PREOPERATIVE DIAGNOSIS: Localized prostate cancer.
POSTOPERATIVE DIAGNOSIS: Localized prostate cancer.
OPERATION PERFORMED: Radical retropubic prostatectomy.
SURGEON: John Doe , MD
ASSISTANT: Jane Doe , MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 950 mL.
DESCRIPTION OF OPERATION: The patient was given Ancef and Flagyl preoperatively. After induction of anesthesia, he was placed in the supine position. His entire lower abdomen was cleaned, prepped, and draped to a sterile field. A 20 French Foley catheter was then placed into the bladder. Scalpel was used to make a longitudinal incision from above the pubic symphysis to below his umbilicus. This was carried down through the subcutaneous tissues. The fascia was identified and scored in the midline. The rectus muscle bellies were split in the middle and the transversus layer was divided to expose the pelvic space. Using a retractor, we were able to sweep up the peritoneum off both iliac fossae and expose the prostate and bladder. Inspection was carried out, but we could see no obvious pathological lymph nodes. At this point, self-retaining retractor was placed with the hole in the Foley balloon and the prostatectomy was begun. We opened up the endopelvic fascia on both sides in the usual fashion to expose the prostate.
We then placed three Vicryls around the plane between the urethra and the dorsal vein and the dorsal vein was tied off x2. The third tie was used for traction. Using the Bovie, we cauterized down through the dorsal vein. Prior to this, an 0 Vicryl back-stitch was placed through the fascia. The dorsal vein was then oversewn with an 0 Vicryl x2. The needle was run through the periosteum for traction. This controlled the bleeding of the dorsal vein and then we identified the urethra. The urethra was opened on the anterior surface with a scalpel. At this point, three anastomotic sutures, 2-0 Vicryls each were placed through the anterior urethra and tagged. The right angle was used to pull up the Foley and the Foley was then cut and tagged with a hemostat for traction.
We then placed a red Robinson, Foley through the urethra to help place our last two anastomotic sutures. They were also 2-0 Vicryls and were placed at the 5 and 7 o'clock positions and tagged as well. With the five sutures in place, we divided the posterior urethra and then divided the rectourethralis fascia to begin to pull the prostate back. On the patient's left side, because all six of his biopsies were positive, no attempt was made to do a nerve sparing on this side. We used right angles and right angle clips to take a wide margin, including the nerve on the left side to go out lateral and included all of this with the specimen. Once we got this back, we worked on the right side.
A right-sided nerve sparing was carried out. We swept the loose fatty tissue off the fascia and then we identified the nerve and we incised the fascia just above it and used a peanut to gently push the nerve down. We worked this from anterior to posterior using small clips on the fascia and pushing the nerve down with the peanut. Once the nerve was pushed back, all the way back toward the apex, we turned our attention back to the midline. Scalpel was used to incise the attachments between the rectum and the seminal vesicles to allow the rectum to completely sweep down. We then identified the seminal vesicles and we used Metzenbaum scissors to expose these. Scalpel was then used to incise the loose areolar tissue over the seminal vesicles and right angle was used to then go out lateral, first on the left side, and start tying down the pedicles. The pedicles were tied off with heavy Vicryls and clips and divided.
Once we had taken down the pedicle on the left side, we worked on the right side. Again, we used right angles with right angle clips and ties to take down the right pedicle out lateral to the seminal vesicle. This allowed the skin a nice plane behind the seminal vesicle and we were able to find the ampulla of the vas. Both vasa were brought up with right angles. They were divided with two clips distal, one proximal, and then incised. Finally, the seminal vesicles were freed up down to the tips. We placed two clips at the base, divided both seminal vesicles to come up with the prostate. We then cauterized the tips of the seminal vesicles and the vas. Next, we allowed the Foley to come back in and began dissection of the bladder neck. There was some connective tissue on both sides and this was divided with right angles and cautery. We stayed close to the bladder neck trying to spare as much bladder neck as possible. We worked incising the bladder neck away from the prostate. This dissection went well. When we got down toward the bladder neck right at the tip of the urethra, a scalpel was used to incise right under the Foley and allowed us to separate the prostate.
The prostate was sent off to pathology. The bladder neck was left fairly intact. We used cautery to control several bleeders. At this point, the bladder was fully irrigated with a bulb syringe of any clots. We inspected the bladder neck. It appeared to be nicely closed and did not need any reconstruction. We irrigated the pelvis completely with sterile water and checked for bleeding. We looked down at the urethra and no bleeding was noted. We checked the pedicles on both sides and then around by the seminal vesicles and no bleeding was noted. When the wound was thoroughly irrigated, we began closure.
At this point, a 25 mL balloon was placed up into the urethra and then up into the bladder. We then took our five anastomotic sutures, and using Mayo needles, we passed them through the corresponding position on the bladder neck and tagged them. Will all five sutures in place, the Foley in the bladder, we inflated the Foley with 10 mL of sterile water and then began by pulling the bladder down to the urethra. This came down quite nicely. Using a sponge stick without a sponge, we tied all five sutures down to complete the anastomosis. The bladder was then irrigated to clear with a Toomey syringe. A JP drain was then placed through a stab wound in the left lower side and sutured in place with a nylon. This was draped over the anastomosis. The muscle layers were then closed with a running chromic. We placed our first On-Q pump through the fascia down on top of the muscle. Next, the fascia itself was closed with 0 looped Maxon running x2. We then irrigated the subcutaneous thoroughly and then placed our second On-Q pump on top of the fascia. Some chromics were used to loosely close the subcutaneous tissue and then staples were used in the skin. The Foley was irrigated. A sterile dressing was applied. The patient was awakened and taken to the recovery room in stable condition. The patient tolerated the procedure well.
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