Operаtive Repоrt PREOPERATIVE DIAGNOSIS: T2c, NX, M0 prоstаte cаncer POSTOPERATIVE DIAGNOSIS: T2c, NX, M0 prоstate cancer OPERATION: Radical retropubic prostatectomy with bilateral pelvic lymph node dissection INDICATIONS: This 62-year-old male had an elevated prostate-specific antigen (PSA) of 12.5 on routine screening. He recently underwent a transrectal ultrasound and biopsy that revealed approximately 9 out of 10 cores positive for adenocarcinoma of the prostate. With hormonal therapy, his PSA preoperatively had decreased to 0.1 on androgen blockade. DESCRIPTION OF PROCEDURE: After administration of general anesthesia, the patient was placed in supine position, prepped, and draped in the usual sterile fashion. A midline incision was made to the left of the umbilicus and carried down to the public bone. The fascia was split in the midline as well as the rectus muscle, and the retropubic space was then entered. Each obturator fossa was delineated using blunt dissection. A fixed Balfour retractor was then placed. A left pelvic lymph node dissection was performed in the usual fashion. Care was taken to preserve the obturator nerve. It was noted that there were no grossly enlarged nodes in the area. Clips were used to control bleeding and lymph drainage. A similar dissection was performed on the right side with no damage to the obturator nerve, and there were no grossly enlarged lymph nodes. Frozen section analysis did not reveal any adenocarcinoma. The endopelvic fascia was then identified and defatted. It was split along its lateral borders from the puboprostatic ligaments and down to the bladder neck. The dorsal vein complex and endopelvic fascia were then gathered using a curved Babcock clamp. Two 0 Vicryl suture ligatures were placed at the bladder neck to control bleeding. A clamp was then passed between the anterior urethra and dorsal vein complex, and a 0 Vicryl suture was then tied around this complex. A second 0 Vicryl suture ligature was also placed in the most distal portion. The dorsal vein complex was divided using electrocautery, and excellent hemostasis was noted. The prostatic apex was identified with further sharp and blunt dissection. The anterior half of the urethra was divided sharply using the #15 blade. Next, the Foley catheter was passed into the wound and divided. The posterior urethra was then sharply transected in a similar fashion. The catheter was used to provide some subtle traction of the prostate. The rectourethralis was taken down using a right-angle clamp and electrocautery. Each neurovascular bundle was also tied and ligated. The prostate could be mobilized up to the bladder neck. The lateral pedicles were controlled using 2-0 Vicryl sutures and divided. A small horizontal incision was then made over the seminal vesicles and ampulla of the vas. Each of these structures was dissected out using sharp and blunt dissection. Clips were used to control bleeding. The seminal vesicles could be removed in their entirety. Each vas was clipped and ligated. An anatomic bladder neck-preserving dissection was then performed, and the prostate was sharply transected off the bladder neck. The bladder mucosa was everted using a running 4-0 Monocryl suture. 2-0 Vicryl sutures were placed at the 6 o’clock position to tighten the bladder neck to 20 French. Four 2-0 Monocryl sutures were placed in this bladder neck at equally spaced distances. A Greenwald sound was then placed into the distal urethral stump, and the corresponding bladder neck sutures were then placed into the urethral stump under direct visualization. The bladder neck was brought down to the urethral stump using a curved Babcock clamp. All bleeding was controlled, and the wound was irrigated with normal saline. The anastomosis was then tied down and, upon testing, shown to be watertight. Two Jackson-Pratt drains were then brought out through each lower abdominal quadrant in a separate stab-wound incision. They were used to drain each obturator fossa and around the anastomosis. The fascia was reapproximated using interrupted #1 figure-of-eight Vicryl sutures. The subcutaneous tissue was closed with a running 2-0 chromic suture. The skin was reapproximated using staples. Each drain was sutured in with a 2-0 silk suture. The patient tolerated the procedure well and was discharged to the recovery room in stable condition. Procedure code:
Cоlpоscоpy with loop electrode biopsy. Procedure code: