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Blunt apical dissection during anatomic radical retropubic prostatectomy.

Namiki K, Kasraeian A, Yacoub S, Rosser CJ - BMC Res Notes (2009)

Bottom Line: We describe a novel technique using careful blunt dissection to better delineate the apex of the prostate, providing a simple means to potentially lessen positive surgical margins at the apex and promote better continence and erectile function in men undergoing an anatomic radical prostatectomy.Median operative time and blood loss were 190 minutes and 675 mL, respectively.Only 10 percent of the patients with positive surgical margins were found to have apical positive surgical margins.Ninety-three percent of patients reported no urinary leakage.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Urology, University of Florida, Gainesville, FL, USA. knamiki@urology.ufl.edu

ABSTRACT

Background: Meticulous apical dissection during a radical prostatectomy is imperative to achieve desirable pathologic and quality of life outcomes.

Findings: We describe a novel technique using careful blunt dissection to better delineate the apex of the prostate, providing a simple means to potentially lessen positive surgical margins at the apex and promote better continence and erectile function in men undergoing an anatomic radical prostatectomy.Median operative time and blood loss were 190 minutes and 675 mL, respectively. Only 10 percent of the patients with positive surgical margins were found to have apical positive surgical margins. Ninety-three percent of patients reported no urinary leakage.

Conclusion: We believe our technique of isolating the DVC with blunt dissection and then ligating and transecting the DVC to be feasible approach that requires larger studies to truly confirm its utility.

No MeSH data available.


Related in: MedlinePlus

After the endopelvic fascia has been incised bilaterally, blunt dissection is used to create a groove between the urethra and dorsal venous complex (DVC). A Mixter forceps is then passed in this groove and a #1 Vicryl tie is used to ligate the DVC. This maneuver helps to clearly delineate the apex and DVC. Next, two figure eight Vicryl sutures are placed as proximal as possible on the DVC. Lastly, two figure eight Vicryl suture (one at the bladder neck and another at the mid portion of the prostate on its anterior surface) are placed to minimize back bleeding. Now with the DVC secured and optimal vision of the apex of the prostate, the DVC may be transected.
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Figure 1: After the endopelvic fascia has been incised bilaterally, blunt dissection is used to create a groove between the urethra and dorsal venous complex (DVC). A Mixter forceps is then passed in this groove and a #1 Vicryl tie is used to ligate the DVC. This maneuver helps to clearly delineate the apex and DVC. Next, two figure eight Vicryl sutures are placed as proximal as possible on the DVC. Lastly, two figure eight Vicryl suture (one at the bladder neck and another at the mid portion of the prostate on its anterior surface) are placed to minimize back bleeding. Now with the DVC secured and optimal vision of the apex of the prostate, the DVC may be transected.

Mentions: Patients underwent an anatomic radical retropubic prostatectomy via a 9 cm infraumblical incision. The space of Reituz was developed and a self-retaining retractor was used to expose the pelvis. Intermediate or high risk patients (i.e., PSA ≥ 10 ng/ml, Gleason score ≥ 7, or ≥ clinical stage T3) underwent a standard bilateral pelvic lymph node dissection. Next, the endopelvic fascia was incised bilaterally with electrocautery and the levator muscle fibers were swept off the anterior and lateral surfaces of the prostate. Electrocautery was not used for any other portion of the case in an attempt to prevent injury to the cavernosal nerves. Subsequently, two figure of eight sutures (2-0 Vicryl with a CT-1 needle) were placed at the base and mid portion of the prostate to minimize back bleeding (Figure 1). Puboprostatic ligaments were not transected. Utilizing gentle blunt dissection with the right index finger, a groove was created between the urethral and dorsal venous complex (DVC) (Figure 1), this is different to previous reports where sharp dissection with a McDougal clamp was employed [5]. A Mixter forceps was used to pass a #1 Vicryl tie around the isolated DVC which was subsequently ligated. This tie is used to better identify the DVC and is routinely cut during transection of DVC. Next, two figure of eight sutures (2-0 Vicryl with a CT-2 needle) were utilized to further ligate the most proximal extent of the isolated DVC. A Mixter forceps was passed posterior to the DVC, which was transected with a 15 blade knife. Rarely will further hemostatic sutures be required in the ligated DVC. At this time, the urethra is clearly identified. Tissue lateral to the urethra was dissected freely and released from the urethra with Metzenbaum scissors. A Mixter forceps is passed inside this tissue and posterior to the urethra. An umbilical tape was passed in the right angle clamp, clearly identifying the urethra. The Foley catheter is lubricated at the urethral meatus and then disconnected from its drainage bag. The anterior surface of the urethra is transected. The external portion of the Foley catheter is transected and eventually brought into the pelvic wound. The posterior aspect of the urethra is transected. The urethralis muscle is transected. The remainder of the procedure was performed as previously reported [4,5].


Blunt apical dissection during anatomic radical retropubic prostatectomy.

Namiki K, Kasraeian A, Yacoub S, Rosser CJ - BMC Res Notes (2009)

After the endopelvic fascia has been incised bilaterally, blunt dissection is used to create a groove between the urethra and dorsal venous complex (DVC). A Mixter forceps is then passed in this groove and a #1 Vicryl tie is used to ligate the DVC. This maneuver helps to clearly delineate the apex and DVC. Next, two figure eight Vicryl sutures are placed as proximal as possible on the DVC. Lastly, two figure eight Vicryl suture (one at the bladder neck and another at the mid portion of the prostate on its anterior surface) are placed to minimize back bleeding. Now with the DVC secured and optimal vision of the apex of the prostate, the DVC may be transected.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2654458&req=5

Figure 1: After the endopelvic fascia has been incised bilaterally, blunt dissection is used to create a groove between the urethra and dorsal venous complex (DVC). A Mixter forceps is then passed in this groove and a #1 Vicryl tie is used to ligate the DVC. This maneuver helps to clearly delineate the apex and DVC. Next, two figure eight Vicryl sutures are placed as proximal as possible on the DVC. Lastly, two figure eight Vicryl suture (one at the bladder neck and another at the mid portion of the prostate on its anterior surface) are placed to minimize back bleeding. Now with the DVC secured and optimal vision of the apex of the prostate, the DVC may be transected.
Mentions: Patients underwent an anatomic radical retropubic prostatectomy via a 9 cm infraumblical incision. The space of Reituz was developed and a self-retaining retractor was used to expose the pelvis. Intermediate or high risk patients (i.e., PSA ≥ 10 ng/ml, Gleason score ≥ 7, or ≥ clinical stage T3) underwent a standard bilateral pelvic lymph node dissection. Next, the endopelvic fascia was incised bilaterally with electrocautery and the levator muscle fibers were swept off the anterior and lateral surfaces of the prostate. Electrocautery was not used for any other portion of the case in an attempt to prevent injury to the cavernosal nerves. Subsequently, two figure of eight sutures (2-0 Vicryl with a CT-1 needle) were placed at the base and mid portion of the prostate to minimize back bleeding (Figure 1). Puboprostatic ligaments were not transected. Utilizing gentle blunt dissection with the right index finger, a groove was created between the urethral and dorsal venous complex (DVC) (Figure 1), this is different to previous reports where sharp dissection with a McDougal clamp was employed [5]. A Mixter forceps was used to pass a #1 Vicryl tie around the isolated DVC which was subsequently ligated. This tie is used to better identify the DVC and is routinely cut during transection of DVC. Next, two figure of eight sutures (2-0 Vicryl with a CT-2 needle) were utilized to further ligate the most proximal extent of the isolated DVC. A Mixter forceps was passed posterior to the DVC, which was transected with a 15 blade knife. Rarely will further hemostatic sutures be required in the ligated DVC. At this time, the urethra is clearly identified. Tissue lateral to the urethra was dissected freely and released from the urethra with Metzenbaum scissors. A Mixter forceps is passed inside this tissue and posterior to the urethra. An umbilical tape was passed in the right angle clamp, clearly identifying the urethra. The Foley catheter is lubricated at the urethral meatus and then disconnected from its drainage bag. The anterior surface of the urethra is transected. The external portion of the Foley catheter is transected and eventually brought into the pelvic wound. The posterior aspect of the urethra is transected. The urethralis muscle is transected. The remainder of the procedure was performed as previously reported [4,5].

Bottom Line: We describe a novel technique using careful blunt dissection to better delineate the apex of the prostate, providing a simple means to potentially lessen positive surgical margins at the apex and promote better continence and erectile function in men undergoing an anatomic radical prostatectomy.Median operative time and blood loss were 190 minutes and 675 mL, respectively.Only 10 percent of the patients with positive surgical margins were found to have apical positive surgical margins.Ninety-three percent of patients reported no urinary leakage.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Urology, University of Florida, Gainesville, FL, USA. knamiki@urology.ufl.edu

ABSTRACT

Background: Meticulous apical dissection during a radical prostatectomy is imperative to achieve desirable pathologic and quality of life outcomes.

Findings: We describe a novel technique using careful blunt dissection to better delineate the apex of the prostate, providing a simple means to potentially lessen positive surgical margins at the apex and promote better continence and erectile function in men undergoing an anatomic radical prostatectomy.Median operative time and blood loss were 190 minutes and 675 mL, respectively. Only 10 percent of the patients with positive surgical margins were found to have apical positive surgical margins. Ninety-three percent of patients reported no urinary leakage.

Conclusion: We believe our technique of isolating the DVC with blunt dissection and then ligating and transecting the DVC to be feasible approach that requires larger studies to truly confirm its utility.

No MeSH data available.


Related in: MedlinePlus