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OPEN RETROPUBIC
PROSTATECTOMY
Dr Shankar HS Ram
Dept of Urology
TDMCH
Goals
• Radical prostatectomy is the only form of
treatment for localized prostate cancer to
reduce progression
• Cancer control, preservation of urinary
control, and preservation of sexual function
Surgical Anatomy
Open Retropubic Prostatectomy
Venous Plexus
• The superficial branch, between the
puboprostatic ligaments, lies outside the
anterior prostatic fascia
• communicating branches over the bladder
itself and into the endopelvic fascia.
Open Retropubic Prostatectomy
Lateral Venous Plexus – Santorini
• Common trunk (above urethra) and lateral
venous plexuses are covered and concealed by
the prostatic and endopelvic fascia
• Communication with pudendal, obturator, and
vesical plexuses – inferior vesical vein - IIV
• Near Puboprostatic ligament small branches
communicate with pelvic side wall muscle
and communicate with internal pudendal vein
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Blood supply
• Inferior vesical artery
• Enter and Division at P/ L V- P Junction -2
• Urethral Branches that supply Bladder neck,
periurethral prostate
• Capsular branches on lateral pelvic fascial P/L
to prostate supply its outer portion .
• Capsular braches –identification landmark for
microscopic pelvic plexus nerves
Pelvic pexus nerves
• Visecral sympathetic - Hypogastric
• Visceral parasympathetic – S234
• Somatic Motor
Nerves
• The nerves innervating the prostate travel
outside the capsule of the prostate and
Denonvilliers fascia until they perforate the
capsule where they enter the prostate.
• The branches to the membranous urethra and
corpora cavernosa also travel outside the
prostatic capsule in the lateral pelvic fascia
dorsolaterally between the prostate and
rectum.
NVB of Walsh
• Cavernous branches join Capsular arteries
• 20 – 30 mm Distal to PV junction
• Spray like distribution
• In Lateral pelvic fascia between prostatic fascia
and levator fascia
• At apex supplies branches of prostate and
striated sphincter –spray dist wide variation.
• pierce urogenital diaphragm ,pass behind Dorsal
penile artery and nerve and enter cavernosa
Blood supply –Cavernosa
• Blood supply of Penis Int Pudendal Artery
• Pedendal vessels can arise from Obturator
and inferior Vesical – Aberrant vessels
• Divided during Radical Prostatectomy
• Compromise Blood supply
• The nerves innervating the prostate travel outside
the capsule of the prostate and
• Denonvilliers fascia until they perforate the
capsule where they enter the prostate.
• The branches to the membranous urethra and
corpora cavernosa also travel outside the
prostatic
• capsule in the lateral pelvic fascia dorsolaterally
between the prostate and rectum
Cavernosal
nerve
Striated spinchter
• Tubular
• Horse shoe shaped
• Surround membranous urethra and smooth
muscle
• At apex the edges fused in midline
• Slow twich – passive control
• Active control – LA (Levator urethrae ,
Pubourethralis)- Pudendal and somatic motor
nerves in plexus
• Kiegel –Pudendal Nerve - LA + striated sphincter
Open Retropubic Prostatectomy
3 prostate fascial covering
• 1.Denonvilliers-
• Cover post surface of prostate & Seminal Vesicle
• dense at base thin at apex .
• Must be excised (A &P in seperable).
• 2.Prostatic fascia (capsule)-
• anterior and lateral in contuinity with prostate
parenchyma.
• Anteriorly lies DVP and
• Santorinis plexus
• 3 .Levator facsia - Laterally fuses with
prostatic fascia forms lateral pelvic fascia
• NVB lies between Levator fascia and
Prostatic fascia .
• In performing a Nerve sparing surgery the
prostatic fascia (capsule) must remain on
the Prostate
Anterior
Pelvic
Fascia
Lateral
Pelvic
Fascia
Superficial branch DVC
Common trunk /
deep branch DVC
Ant Pelvic Fascia Extn
Sphincter Ant layer
Urethral mucosa Ant layer
Lumen with Foley
Smooth muscle Post Layer
NVB
Sphincter Post layer
Denonvilliers fascia
Smooth muscle Ant Layer
Layers of Apical Dissection in RRP
Lateral Pelvic Facsia
Urethral mucosa post layer
Ram S
Open Retropubic Prostatectomy
• Surgery is deferred for 6 to 8 weeks after PNB
and 12 weeks after TURP.
• Helps to preserve NVB and
• Prevents Rectal Injury
Extraperitoneal midline
• PLND (Iliac + Obturator) done before
prostatectomy.
• Preserve soft tissue over EIA .
• Inferiorly up to Femoral canal
• Cloquet node not removed
• obturator nerve preserved
• Obturator and Hypogastric vessels skeletonised
Open Retropubic Prostatectomy
Frozen section
• If the patient has a well differentiated
to moderately well-differentiated
tumor (Gleason grade < 8) and
• The lymph nodes are normal to
palpation, frozen-section analysis is
not performed
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Superficial branch
ligated
• Incision in the endopelvic fascia and division
of the puboprostatic ligaments.
• Expose the juncture between the apex of the
prostate and the anterior surface of DVC
• Pubourethral component of the complex is
intact to preserve anterior fixation of the
striated sphincter to the pubis.
• Small arterial and venous branches from the
pudendal vessels are encountered that
perforate the pelvic musculature to supply the
prostate.
• pudendal artery and nerve, which are located
just deep to pelvic muscle as they travel along
the pubic ramus.
• These vessels should be ligated with clips to
avoid coagulation injury to the pudendal
Open Retropubic Prostatectomy
• Large visible accessory pudendal arteries are
present in 4% of men – preserved to prevent ED.
• Careful dissection avoids bleeding
• Division of the endopelvic fascia lateral to the
vessels and division of the puboprostatic ligament
• (the vessels are beneath the puboprostatic
ligament)
Open Retropubic Prostatectomy
LIGATION OF DVC
Open Retropubic Prostatectomy
• The goal is to divide the complex with minimal
blood loss while avoiding damage to the
striated sphincter and inadvertent entry into
the anterior apex of the prostate.
• sponge stick
• figure-of-eight horizontal mattress suture ON
DVC , which is then tied
• Another on anterior surface of the prostate to
reduce bleeding from the proximal dorsal
venous complex.
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
DIVISION OF URETHRA
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
s
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
DIVISION OF BLADDER NECK
SEPERATION OF SEMINAL VESICLES
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
Open Retropubic Prostatectomy
References
• https://www.youtube.com/watch?v=sasFpBlv
xLg
• RRP as performed by Patrick Walsh
• Campbell 11 edition

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Open Retropubic Prostatectomy

  • 1. OPEN RETROPUBIC PROSTATECTOMY Dr Shankar HS Ram Dept of Urology TDMCH
  • 2. Goals • Radical prostatectomy is the only form of treatment for localized prostate cancer to reduce progression • Cancer control, preservation of urinary control, and preservation of sexual function
  • 5. Venous Plexus • The superficial branch, between the puboprostatic ligaments, lies outside the anterior prostatic fascia • communicating branches over the bladder itself and into the endopelvic fascia.
  • 7. Lateral Venous Plexus – Santorini • Common trunk (above urethra) and lateral venous plexuses are covered and concealed by the prostatic and endopelvic fascia • Communication with pudendal, obturator, and vesical plexuses – inferior vesical vein - IIV • Near Puboprostatic ligament small branches communicate with pelvic side wall muscle and communicate with internal pudendal vein
  • 10. Blood supply • Inferior vesical artery • Enter and Division at P/ L V- P Junction -2 • Urethral Branches that supply Bladder neck, periurethral prostate • Capsular branches on lateral pelvic fascial P/L to prostate supply its outer portion . • Capsular braches –identification landmark for microscopic pelvic plexus nerves
  • 11. Pelvic pexus nerves • Visecral sympathetic - Hypogastric • Visceral parasympathetic – S234 • Somatic Motor
  • 12. Nerves • The nerves innervating the prostate travel outside the capsule of the prostate and Denonvilliers fascia until they perforate the capsule where they enter the prostate. • The branches to the membranous urethra and corpora cavernosa also travel outside the prostatic capsule in the lateral pelvic fascia dorsolaterally between the prostate and rectum.
  • 13. NVB of Walsh • Cavernous branches join Capsular arteries • 20 – 30 mm Distal to PV junction • Spray like distribution • In Lateral pelvic fascia between prostatic fascia and levator fascia • At apex supplies branches of prostate and striated sphincter –spray dist wide variation. • pierce urogenital diaphragm ,pass behind Dorsal penile artery and nerve and enter cavernosa
  • 14. Blood supply –Cavernosa • Blood supply of Penis Int Pudendal Artery • Pedendal vessels can arise from Obturator and inferior Vesical – Aberrant vessels • Divided during Radical Prostatectomy • Compromise Blood supply
  • 15. • The nerves innervating the prostate travel outside the capsule of the prostate and • Denonvilliers fascia until they perforate the capsule where they enter the prostate. • The branches to the membranous urethra and corpora cavernosa also travel outside the prostatic • capsule in the lateral pelvic fascia dorsolaterally between the prostate and rectum
  • 17. Striated spinchter • Tubular • Horse shoe shaped • Surround membranous urethra and smooth muscle • At apex the edges fused in midline • Slow twich – passive control • Active control – LA (Levator urethrae , Pubourethralis)- Pudendal and somatic motor nerves in plexus • Kiegel –Pudendal Nerve - LA + striated sphincter
  • 19. 3 prostate fascial covering • 1.Denonvilliers- • Cover post surface of prostate & Seminal Vesicle • dense at base thin at apex . • Must be excised (A &P in seperable). • 2.Prostatic fascia (capsule)- • anterior and lateral in contuinity with prostate parenchyma. • Anteriorly lies DVP and • Santorinis plexus
  • 20. • 3 .Levator facsia - Laterally fuses with prostatic fascia forms lateral pelvic fascia • NVB lies between Levator fascia and Prostatic fascia . • In performing a Nerve sparing surgery the prostatic fascia (capsule) must remain on the Prostate
  • 22. Superficial branch DVC Common trunk / deep branch DVC Ant Pelvic Fascia Extn Sphincter Ant layer Urethral mucosa Ant layer Lumen with Foley Smooth muscle Post Layer NVB Sphincter Post layer Denonvilliers fascia Smooth muscle Ant Layer Layers of Apical Dissection in RRP Lateral Pelvic Facsia Urethral mucosa post layer Ram S
  • 24. • Surgery is deferred for 6 to 8 weeks after PNB and 12 weeks after TURP. • Helps to preserve NVB and • Prevents Rectal Injury
  • 25. Extraperitoneal midline • PLND (Iliac + Obturator) done before prostatectomy. • Preserve soft tissue over EIA . • Inferiorly up to Femoral canal • Cloquet node not removed • obturator nerve preserved • Obturator and Hypogastric vessels skeletonised
  • 27. Frozen section • If the patient has a well differentiated to moderately well-differentiated tumor (Gleason grade < 8) and • The lymph nodes are normal to palpation, frozen-section analysis is not performed
  • 31. • Incision in the endopelvic fascia and division of the puboprostatic ligaments. • Expose the juncture between the apex of the prostate and the anterior surface of DVC • Pubourethral component of the complex is intact to preserve anterior fixation of the striated sphincter to the pubis.
  • 32. • Small arterial and venous branches from the pudendal vessels are encountered that perforate the pelvic musculature to supply the prostate. • pudendal artery and nerve, which are located just deep to pelvic muscle as they travel along the pubic ramus. • These vessels should be ligated with clips to avoid coagulation injury to the pudendal
  • 34. • Large visible accessory pudendal arteries are present in 4% of men – preserved to prevent ED. • Careful dissection avoids bleeding • Division of the endopelvic fascia lateral to the vessels and division of the puboprostatic ligament • (the vessels are beneath the puboprostatic ligament)
  • 38. • The goal is to divide the complex with minimal blood loss while avoiding damage to the striated sphincter and inadvertent entry into the anterior apex of the prostate. • sponge stick • figure-of-eight horizontal mattress suture ON DVC , which is then tied • Another on anterior surface of the prostate to reduce bleeding from the proximal dorsal venous complex.
  • 58. s
  • 84. DIVISION OF BLADDER NECK SEPERATION OF SEMINAL VESICLES
  • 104. References • https://www.youtube.com/watch?v=sasFpBlv xLg • RRP as performed by Patrick Walsh • Campbell 11 edition