Transperineal prostatectomy

The advantage of perineal prostate semicircular resection for prostate cancer is that the postoperative reaction is mild, the elderly are easy to tolerate; the bleeding during surgery is relatively small; the bladder neck and urethra are clearly revealed, and the anastomosis is easy; the drainage is known to have a prostate infection. More suitable. It is especially suitable for patients with poor constitution and obesity and emphysema. However, this path cannot check and remove the pelvic lymph nodes, and it is not possible to perform an enlarged radical operation. If urinary flow is required to be diverted, the abdominal route must be used. Those with hip stiffness can not take the bladder lithotomy position, and this path is contraindicated. Treatment of diseases: prostate cancer Indication Perineal prostate cystectomy is suitable for patients with prostate cancer indications, especially those with prostate infection and poor constitution, obesity, emphysema. Contraindications Those who have hip stiffness can not take bladder lithotomy, and may need to expand radical surgery, urinary diversion. Surgical procedure Skin disinfection The range is from the cost of the rib to the middle of the thigh. Disinfect the sanitary napkins, disinfection napkins for the anus and ischial tuberosity or O'Conor coverslips (a rubber sheet with small holes in the middle for rectal examination) to prevent contamination during surgery. 10.2 2. Insert the Lowsley curved prostate retractor into the urethra The retractor is coated with a sterile lubricant and gently inserted into the bladder from the urethral opening. The tractor facilitates the identification of the urethra and prostate tip during surgery and can pull the prostate to the superficial portion of the surgical incision. 3. Incision The perineum is made into a "U" shaped incision. The two ends reach the inside of the ischial tuberosity. The curved section is 1.5 to 2.0 cm away from the anus. If necessary, the incision can be extended vertically in the middle of the incision to facilitate exposure of the large prostate. 4. Cut off the center of the perineum After the skin is cut, the fascia is placed on both sides of the incision. The perineal center is located between the perineal transverse muscle and the external anal sphincter. The insertion finger gently separates the perineal center from the lateral side of the rectum. After separation from the rectum, the center can be cut off. The position of the rectum is indicated by the insertion of the rectus in the rectal fossa. The rectal wall is relatively tough and elastic. The finger is inserted from the side of the rectal fossa in the posterior direction of the perineal center. The correct separation plane is found in the rectal fascia. The surface is carried out and generally does not damage the rectum. Separation is too shallow. Only part of the perineal center is separated. No lustrous rectal fascia can be found. It is often blindly separated at the high point of the perineal wound. It is easy to cause bleeding and rectal injury. Experienced surgeons prefer to cut the center of the perineum directly toward the rectal fascia. If the rectal fascia is unclear, apply a finger to the rectal guide. 5. Cut the rectal urethra muscle After the perineal center is cut, the next step is to separate the rectum from behind the prostate capsule. The rectum is turned at a right angle at the tip of the prostate. The key to the operation is to cut the rectal urethral muscle. After it is cut, the right angle of the rectum disappears to a horizontal position, and the prostate and seminal vesicles can be revealed. The rectal urethra muscle is unclear and can easily cut or tear the rectum. In order to reveal the rectal urethral muscle, the anterior and posterior perineal transverse muscles are pulled open with a hook to tighten the rectal fascia, bluntly separate, and the levator ani muscles are torn upwards to the sides until the rectal urethra can be seen in the middle. The muscle fibers. It can be a distinct muscle bundle or just a few fiber bands from the rectum to the urogenital sac near the external urinary sphincter. The prostate grommet or balloon catheter is pulled outward, and the position of the muscle can be touched at the tip of the prostate deep in the wound. In the era before antibiotics were found, transsexual surgery to free and sever the rectal urethra muscle was considered a specialized technique because rectal injury can have serious consequences. Nowadays, unless the rectal urethral muscle is very obvious, it is generally the surgeon who inserts a finger in the rectum to guide the attachment of the muscle to the proximal rectal fascia, which saves time and reduces the chance of damaging the nearby sphincter. 6. Separation of the rectum After the rectal urethral muscle is cut, the rectum can be separated from the prostate and the seminal vesicle. Separation can be performed between the two layers of the fascia, or between the rectal fascia and the posterior layer of the fascia. It is easier to separate the rectum between the anterior and posterior layers of the fascia. From the 1.0cm below the tip of the prostate (at this point, the two layers of fascia are often fused), transversely cut the Philippine fascia posterior layer, revealing the shiny anterior layer of the fascia. The blunt dissection between the two layers of fascia separates the rectum until the upper end of the seminal vesicle. Another method is to separate between the rectal fascia and the posterior layer of the fascia. This path separation is not difficult, but there is an increased chance of bleeding and rectal injury. Some doctors routinely use this path to separate the rectum. The purpose is to protect the cancer with a layer of fascia. It is theoretically valuable for cancer surgery, especially when the cancer is extensive or the adhesion of the anterior and posterior layers of the fascia is more meaningful. After the rectum is completely separated, the gauze pad is used to protect the push open. If the prostate is large, the levator ani muscle may be partially cut off to increase the exposure. If a biopsy is required, remove a piece of wedge tissue from the back of the prostate and send a cryosection. Biopsy incision coagulation, or intermittent suture. 7. Cut the prostate urethra The tip of the prostate is revealed and a curved vascular clamp is used to pass the lateral prostatic fascia below the junction of the prostate and the urethra. Here you can palpate the prostate pull hook to help locate, and then use the knife to cut the urethra there. When the urethra is cut, the blood vessel is clamped to prevent injury to the vascular plexus around the prostate. It must be cut at the junction of the prostatic urethra, such as cutting the urethra too far from the tip of the prostate, causing difficulty in bladder urethral anastomosis and postoperative urethral stricture. Remove the prostate retractor before the urethra is completely cut. After cutting, insert the prostate retractor from the broken end or insert a balloon catheter for traction. If the cancer has a certain distance from the tip of the prostate, the prostate tip capsule (with the gland left in the capsule) and the bladder neck anastomosis should be left within 0.5 cm, which can reduce postoperative urethral stricture and increase postoperative stenosis. The ability to control urination. 8. Cut the bladder neck After the urethral resection of the prostate is performed, the tractor or balloon catheter is pulled downward to facilitate the separation of the prostate. The separation should be performed under the anterior prostatic fascia toward the bladder neck. Thus, the pubis ligament can be avoided. The deep vein between the back of the penis and the venous plexus of the prostate. Sometimes you can't find the separation gap under the prostatic fascia, you need to cut and ligature the pubis prostate ligament. Be careful to avoid damage to the upper fascia of the prostate. Otherwise, it is difficult to control bleeding. 9. Ligation of vascular bundles In order to fully reveal the upper seminal vesicle, it is best to first ligature the vascular bundle of the posterior margin of the prostate. Use a pointed vascular clamp to press the finger pressed from below to the fascia on both sides of the vascular bundle. Sometimes the vascular bundle near the prostate is thicker and should be ligated in several stages. The proximal end of the vascular bundle should be ligated or double ligated. If the ligation slips, the vascular bundle retracts into the fascia, and deep in the wound, it is very difficult to stop bleeding. 10. Cut off the vas deferens After the vascular bundle was cut and ligated, the vas deferens were ligated with a finger in the middle of the prostate. Usually ligated together with the fascia around the vas deferens. If the fascia is opened to release the vas deferens and ligated separately, not only will the vas deferens be brittle and fragile, but also increase the chance of tumor spread. After the vas deferens are ligated and cut, the prostate can be further pulled out to reveal the top of the seminal vesicle. It is usually unnecessary to open the fascia to see the position of the ureter in order to see the top of the seminal vesicle. If the tumor is beyond the seminal vesicle, it should be removed as much as possible. After the tumor is resected, the rouge is injected intravenously, and the ureteral injury is observed from the inside and outside of the bladder. The ureteral catheter can also be inserted. 11. bladder neck and urethral anastomosis and suture incision If the bladder neck is not removed, it can usually directly match the bladder neck and membrane urethra or prostate button button. The balloon catheter was inserted from the urethra, and the 3-0 absorbable line was completely anastomosed to the bladder neck and urethra, at least 6 needles. The urethra of the membrane is brittle and can be sutured with a suture. The anastomosis must be tension free. When suturing the posterior wall of the bladder outlet, avoid the ureteral orifice being sewn and compressed. Usually the ureteral catheter is removed after the anastomosis is completed. The new bladder outlet diameter is maintained at 1.5 cm. Fingers are inserted into the rectum for careful examination, except for damage. Under the bladder, the rubber tube is drained, and the perineal part is poked. The levator ani muscle can be sutured by the absorption line, the center of the perineum is sutured, and the skin is sutured intermittently. The catheter is sutured and fixed on the head of the penis or the foreskin to prevent slipping. complication 1, bleeding. 2, rectal injury. 3, ureteral obstruction.

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