Ca Prostate with life expectancy of
more than 10 yrs
 Patients with high risk organ confined Ca
Prostate with life expectancy of more than 10
yrs as a part of multimodality therapy
 Patients with locally advanced Ca Prostate as
a part of multimodality therapy
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Dept of Urology, GRH and KMC,
Chennai.

12.  A complete medical, surgical, and anesthesia
history.
 The preoperative assessment should identify
factors
◦ prior abdominal or pelvic surgery and irradiation,
◦ prior transurethral surgery,
◦ extensive prostate biopsies,
◦ history of significant inflammatory bowel disease,
◦ prior use of mesh during inguinal or incisional
hernia repairs
◦ the size of the prostate.
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Dept of Urology, GRH and KMC,
Chennai.

13.  Surgery is deferred for
◦ 6 to 8 weeks after needle biopsy of the prostate .
◦ 12 weeks after transurethral resection of the
prostate.
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Dept of Urology, GRH and KMC,
Chennai.

14.  General endotracheal anesthesia (GA)is the
preferred anesthesia.
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Dept of Urology, GRH and KMC,
Chennai.

15.  Place the patient in the supine position with
his pubis centered over the break in the table.
 Slightly hyperextend the patient by raising
the kidney rest and reflexing or breaking the
table, placing the patient in an approximately
20-degree Trendelenburg position to elevate
the pelvis and facilitate exposure.
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

17.  A vertical midline incision is made extending
from just above the symphysis to approximately
halfway below the umbilicus.
 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.
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Dept of Urology, GRH and KMC,
Chennai.

18. 1.Pelvic lymphadenectomy
2.Opening of the endopelvic fascia and limited incision of
the puboprostatic ligaments
3.Suture ligation and transection of Santorini dorsal venous
complex
4.Dissection of the urethra at the apex of the prostate and
transection of the urethra
5.Dissection of the prostate from the neurovascular bundles
6.Securing and transection of the prostatic pedicles
7.Transection and reconstruction of the bladder neck.
8.Dissection of the seminal vesicles and ampullary portions
of the vasa deferentia
9.Performance of the vesicourethral anastomosis
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

21.  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.
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Dept of Urology, GRH and KMC,
Chennai.

22.  The fibroadipose tissue covering the prostate
is carefully dissected away to expose the
pelvic fascia, puboprostatic ligaments, and
superficial branch of the dorsal vein.
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

30.  Once this horizontal mattress suture is tied,
three important goals are accomplished:
◦ (1) control of much of the venous bleeding without
a “bunching” effect—this flat surface is much easier
to divide;
◦ (2) recapitulation of the puboprostatic ligaments to
provide additional anterior support of the striated
sphincter; and
◦ (3) fixation of the dorsal vein complex anteriorly.
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

32.  The striated sphincter and the surrounding
dorsal vein must be divided with care to avoid
inadvertent incision into the apex of the
prostate, the most common site for positive
margins.
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

34.  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 complex.
 This is usually started on the left edge of the
complex where the junction with the apex of
the prostate usually can be seen well .
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

38.  The urethra should be divided first in
performing a standard nerve release.
 If more aggressive nerve preservation is
performed, the urethral incision should occur
after nerve release.
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

42. Standard nerve release begins after incision of
the urethra, placement of urethra sutures, and
release of the posterior striated sphincter.
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Dept of Urology, GRH and KMC,
Chennai.

43.  A Babcock clamp or sponge
stick is used during release
of the NVB to manipulate
the prostate.
 The clamp facilitates gentle
elevation of the prostate
during the release and can
result in less traction on the
NVB because the prostate is
released from the bundle
rather than the bundle
being released from the
prostate.
 This dissection should
begin at the bladder
neck, where this fascia
forms a thick band.
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

47. 1. At the apex, there are often
prominent apical vessels , the
prostate has been elevated on
its side across the midline, this
distorts the direction of the NVB
by kinking it.
2.The bundle may travel more
anteriorly in some patients. In
these patients, one can confuse
the groove with the potential
space between the prostate and
rectum.
3.Some patients have many veins
on the lateral surface of the
prostate that anastomose
between the Santorini plexus
anteriorly and the NVB
posteriorly.
The apical approach to the
bundle facilitates management
of this condition
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

49.  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
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

55.  Before excision of the NVB unilaterally, the
contralateral NVB should be freed from the
prostate, starting at the apex.
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

65.  The bladder neck is
reconstructed with a
running suture or
interrupted 2-0
absorbable sutures to
approximate full-
thickness muscularis
and mucosa, forming a
TENNIS RACQUET
CLOSURE
 The closure is initiated in
the midline posteriorly
and proceeds anteriorly
until the bladder neck is
narrowed to approximate
the diameter of the
urethra.
 By incorporating the
mucosa in the closure,
troublesome hematuria
can be avoided.
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

67.  At this point, the bladder neck can be
anastomosed to the urethra, or buttressing
sutures can be used to intussuscept the
bladder neck .
 These sutures prevent the bladder neck from
pulling open as the bladder fills.
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.

72.  Clear liquid diet on
the evening of surgery
 Regular low-fat diet
the next day.
 A single closed suction
drain is left in place .
 The urinary catheter is
left in place for 7 to 10
days postoperatively,
 Routinely performing
cystography at 1 week
 Severe bladder spasms
 Oxybutynin 5mg
 Diazepam (oral
Valium, 5 to 10 mg)
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Dept of Urology, GRH and KMC,
Chennai.

73.  Hemorrhage-mc
 Obturator nerve injury
 Rectal injury
 Ureteral injury
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Dept of Urology, GRH and KMC,
Chennai.

74.  Usually from venous structures
◦ Packing
◦ Exposure and suture/clip
 Other possible areas
◦ incision in the endopelvic fascia,
◦ during division of the puboprostatic ligaments, or
◦ during exposure of the apex of the prostate with
transection of the dorsal vein complex
 Average blood loss-
◦ 300-1000ml
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Dept of Urology, GRH and KMC,
Chennai.

75.  Hemorrhage
 Thrombo embolic events
 Bladder neck contracture
 Urinary incontinence
 Erectile dysfunction
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Dept of Urology, GRH and KMC,
Chennai.

76.  Significant bleeding after radical
prostatectomy is defined as postoperative
hemorrhage requiring the acute transfusion
of blood to support blood pressure.
 Patients requiring acute transfusions for
severe hypotension after radical
prostatectomy should be explored early .
 To evacuate the pelvic hematoma in an effort
to decrease the likelihood of bladder neck
contracture and incontinence.
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Dept of Urology, GRH and KMC,
Chennai.

77.  Deep venous thrombosis
(DVT) with pulmonary
embolism.
 Highest rates were seen
when pelvic lymph node
dissection was performed
as part of the procedure .
 The highest likelihood
occurred between 14 and
28 days after the
procedure.
 Watch for signs
 Measures to prevent
DVT
 LMWH
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Dept of Urology, GRH and KMC,
Chennai.

78.  0.5-10%
 Cause:
◦ Inadequate coaptation of the mucosal surfaces.
◦ Inadequate approximation at the time of surgery
◦ Urinary extravasation
◦ Distraction of the bladder neck from a
hematoma.
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Dept of Urology, GRH and KMC,
Chennai.

79.  The diagnosis should
be considered in any
patient who complains
of
◦ a poor urinary stream or
◦ prolonged unexplained
incontinence.
 Treatment:
◦ simple cystoscopic dilation
◦ direct cold-knife incision
of the bladder neck at 3-,
6-, and 9-o’clock followed
by intermittent self-
catheterization.
 Recalcitrant bladder
neckcontractures:injectio
n of triamcinolone
acetonide (200 mg in 5
mL) at the bladder neck
after cold-knife incision
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Dept of Urology, GRH and KMC,
Chennai.

80.  After radical prostatectomy, incontinence is
usually secondary to intrinsic sphincter
deficiency.
 the predominant cause of this deficiency is
◦ injury during ligation and division of the dorsal
vein complex.
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Dept of Urology, GRH and KMC,
Chennai.

81.  Continence damaged by
placement of large, deep
sutures for the anastomosis
or denervated by injury to
the NVBs.
 Bladder neck must be
supple, with a diameter that
is not excessively large.
 Urinary continence can be
hampered by the
development of a bladder
neck contracture or a wide
bladder neck.
 Prevention:
◦ preserve the striated
sphincter during the apical
dissection
◦ avoid tension on the final
anastomosis
◦ reconstruct the bladder
neck so that the opening is
small and supple
◦ accomplish a precise
mucosa-to-mucosa
anastomosis
◦ Intussuscepting the
bladder neck
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Dept of Urology, GRH and KMC,
Chennai.

82.  Three factors are important in the recovery of
erectile function after radical prostatectomy:
◦ age of the patient (younger than 65 years),
◦ status of potency preoperatively, and
◦ ability to intraoperatively preserve both NVBs.
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Dept of Urology, GRH and KMC,
Chennai.

83.  Walsh and colleagues
evaluated incontinence by a
validated questionnaire.
 At 18 months, 86% of the
patients were able to have
unassisted intercourse with
or without sildenafil citrate.
 The recovery of sexual
function occurred gradually:
◦ 38% were potent at 3 months,
◦ 54% at 6 months,
◦ 73% at 12 months, and
◦ 86% at 18 months.
 Recovery of sexual function
also correlated with the age
of the patient at the time of
surgery:
◦ 100% in men 30 to 39 years,
◦ 88% in men 40 to 49 years,
◦ 90% of men 50 to 59 years,
and
◦ 75% in men 60 to 67 years.
 In patients in whom only
one NVB is preserved, 65%
of patients are potent.
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Dept of Urology, GRH and KMC,
Chennai.

84.  Phosphodiesterase type 5 (PDE5) inhibitors
augment sexual recovery after radical
prostatectomy.
 Until recently, however, the best dosing
schedule (nightly or on demand) for these
medications was unclear.
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Dept of Urology, GRH and KMC,
Chennai.

85.  Bladder neck(sparing) preservation
 Seminal vesical sparing
 Interposition nerve grafting
 Salvage radical prosatatectomy
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Dept of Urology, GRH and KMC,
Chennai.

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Dept of Urology, GRH and KMC,
Chennai.