Transperineal prostatectomy

Transperineal prostatectomy is less invasive, has less systemic effects, and has lower postoperative mortality. It is especially suitable for elderly patients with poor general condition. However, the anatomy of the perineum is complicated, the surgical incision is small, the exposure is poor, it is difficult to stop bleeding, the operation is difficult, the rectal injury is prone to occur, the urethral rectum or perineal rectal fistula is caused, the incidence of postoperative sexual dysfunction is high, and the surgery requires some special equipment. General surgeons are not familiar with this path. Therefore, in recent years, there have been fewer applications of perineal prostatectomy. Treatment of diseases: prostatic stones Indication Perineal prostatectomy is applicable to: 1. Suspected prostate cancer, biopsy under the direct observation of the perineum, frozen section confirmed the cancer, and changed to radical prostatectomy. 2. Prostatic stones, especially large prostate stones, occupy the entire gland and cause intractable infections. The stones can be removed under the direct view of the perineum, the infected lesions are treated, and the prostate is removed. 3. Prostate abscess is often an indication of perineal prostate resection. 4. The pelvic outlet is wide, the patient with thin and thin stools, or the body is obese. If the prostate is difficult to remove the pubis or the pubis, it is a good choice to remove the prostate through the perineum. 5. Due to the operative mortality and postoperative cardiopulmonary complications, the removal of the prostate by the perineum is particularly suitable for patients with poor general condition. 6. After transurethral resection of the prostate, stones and infections persist in the prostate, and perineal prostatectomy can also be performed. Contraindications 1. Large benign prostatic hyperplasia, it is not easy to remove the prostate from the perineal incision. 2. The patient is younger and more concerned about the preservation of sexual function. It is better to remove the prostate without the perineum. 3. The hip joint and the spine are stiff and cannot be placed in the position of the stone. 4. Patients with bladder tumors, diverticulum or other intravesical diseases need to be treated at the same time. Preoperative preparation Patient preparation 1 According to the results of urine culture and drug sensitivity test, effective antibacterial drugs should be used reasonably before surgery. Fasting 8 hours before surgery; preparation of blood 400 ~ 600ml. 2 Clean the enema without using laxatives and intestinal disinfection antibiotics. 3 skin preparation: Because the surgical incision is close to the anus, the skin preparation range should include the lower abdomen, the suprapubic region, the scrotum, the perineum, the perianal and the two thighs. 2. Instrument preparation After perineal prostatectomy, some special surgical instruments, such as prostate retractor and prostate forceps, are needed. Prostate tractors generally use Lowsley prostate retractors, both straight and curved. Their ends have traction blades that can be flared 180° to the sides. The curved shape is generally used for transposition into the bladder neck through the urethra for straight traction, and the straight shape is directly inserted into the prostate through the perineal incision for traction. After perineal prostatectomy, the assistant needs to use his fingers to reach into the rectum during surgery to help push the prostate or protect the rectal wall from damage, so it is important to prevent wound infection. A special disinfectant towel is usually required, and a small hole is left in the middle for rectal examination. The disinfecting towel covers the surface of the ischial tuberosity below the anus. Surgical procedure 1. Skin disinfection, ranging from under the costal margin 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. 2. Insert the Lowsley curved prostate retractor into the urethra: the tractor is coated with a disinfectant 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. The incision perineal part is made into a "U" shaped incision, the two ends reach the inside of the ischial tuberosity, and the arc segment is 1.5 to 2.0 cm from the anus. If necessary, the incision can be extended vertically in the middle of the incision to facilitate the exposure of the large prostate. 4. Cut the center of the perineum, cut the skin and subcutaneous tissue, bluntly separate the rectal fossa of both sides of the ischial, and insert the left hand between the rectal wall and the central malleolus. The center of the perineum is actually an extension of the subcutaneous fibers of the external anal sphincter to the urethra of the ball. The width and thickness of the vaginal canal vary greatly. Sometimes it can be fused with the levator ani muscle to both sides and is mistaken for the rectal urethra muscle. Keep away from the anal external sphincter and close the ball in the urethra. Several small arteries were cut off when the center was cut and should be ligated. 5. Cut the rectal urethral muscle with the left hand finger and the middle finger to press the lower edge of the incision, push the connective tissue up along the front of the rectum, you can see the lateral edge of the levator ani muscle, pull the hook to reveal the rectal urethral muscle, and cut the muscle . 6. After the rectal urethral muscle is removed from the prostate, the rectum is pushed back. Then along the plane between the anterior and posterior layers of the Denonvillier fascia, the vaginal canal and the urethra of the membrane can be revealed after pushing the deep transverse muscle. If the prostatic hyperplasia is large and the exposure is not satisfactory, the levator ani muscles on both sides can be partially cut off to enlarge the surgical field. 7. Replace the prostate retractor After the prostate is separated, a 1 cm long longitudinal incision is made in the urethra or prostate tip of the membrane to remove the curved Lowsley prostate retractor in the urethra. A straight Lowsley prostate retractor was inserted from the incision to make an inverted "V" shaped incision in the surgical envelope. 8. Remove the enlarged prostate through the "V" shaped incision insertion finger, bluntly separate the prostate between the surgical capsule and the plane of the prostate gland, or combine the blunt and sharp separation, and pass the inverted "V" shape The incision removes the prostate. 9. Prostate fossa hemostasis After removal of the prostate, the prostate fossa is filled with hot saline gauze and pressure is stopped for a few minutes. After taking out the gauze, carefully check the bleeding point and suture the blood with absorbable thread. The bladder neck is clamped with a tissue forceps and pulled outward. The index finger is inserted through the bladder neck to touch the lesion. 10. The urethra and suture capsule were inserted into the balloon catheter through the urethra, and the balloon was filled with water 30 ml for postoperative traction and drainage of urine. The catheter was used as a stent, and a 3-0 absorbable line was used around the catheter to make the distal end of the prostate urethra and the end of the bladder neck. The prostate capsule incision was sutured with a 2-0 absorbable thread. 11. Closing the incision The levator ani muscle is sutured with an absorbable thread, which is important for rebuilding the pelvic floor and restoring the rectum. A rubber tube is placed on both sides of the incision for drainage. The center of the suture is sutured, and the skin is sutured intermittently. complication 1. Urine leakage. 2. Urinary incontinence. 3. Rectal injury. 4. Postoperative bleeding. 5. Infection.