Pudendal nerve branch injury during radical perineal prostatectomy

We report the first case of direct surgical injury to a pudendal nerve branch during radical perineal prostatectomy. A 65-year-old patient presented with typical symptoms of a pudendal nerve lesion after radical perineal prostatectomy. As the patient did not respond to conservative treatment, surgical exploration and exeresis of the injured sensory branch of the pudendal nerve was necessary, resulting in pain improvement. Urologic surgeons should be aware of the typical symptoms after iatrogenic injury to the pudendal nerve or its branches. Early diagnosis and neurosurgical intervention are important to obtain a more favorable outcome.     

Venous air embolism during radical perineal prostatectomy

An abrupt decrease in end-tidal carbon dioxide (CO₂) occurred in an anesthetized male who was placed in the head down position during radical perineal prostatectomy. The end-tidal CO₂ was restored after insertion of a wet pack into the operative site, which strongly indicated venous air embolism as the cause. Predisposing factors, detection, and treatment of venous air embolism in this setting are discussed.     

Potency-sparing radical perineal prostatectomy

We evaluated the results of a unilateral nerve-sparing radical perineal prostatectomy in a prospective study. Thirty patients with histologically confirmed unilateral prostate cancer and adequate erectile function preoperatively underwent a nerve-sparing procedure. The criteria were a PSA of <10 ng/ml, prostate volume of <60 ml, and a Gleason score <7. In 29 patients the procedure was technically feasible. In one patient significant damage to the neurovascular bundle was seen at the end of the procedure. Bilateral tumors were present in 18 patients on final pathology. Positive surgical margins were observed in five patients (pT2: 2/20; pT3: 3/10). After a follow-up of 3-12 months, 15 of 29 patients (51%) reported some erectile function without additional medication. Of 14 patients, 2 had enough rigidity for penetration within 3 months.The short-term results after unilateral nerve-sparing perineal prostatectomy are encouraging. Since the neurovascular bundle can be exposed very well, interposition of sural nerve should be considered.     

Immediate robot-assisted ureteral reimplantation during robotic prostatectomy in locally advanced prostate cancer

We report the technique and outcomes of immediate robot-assisted ureteral reimplantation due to unexpected ureteral injury during robot-assisted laparoscopic prostatectomy (RALP). A 61-year-old male was diagnosed with locally advanced prostate adenocarcinoma (T3bN0M0). Multiple positive margins at the bladder neck were noted on frozen section during RALP, and re-excision of the bladder neck was done. Unfortunately, the distal third of right ureter was transected. We immediately performed robot-assisted ureteroneocystostomy with double J stent insertion. No complications developed during the follow-up period.     

Contemporary appraisal of radical perineal prostatectomy

PURPOSE: In the age of minimally invasive surgery there has been renewed interest in the perineal approach for the surgical treatment of prostate cancer. We reviewed recent publications regarding radical perineal prostatectomy (RPP) in an effort to define its role in the current management of localized prostate malignancy. At the same time we reviewed the relevant perineal anatomy and surgical approach necessary to perform this operation. MATERIALS AND METHODS: We performed a review of the literature with respect to RPP and included our own extensive experience with this operation, emphasizing patient selection, the current role of pelvic lymph node dissection, surgical anatomy, oncological outcomes and complications. RESULTS: RPP is an effective treatment for localized adenocarcinoma of the prostate with oncological outcomes similar to those of the retropubic technique. In comparison to RRP, patients undergoing RPP have less postoperative discomfort, more rapid return of bowel function, more rapid return to work and a decreased transfusion rate. In addition, RRP is now often performed with cavernous nerve sparing. Prostate specific antigen screening has made the rate of lymph node metastasis low enough to omit lymphadenectomy in many cases. CONCLUSIONS: There is still a role for RPP in the treatment of localized prostate cancer. Erectile dysfunction after nerve sparing and incontinence rates are similar to those of RRP. In addition, it is less morbid then RRP without being as technically challenging as laparoscopic radical prostatectomy.     

The technique of radical perineal prostatectomy

The resurgence of the radical perineal prostatectomy for the treatment of localized prostate cancer has been facilitated by the current emphasis on reducing medical costs, the identification of more cases of localized disease, the selected use of lymphadenectomy, and the use of laparoscopic techniques to perform node sampling. This technique provides a cost-effective, low-morbidity, and efficacious means of treating localized prostate cancer.     

Reappraisal of radical perineal prostatectomy.

Radical prostatectomy is frequently the treatment of choice for localized adenocarcinoma of the prostate. The procedure can be accomplished through either a perineal or a retropubic approach; both have their advantages and disadvantages. Recently, concerns over transmission of blood-borne viruses during transfusions and the advent of laparoscopic pelvic lymphadenectomy have resulted in a rejuvenation of interest in perineal prostatectomy. Herein, we discuss the history of perineal prostatectomy, the technique and its advantages and disadvantages.     

Identification and conservative management of a distal ureteral injury occurring during robotic-assisted laparoscopic radical prostatectomy

Iatrogenic ureteric injury following open radical prostatectomy and laparoscopic radical prostatectomy is a rare but known complication. We report a unique case of ureteric injury diagnosed postoperatively following robot-assisted laparoscopic radical prostatectomy (R-LRP). Conservative management of the injury using percutaneous drainage and anterograde ureteral stenting allowed for complete resolution of the ureteral injury.     

输尿管导管在妇科腹腔镜手术中预防输尿管损伤的应用

目的探讨盆腔粘连患者行腹腔镜手术时放置输尿管导管预防输尿管损伤的可行性。方法随机选取盆腔粘连患者27例,实验组15例于术前在膀胱镜下放置输尿管导管,对照组12例按正常程序实施手术。结果实验组避免输尿管损伤有效率为100％,对照组有效率为91.67％,差异有统计学意义（P〈0.05）。在子宫次全切除术及子宫全切除术中,实验组手术时间均明显短于对照组（P〈0.05）,差异有统计学意义。结论盆腔粘连患者行腹腔镜手术时放置输尿管导管,可有效防止输尿管损伤,手术操作安全,快捷。     

Simple preoperative parameters to assess technical difficulty during a radical perineal prostatectomy

Purpose

We aimed to propose a practical selection method predicting the easier radical perineal prostatectomy (RPP) cases before the operation.

Methods

Fifty sequential RPP cases were divided into two groups according to the estimated difficulty of the operation (Group I: Easier, Group II: Difficult) which was assessed by using a RPP difficulty scale, constituted by three parameters (operation time, blood loss, and the judgment of the surgeon) each ranging between 1 and 3 points. As the localization parameters, skin-to-prostatic apex (SPAD) and skin-to-prostatic base (SPBD) distances and distance between bilateral ischial tuberosities (ITD) were measured. During suprapubic ultrasonography, a probe-divergence angle (PDA) and prostate volumes (PV) were recorded. These parameters were compared between the groups.

Results

In Group I (n = 29) and Group II (n = 21), the difficulty scores were 4.37 (3–5) and 6.80 (6–9), respectively. Data of age, clinical stages, and findings of digital rectal examination were not different between groups. While SPBD, SPAD, and ITD values were found similar (p > 0.05), PDA and PV were significantly different. PDA was > 45 degree in 21 cases in Group I (72.4 %) and in 7 cases in Group II (33.3 %) (p = 0.011). The mean of PV was 37.4 (20–60) cc and 49.9 (30–75) cc in Group I and Group II, respectively (p = 0.001).

Conclusions

While planning RPP operations, by selecting the prostate cancer cases with a prostate of low volume and localized deeper in the pelvis during suprapubic ultrasonography, urologists may have a chance to perform this technique more easily during the learning period.     

Feasibility of radical perineal prostatectomy under spinal anaesthesia

OBJECTIVE: To evaluate the possibility of a perineal radical prostatectomy (PRP) under spinal anaesthesia, as although it is usually done under general anaesthesia, there is currently a need to minimize costs and morbidity. PATIENTS AND METHODS: Between January and December 2003, there were 337 PRPs at our institution, of which 47 were on patients under combined spinal/epidural (CSE) anaesthesia administered via a standard L3/4 or L4/5 approach. We analysed the feasibility of PRP under CSE and evaluated perioperative morbidity, including blood loss and hospital stay. RESULTS: All 47 procedures were done under CSE with no need for conversion to general anaesthesia. The mean (range) duration of PRP was 56 (43-112) min, the mean blood loss 270 mL, and the transurethral catheter was removed at 7 days in 40 and at 14 days in the remaining seven patients. There were no complications during surgery, e.g. rectal or ureteric lesions. The mean hospital stay was 8.2 days. CONCLUSION: PRP is safe under CSE anaesthesia; this may be helpful in minimizing morbidity and medical costs, as well as providing an alternative in patients in whom general anaesthesia is not recommended.