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PATIENT SELECTION AND INDICATION

  1. Top of page
  2. PATIENT SELECTION AND INDICATION
  3. PATIENT PREPARATION
  4. SPECIAL INSTRUMENTS
  5. ANATOMICAL CONSIDERATIONS OF THE CAVERNOSAL NERVES
  6. POSTOPERATIVE MANAGEMENT
  7. SURGEON TO SURGEON

Radical prostatectomy should be reserved for men diagnosed with localized prostate cancer with a total PSA level of <15 ng/mL who are likely to be cured and have a life-expectancy of ≥10 years. Surgery is deferred for ≥2 months after prostate biopsy and for 3 months after TURP. This delay enables inflammation or haematoma to resolve so that the anatomical relationships between the prostate and the surrounding tissue return to a near-normal state.

PATIENT PREPARATION

  1. Top of page
  2. PATIENT SELECTION AND INDICATION
  3. PATIENT PREPARATION
  4. SPECIAL INSTRUMENTS
  5. ANATOMICAL CONSIDERATIONS OF THE CAVERNOSAL NERVES
  6. POSTOPERATIVE MANAGEMENT
  7. SURGEON TO SURGEON

Patients are admitted to the hospital 1 day before surgery, and blood and urine samples are assessed; in the afternoon patients are shaved and receive one colonic enema. On the day of surgery patients wear compression stockings.

SPECIAL INSTRUMENTS

  1. Top of page
  2. PATIENT SELECTION AND INDICATION
  3. PATIENT PREPARATION
  4. SPECIAL INSTRUMENTS
  5. ANATOMICAL CONSIDERATIONS OF THE CAVERNOSAL NERVES
  6. POSTOPERATIVE MANAGEMENT
  7. SURGEON TO SURGEON

Radical retropubic prostatectomy requires few special instruments. A headlight and magnifying loupes are very useful for the procedure, especially for a sufficient nerve-sparing procedure. We use a standard Balfour retractor to provide cranial and posterior retraction on the peritoneum and bladder. A right-angle clamp (Scott McDougal), a coagulating forceps and small clips are the only special instruments that should be available.

ANATOMICAL CONSIDERATIONS OF THE CAVERNOSAL NERVES

  1. Top of page
  2. PATIENT SELECTION AND INDICATION
  3. PATIENT PREPARATION
  4. SPECIAL INSTRUMENTS
  5. ANATOMICAL CONSIDERATIONS OF THE CAVERNOSAL NERVES
  6. POSTOPERATIVE MANAGEMENT
  7. SURGEON TO SURGEON

According to anatomical studies in 29 male fetuses, at our institution, the original course of the cavernosal nerves could be detected during the early stages of fetal development, as the prostate does not start to develop before fetal week 13. Because there is no prostate and the nervous structures are relatively thick, the cavernosal nerves were visible running downward lateral and dorsal to the prostatic and the membranous urethra, and the omega-shaped rhabdosphincter, which covered the ventrolateral aspects of the prostatic and membranous urethra between the bulb of the penis and the bladder neck.

After 13 weeks of gestation the prostate begins to develop. Because of the growth and increasing volume of the prostate, the course of the cavernosal nerves begins to change. By contrast, the prostate increasingly displaces the cavernosal nerves dorsolaterally. In this region the nerve fibres and vessels are increasingly dispersed along the convex surface of the prostatic capsule. Therefore, the cavernosal nerves running in the neurovascular bundles increasingly assume a shape that can best be compared to the concave ‘steep turn of a bob-sleigh run’ or a concave ‘curtain’ covering both prostatic lobes. At the apex of the prostate the nerve fibres of the neurovascular bundles converge again, like the exit of a steep turn of a bob-sleigh run, and lie adjacent to the membranous urethra. According to these anatomical findings, the modified apical preparation and the dissection of the neurovascular bundle is described and illustrated.

POSTOPERATIVE MANAGEMENT

  1. Top of page
  2. PATIENT SELECTION AND INDICATION
  3. PATIENT PREPARATION
  4. SPECIAL INSTRUMENTS
  5. ANATOMICAL CONSIDERATIONS OF THE CAVERNOSAL NERVES
  6. POSTOPERATIVE MANAGEMENT
  7. SURGEON TO SURGEON

Drains are routinely removed 3 days after surgery; the diet is advanced as tolerated, with normal intake by 3 days in most patients. Antibiotic prophylaxis with amoxicillin continues after surgery until the catheter is removed. On the 10th day gravity cystography is used under fluoroscopic control. The bladder is filled with 150–250 mL of a contrast agent until the patient experiences a sense of fullness and slight discomfort. The urinary catheter is removed if there is no extravasation. During gravity cystography all patients are instructed how to exercise the rhabdosphincter. It is essential that patients can see the elevation of the anastomotic site while contracting the rhabdosphincter, and therefore understand and participate cognitively in these exercises. At 11 days patients are discharged from the hospital.

SURGEON TO SURGEON

  1. Top of page
  2. PATIENT SELECTION AND INDICATION
  3. PATIENT PREPARATION
  4. SPECIAL INSTRUMENTS
  5. ANATOMICAL CONSIDERATIONS OF THE CAVERNOSAL NERVES
  6. POSTOPERATIVE MANAGEMENT
  7. SURGEON TO SURGEON

Every surgeon has their way of improving the results of radical prostatectomy in terms of continence and potency rates. We consider the use of magnifying loupes and a correctly positioned headlight to be very important, as they aid in identifying the neurovascular bundles and external striated sphincter. By using these two devices a bloodless operating field is more likely. This enables the surgeon to meticulously dissect the prostatic apex and preserve the complex of the rhabdosphincter and the distal part of the neurovascular bundles containing the cavernosal nerves, as well as the branches of the pudendal nerve. The integrity of the rhabdosphincter tendon and pudendal nerve supply is important for preserving continence. Thus, manipulating the urethra should be minimized so that all periurethral tissue distal to the apex remains intact.

Radical retropubic prostatectomy by an experienced surgeon is safe, with fewer complications during and afterward; the duration is usually <2.5 h. With proper patient selection, positive surgical margins are <10%, with pathologically organ-confined prostate cancers in 85–90%. In experienced centres, continence rates reach 95% and potency rates ≥80% after surgery.