LESSON 3: Procedures in Genitourinary Surgery

Section Iv: operations on the bladder and prostate

3-30

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3-30. PERINEAL PROSTATECTOMY

a. General. Either enucleation of adenomas or radical prostatectomy may be carried out through a perineal exposure.

b. Patient Preparation. The patient is placed on the operating table in an extreme lithotomy position. The buttocks are elevated on pads sufficient to tilt the pelvis and flatten the perineum on the vertical plane. The thighs are fully flexed with the knees to the chest and the feet are supported in stirrups. The arms are extended on armboards and shoulder braces applied with the usual precautions. Measures must be taken to reduce strain on the muscles and nerves of the back and legs and also prevent respiratory embarrassment from compression of the abdomen and chest. Draping is with an O'Connor drape and perineal sheet.

c. Operative Procedure.

(1) Through a curved incision made just above the anal margin, the skin, fat, and subcutaneous fascia are divided. Straight hemostats are used for bleeding vessels in the superficial tissues and curved hemostats for deeper tissues. The tissue on either side of the central tendon is dissected, using Metzenbaun scissors and forceps. McBurney retractors followed by Young bifurcated prostatectomy retractors are placed as dissection progresses. The levator ani muscles are exposed and retracted.

 

(2) The gland is exposed and enucleated. The surgeon manipulates the gland with a finger in the rectum via the O'Connor drape finger cot or with the hand protected by a second glove.

 

(3) Bleeding is controlled with sutures and electrocautery. A multieyed Robinson or Foley retention catheter is inserted into the urethra. In radical prostatectomy, the bladder neck is approximated to the urethra to cover the defect of the excision.

 

(4) A Penrose drain is placed in the wound. The wound is closed in layers with chromic number 0 gut sutures swaged on medium Ferguson number 14 needles. The skin edges are approximated with interrupted sutures on straight needles.

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