1, Radical cystectomy
(i) Bleeding
1, Before dealing with the lateral bladder ligament, the lateral bladder ligament should be fully freed, such as the posterior wall of the bladder is freed to the posterior of the prostate, the superior middle artery of the bladder is pre-treated and the lateral bladder ligament is clamped under direct vision, the cut should not exceed the tip of the vascular clamp and must be sutured.
2. When dealing with the lateral ligament of the bladder and the vascular tip of the prostate, hemorrhage may occur due to vascular slippage, poorly revealed, and blind clamping with forceps in a pool of blood will result in greater injury. The hemorrhage should be stopped immediately with gauze compression, fully exposed, remove the gauze, clamp the bleeding site accurately and make a figure of 8 suture. For pelvic wall vein bleeding, the surrounding tissue is sutured to cover the bleeding point.
3, Santorinis plexus injury bleeding, pay attention to avoid blind clamping, suturing and tearing the vein. In this case, the intrapelvic fascia should be cut, the pubic prostatic ligament should be cut, and a suture should be placed across the venous bundle without cutting this bundle for suturing to stop bleeding.
(ii) Rectal injury
Separation of the bladder, seminal vesicles, and prostate from the rectum without separation in the plane between the anterior and posterior layers of Denonillier’s fascia can easily cause rectal injury. It is also possible to damage the anterior wall of the rectum by blindly cutting the prostate tip with scissors before completing the separation of the rectum from the prostate tip, or by separating the rectum from the prostate tip without pressing against the prostate. For those who have made bowel preparation before surgery and have not received radiation therapy, double interrupted sutures with silk thread can be used to close the damaged rectal fissure and to drain the perineum; otherwise, a temporary sigmoid colostomy should be made to ensure healing.
(iii) Closed nerve injury
During the removal of pelvic lymphatic tissue, the foramen occulans nerve may be severed or ligated. When the lymph node of the foramen ovale is invaded and adheres to the nerve, the foramen ovale nerve on that side may be removed. Injury to one side has no serious consequences, while injury to bilateral foraminal nerves may cause difficulty in walking. Intraoperative care should be taken to identify and protect the foramen ovale nerve, and if the foramen ovale nerve is found to be severed, a one-stage repair should be performed.
(iv) Residual seminal vesicle, ureteral end or penetration of bladder wall
When separating the bladder floor, the fingers mistakenly separate in front of the seminal vesicle and penetrate the bladder wall, resulting in contamination and anatomical level disorder, and the ends of seminal vesicle and ureter often remain in the anterior rectal wall and both sides, affecting the effect of radical surgery. During surgery, the vas deferens should be used as a guide to separate the bottom of the bladder, lift the distal end of the vas deferens and the ureteral stump, and separate the bladder, seminal vesicle and its jugular abdomen, prostate and rectum after the seminal vesicle. The lateral ligaments should not be clamped too close to the bladder wall, as this can damage the bladder and increase the risk of tumor spread. Once the bladder is broken, after cystectomy, flush the pelvic cavity with a large amount of distilled water to reduce the possibility of tumor implantation.
(v) Damage to cavernous nerves and blood vessels
The following steps are likely to cause injury to the cavernous nerve and vascular bundle: ① when separating and cutting the prostate tip; ② when separating the prostate from the rectum; ③ when separating and ligating the posterior bladder tip and the upper and lower prostate tips; ④ when blindly ligating the urethral bulb artery, which may cause injury to the internal pubic artery and lead to postoperative vascular impotence; ⑤ when removing the membranous urethra, excessive separation and removal of the lateral and posterior lateral tissues of the membranous urethra may damage the cavernous nerve.
The above scenarios are more common, and I hope you will discuss other possible or previously encountered scenarios of this procedure, as well as intraoperative accidents and management of other commonly performed urological procedures! Especially now that the development of cavernous surgery has made everyone more aware in the future. Throwing in the towel! Thank you!
Peritoneal water extravasation during electrosurgery of the prostate
The prostate is sometimes cut through the prostate envelope during electrosurgery, if it continues to flush under high pressure, after a certain period of time there will be extravasation of flushing fluid, which in turn will enter the entire abdominal cavity, causing abdominal distention and respiratory and circulatory dysfunction, so when doing electrosurgery there is a break in the envelope cut, you must pay attention to water extravasation and try to shorten the operating time, pay attention to whether the abdomen is distended, whether the anal canal and rectal mucosa is turned out and protruding, the patient If the patient is irritable and distended, these conditions indicate that there is extravasation of water, which requires late laparotomy and clear liquid, the electrodes should be suspended immediately and the suprapubic abdominal incision should be made to remove and drain the intra-abdominal or/and extra-peritoneal fluid, this process must be fast, otherwise there will be water intoxication and respiratory and circulatory dysfunction, endangering the patient’s life.
Urethral preserving prostatectomy
I. Surgical field bleeding
1. Causes and prevention of bleeding
The blood supply to the prostate comes from the subbladder, middle hemorrhoid and internal pubic arteries, with the former predominant. Suture ligation of the prostatic artery can reduce surgical field bleeding. Due to poor exposure, if only the prostatic vein is sutured and the artery is not tied, it can cause bleeding during stripping. Therefore, attention to separating the prevascular fatty layer and ligating the arteries together can significantly reduce bleeding.
Injury to the anterior prostatic plexus and lateral venous plexus is the most common site of bleeding. Because of the deeper operative field and the fat covering the angry veins, blind suturing can often cause uncontrollable bleeding. Therefore, gentle removal of the fat layer, clear exposure of the venous plexus, selection of suture needles of suitable size, thickness and curvature, and accurate and reliable needle entry are the keys to prevent bleeding.
2.Handling of bleeding
(1) bleeding when suturing the blood vessels, mostly venous bleeding, compress the bleeding point with a small gauze block and suture again at its distal end to stop the bleeding, if necessary, cut the prostatic pubic ligament to expose the distal end of the bleeding vein, which can be sutured smoothly.
(2) Bleeding from the perineal margin of the prostate, the distal margin is mostly venous bleeding and can be stopped by re-stitching with its distal end. The proximal side is mostly a small artery from the bladder neck, which can be sutured with the proximal side.
If the prostatic fossa bleeds, the prostatic artery is not completely sutured, and then sutured at the junction of the bladder and prostate, it can obviously stop bleeding; if there are still bleeding points, the local ligature, electrocoagulation, bleeding with hemostatic sponge, hemostatic spirit can be solved, but the prostatic peritoneum should not be sutured, in order to prevent a small amount of blood clots compressing the urethra, affecting urination.
Second, urethral injury
1, the cause of urethral injury
(1), prostate segment urethra with the glandular tissue hyperplasia and widening, deformation, its cross-section often into a star-shaped protrusion between the glandular nodules (Figure 12), when the dissection of the urethra traction gland, and glandular nodules between the adhesion can be lifted into a curtain away from the catheter, and even up to 2cm or more, easy to be accidentally injured. (Figure 16)
(2) The prostate segment of the urethra has no spongy body, very little muscle layer, only mucosa and a little submucosa loose connective tissue, very fragile, blunt stripping and traction force is easy to be torn. The micro blue mucosa and the urethral catheter are visible after the injury and are easily detected.
(3), hyperplastic prostate in the urethra before and after, left and right asymmetric, the urethra can be squeezed and pushed by the gland, anatomical identification and injury.
2, prevention of urethral injury
(1) When dissecting the anterior union of the gland longitudinally, touch the retained Foley catheter while cutting to prevent injury to the urethra.
(2) When dissecting deeper, suture the traction line while cutting to clearly reveal the urethra. At the same time, the urethra should be thought of and identified as widened and lifted into a curtain shape to prevent injury.
(3) Do not bluntly peel the urethra, because the urethral mucosa is thin and easily peeled.
(4) The anatomical level is correct and should be dissected sharply between the gland and the loose connective tissue under the urethra mucosa, which can effectively prevent urethral injury.
(5), during dissection of the urethra, attention should be paid to the gland extrusion pushing the urethra to prevent injury during separation. When the back of the urethra and the gland have not been separated and the catheter is retained, the posterior wall is relatively fixed and the traction force forward to both sides is not too great to prevent tearing of the urethra.
3.Treatment of urethral mucosa injury
Once the urethra is injured, first of all, traction should be prevented to continue to expand the fissure; intermittent or continuous sutures with 5-0 intestinal thread, appropriately extend the retention of Foley catheter time, such as the urethra posterior wall injury is not easy to suture, the catheter can be retained for 5 days, does not affect the surgical results.
Bladder neck mucosal injury
1, the cause of bladder neck mucosal injury
(1), poorly exposed, not completely separated under direct vision, especially when dissected upward between the middle lobe and the bladder neck, not well exposed, easy to accidentally injured.
(2) The mucosa is fragile and easily torn by blunt peeling.
(3) When the middle lobe is tracted downward, the mucosa of the bladder neck in front of it tends to crumple into a mass, which is also a cause of easy misinjury. Once the bladder is injured, it often flows a small amount of clear urine, which should be noted for further examination.
2, bladder neck mucosal injury
Prevention and prevention of urethral injury the same, that is, good exposure, correct separation level, sharp dissection, traction do not force outside, should pay attention to.
(1) The order of stripping is to first sharply dissect the bladder mucosa in front of the middle lobe gland, separate the bladder mucosa, and then strip the gland from the posterior peritoneum. If the gland is first peeled between the gland and the posterior peritoneum and the finger is used to lift it forward, it is easy to damage the mucosa of the bladder neck on both sides of the middle lobe, especially in the huge middle lobe. Modified Ⅰ style peeling upward from behind the pubic bone or modified Ⅱ style peeling downward through the bladder should be done in this order, which can effectively prevent mucosal injury of the neck.
(2), dissect the bladder mucosa upward via the posterior pubic bone and traction downward on the middle lobe glands, the mucosa is often folded into a mass, which is not easily identified and exposed, to prevent injury to the bladder mucosa for exposing the upper edge of the middle lobe and pulling upward with force with a small pulling hook.
3, treatment of bladder neck mucosal injury
When dissecting upwards via the posterior pubic bone, a little urine is found to flow out, that is, it has been damaged, and often it is not easy to find the rupture. After excision of the gland, saline is injected from the catheter and the bladder neck is gently pulled downward to find the rupture and repair it.
Fourth, ureteral orifice injury
Although ureteral orifice injury has not been reported, attention should be paid to prevent injury. If the middle lobe of the prostate is hyperplastic and protrudes upward into the bladder for more than 5 cm, its upper edge exceeds the ureteral orifice, if the forward protrusion into the bladder is predominant, the ureteral orifice is mostly located in the posterior groove of the hyperplastic middle lobe, and it is less likely to damage the ureteral orifice by postpubic resection. If upward protrusion of the middle lobe is predominant, the ureteral orifice can be squeezed and pushed and located in the posterior wall of the middle lobe, or even apically, or individually in the anterior wall, and the lower part of the ureter can be touched during separation. Therefore, modified type II should be used to prevent damage to the ureteral orifice and its lower segment, and if it is free, a stent tube should be placed if necessary.
V. Other intraoperative injuries
In cases of prostatic hyperplasia combined with chronic inflammation, it is difficult to peel off the adhesions between the gland and the posterior peritoneum. In some cases, it has been reported that the posterior peritoneum is damaged by the separation of the seminal vesicles and rectum. Therefore, for those with significant inflammation, TURP is appropriate.
Postoperative complications and other problems]
The postoperative complications after urethral resection are significantly less than those after non-urethral resection and TURP.
1. Postoperative difficulty in urination Postoperative difficulty in urination is extremely rare and may have the following causes
(1) After resection of the hyperplastic middle lobe, the front bladder mucosal flap obstructs the bladder neck of the prostate middle lobe protrudes into the bladder 3 to
If the Foley catheter is removed earlier, the mucous membrane is not yet healed with the posterior prostatic tegument, which can lead to interruption of urinary flow and difficulty in urination. The Foley catheter should be kept for 5 to 6 days after surgery for those who have obvious enlargement of the middle lobe into the bladder, and the water bladder should be filled up to 30 ml so that the free bladder mucosa can be adhered to the posterior tegument. The modified type II can be used to remove the excess bladder neck mucosa under direct vision, effectively preventing the resulting difficulty in urination.
(2) Blood accumulation in the prostatic fossa and encapsulation of this section of the urethra, mechanization and scar contracture cause dyspareunia when the prostate
The prostate fossa still has a little blood seepage after prostatectomy, which should be stopped as thoroughly as possible and the prostate peritoneum should not be sutured to facilitate drainage. If the prostate fossa is still bleeding a little bit after the prostatectomy, try to stop the bleeding completely and do not suture the prostate peritoneum to facilitate drainage. The first step is to perform urethral dilatation, and if this is not effective, transurethral resection is feasible.
2, prostate enlargement recurrence problem
The recurrence rate after urethral resection of the prostate is slightly higher than that of transcystic prostate removal. It may be related to preserving a little glandular tissue next to the urethra in order to protect that section of the urethra from injury. Therefore, complete removal should be done as much as possible. Generally, when people are reviewed more than 5 years after surgery, it is found by rectal examination and ultrasound, but most of them have no conscious symptoms. If symptoms such as thin urine stream and poor urination occur, medication can be given and TURP or open surgery can be performed if necessary.
3.Prostate cancer problem
Postoperative pathological finding of prostate cancer, although rare, should attract the attention of clinical work. Preoperatively, in addition to finger diagnosis, imaging and PSA examination, puncture histological examination is performed if necessary. If prostate cancer is confirmed, radical prostatectomy is performed without Madigan surgery. If the prostate tissue is peeled off during surgery, the following conditions should be highly noted: uneven hardness and softness of the nodule; surface is not smooth; local adhesions with the peritoneum are obvious; the tissue is fragile and can be easily broken when separated, etc. If the nodule is confirmed to be prostate cancer, it should be sent to frozen section in time, and radical resection should be performed instead. Postoperative pathology confirmed as incidental prostate cancer, although more limited, should also perform debulking surgery, oral flutamide, etc. If necessary, treatment such as estradiol phosphate nitrogen mustard should be given.