Perineal Prostatectomy

Walking in the Land of Dinosaurs Sam D Graham, Jr

Blue Ridge Urology

There was a time when ships were wood and men were steel Al Weyman Chief Resident, Surgery University of Rochester 1974

Perineal Lithotomy Perineal Prostatectomy Johns Hopkins Modern Modifications

History of Perineal Surgery

A strong and intelligent person being seated on a high stool, lays hold of the patient in a supine posture, with his back towards him, and his hips being placed on his knees, with his legs drawn backwards he orders the patient to seize his own hams with his hands, and to draw them towards his body with all his power, and at the same time he secures them in that position. Then the physician, having carefully pared his nails, introduces his index and middle fingers of the left hand, first the one gently, afterwards the other into the anus, and places the fingers of his right hand lightly on the lower part of the abdomen. First of all the stone must be sought for about the neck of the bladder and when it has been brought into that position a lunated incision must be made through the integuments immediately over and extending to the neck of the bladder near the anus, with the horns a little inclined towards the ischia; then a second incision is to be made in the transverse form in the convex part of the wound so as to open the neck of the bladder."

15th Century Op Note, Celsian Lithotomy

Ambrose Pare’

Frere Jaques

1866-H Kuchler Partial Prostatectomy for Cancer 1867-Theodur Bilroth Perineal Prostatectomy

1903 Hugh Young

The Teachers

The Instruments

The Position

The New Teachers

The New Instruments

The Same Instruments

The New Position

The Incision

Central Tendon

Recto-Urethralis

Denonvilliers Fascia

Nerve Sparing

Urethra

Reconstruction

Postoperative Care

109 minutes average operating time

1 day stay in hospital

Average blood loss < 100 cc

Rare use of narcotics (< 5% use prescriptions)

Sitz baths at least twice a day

Catheter out in 10 days

Advantages of Perineal Prostatectomy

Minimal Capital Outlay

High Risk Patients not suitable for other approaches Obese patients

Prior abdominal surgery

Prior mesh hernia repair

Perineal Prostatectomy in the Obese Patient

Group I BMI 30-34.9

(n=27)

Group II BMI 35-39.9

(n=22)

Group III BMI > 40 (n=9)

Blood Loss (cc)

500 529 544

OR Time (min)

104 105 107

Perineal Prostatectomy in the Obese Patient

Group I BMI 30-34.9

(n=27)

Group II BMI 35-39.9

(n=22)

Group III BMI > 40 (n=9)

Continent 24 18 7

Stress 1 0 1 Urge

Incontinence-2ppd

Mild Stress (<1 ppd)

1 3 1

Perineal Prostatectomy in the Obese Patient

Group I BMI 30-34.9

(n=27)

Group II BMI 35-39.9

(n=22)

Group III BMI > 40 (n=9)

Spontaneous 3 2 3

Partial/Assisted 16 9 4

None

4 4 2

Not Discussed 4 7