Radical perineal prostatectomy in 10 easy steps

In this manuscript, the surgical technique step by step (ten easy steps) and current indications of radical perineal prostatectomy will be described. The procedure is not recommended if the patient has preexisting conditions that make a lithotomy position unwise in which case the retropubic approach should be utilized. An understanding of the anatomy of the different fascia layers surrounding the prostate gland and seminal vesicle and their relationship to the rectum and other pertinent structures is extremely germane to any study of radical perineal prostatectomy. Furthermore, attempts at potency-sparing prostatectomy are facilitated by accurate knowledge of the course of the neurovascular bundles. Step - 1 - Skin incision: The patient is placed in exaggerated dorso-lithotomy position with the perineum parallel to the floor. An inverted U-shape incision is marked medial to the ischial tuberosities outside to the external anal sphincter. Step - 2 Development of the ischiorectal fossa. Development of the ischiorectal just medial to the ischial tuberosities. Step - 3 Division of central perineal tendon. By inserting finger into both ischiorectal fossa and palpating medially, one can feel the rectal sheath and location of the rectum. Step - 4: Division of the rectourethralis muscle. By dividing this muscle one will be able to separate the rectum from Denonvilliers' fascia of muscle fiber tissue present. Step - 5: Ligation of vascular pedicles. The lateral pedicles can be visualized and palpated as a bundle of tissue lateral to the seminal vesicles. The prostate is further mobilized laterally by blunted dissection. Step - 6: Division of urethra: Meticulous urethral division will ensure an adequate vesico-urethral anastomosis later in the procedure...