RU2305505C1 - Radical surgical treatment method for treating localized prostate carcinoma cases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out radical prostatectomy and lymphadenectomy with single perineal section. Prostate traction and mobilization is carried out with device having rods in handle. The rods have blade-like working ends. Pelvic lymphadenectomy is carried out in turn on both sides. Perineal muscles are deflected aside. Endopelvic fascia right half is separated. Fat cellular tissue adjacent to obturator fossa is separated under visual control. The obturator nerve, exterior iliac vein and exterior iliac artery are exposed in turn. Lymphatic nodes are isolated and removed. Urinary bladder cervix is formed and urethral anastomosis is created.

EFFECT: enhanced effectiveness of treatment; reduced risk of intraoperative and postoperative complications; accelerated operation process; avoided disease recurrence.

Description

The invention relates to medicine, namely to urology, methods of surgical treatment of patients with localized prostate cancer.

Prostate cancer (PCa) is one of the most widespread malignant neoplasms in men, which is a significant social and medical problem. In terms of the growth rate of the incidence of prostate cancer, it is in second place (31.4%), behind skin cancer (35.0%). The increase in the standardized incidence rate (world standard) in the Russian Federation for the period from 1991 to 2000 amounted to 64.4%. In just the next three years from 2001 to 2004, this indicator grew to 86.31% (Chisov V.I., Starinsky V.V., Petrova G.V. Malignant neoplasms in Russia in 2004. - M.: FGU MNIII im P.A. Herzen, Roszdrav, 2006).

The result of surgical treatment largely depends on the correct choice of access, which should provide an adequate safe approach and maximum overview of the surgical field. Currently, radical prostatectomy (RPE) from the posterior and perineal accesses is the main treatment for localized prostate cancer (Petrov SB, Veliev EI, Shpilenya ES, Goryacheva IA. Modern problems of diagnosis and treatment cancer of the prostate gland. // Bulletin of Surgery named after I.I. Grekov. - 1998. - 157 (5). - P.44-8).

A known method of radical surgical treatment of patients with localized prostate cancer (Walsh P.C., Worthington J.F. Dr Patrick Walsh's Guide to Surviving Prostate Cancer // Warner books-New York. - P.229-37). The method consists in removing the prostate and pelvic lymph nodes from the posterior approach. The operation is performed under endotracheal anesthesia. A lower midline posterior incision is made on both sides in the region of the obturator fossae and pelvic lymph nodes are isolated and removed along the external iliac vessels. Subsequently, after dissection of the endopelvic fascia and mobilization of the dorsal venous complex, lateral lobes of the prostate gland are isolated. A mobilized prostate gland, together with seminal vesicles, is crossed and removed in the cystic prostatic area, followed by a vesicalization of the bladder neck and the application of a vesicourethral anastomosis. After application of the vesicourethral anastomosis, the surgical wound is sutured with active drainage in the region of the obturator fossae.

The disadvantage of this method is that its use is limited: in patients with overweight (with a body mass index of 40 kg / m or more) due to significant technical difficulties in mobilizing the dorsal venous complex and imposing a vesicourethral anastomosis; in patients who underwent numerous operations on the organs of the abdominal cavity; in the presence of vascular prostheses of the iliac arteries that increase the risk of intraoperative injury (Dahm P., Yang BK, Salmen CR, Moul JW, Gan TJ Radical perineal prostatectomy for the treatment of localized prostate cancer in morbidly obese patients // J. Urol. - 2005. - V.174, No. 1. - P.131-134.). The high cost of this surgical intervention plays an important role (Silverstein AD, Weizer AZ, Dowell JM, Auge BK, Paulson DF, Dahm P. Cost comparison of radical retropubic and radical perineal prostatectomy: single institution experience // Urology. - 2004. - V. 63, No. 4. - P.746-750). Lateral access is the most traumatic. According to the literature, in the study of 2 groups of patients after perineal and posadilon RPE, no significant difference in the quality of life was revealed. Meanwhile, the average values of a clinical study - blood loss during surgery, the duration of analgesics, the time to return to a normal diet, showed the benefits of perineal versus lateral access (Sullivan LD, Weir MJ, Kinahan JF, Taylor DL A comparison of the relative merits of radical perineal and radical retropubic prostatectomy // BJU. - 2000. - V.85, No. 1. - P.95-100).

There is also known a method of radical surgical treatment of patients with a localized form of prostate cancer, proposed by Japanese surgeons (Saito S., Murakami G. Radical perineal prostatectomy: a novel approach lymphadenectomy from perineal incision // J. Urol, 2003 Vol.170. - P. 1298-1300), including laparoscopic removal of the obturator and external iliac lymph nodes and radical prostatectomy from the perineal access. The method is based on dilatation of the intrathoracic space with subsequent laparoscopic pelvic lymphadenectomy with the release of neurovascular elements and dissection of the lymph nodes in the region of the obturator fossa, along the external iliac vessels. In this case, the pancreas is not removed, but taken to the side, which significantly reduces the operational review and limits the area of the surgical field. As the authors themselves note, this complicates lymphadenectomy, sharply increases the duration of the operation and the likelihood of intraoperative injury. In addition, the technique is technically laborious and difficult to perform.

As the closest analogue, a method of radical surgical treatment of patients with localized prostate cancer was adopted (Salomon L., Hoznek A., Lefrere-Belda MA, Bellot J., Chopin DK, Abbou CC Nondissection of pelvic nondes does not influence the results of radical perineal prostatectomy in selected patients // Eur. Urol. - 2000. - Vol. 37, No. 3. - P.297-300). The method includes a radical prostatectomy from the perineal access and laparoscopic posterior pelvic lymphadenectomy. Under combined anesthesia (cerebrospinal anesthesia and endotracheal anesthesia), a laparoscopic pelvic lymphadenectomy is performed on the patient from the backward access. After the stage of laparoscopic back-end pelvic lymphadenectomy, the patient on the operating table is transferred to the position for performing perineal radical prostatectomy: the legs are bent at the hip and knee joints, the pelvis is thrown back so that the perineum plane is as parallel as possible to the plane of the operating table. Subsequently, radical prostatectomy is performed from the perineal access: isolation, mobilization of the prostate gland and its removal, the formation of the neck of the bladder and the imposition of a vesicourethral anastomosis.

The disadvantage of this method is the need to perform additional suprapubic access. With a high probability of metastasis to the pelvic iliac lymph nodes (Gleason sum ≥7 and / or PSA level> 11 ng / ml), the patient is additionally performed suprapubic laparoscopic pelvic lymphadenectomy, which significantly increases the duration and invasiveness of the operation, increases the risk of intraoperative trauma and postoperative complications, which worsens the prognosis of the disease in this category of patients. Thus, the question of developing a technique for performing radical prostatectomy and pelvic lymphadenectomy from one perineal access, which is the most physiological, remains relevant.

The objective of the invention is to provide a method for the radical surgical treatment of localized pancreatic cancer, which has broad functional capabilities, which allows to reduce the number of intra- and postoperative complications, reduce the duration of the operation and prevent the occurrence of relapses.

Using the invention allows to obtain the following technical result.

The method allows from one perineal access, which is the most physiological and preferred, to perform all stages of the radical surgical treatment of localized prostate cancer, prostatectomy, lymphadenectomy, the formation of the bladder neck and the imposition of a vesicourethral anastomosis without risk associated with insufficient output from the pelvis, factors , which may adversely affect the results of the operation or during the course of its implementation to change surgical tactics.

Moreover, the tactics developed by the authors and the sequence of execution of all stages of the operation allow it to be performed in the most optimal volume. The developed technology makes it possible to reduce the complexity and facilitate the course of surgery, to reduce its duration by at least 1 hour.

Trauma to tissues and the possibility of damage to the neurovascular elements of the obturator fossa are minimized, which reduces the risk of intra- and postoperative complications associated with this, and avoids blood loss. The postoperative period for the patient proceeds most smoothly and comfortably.

The method has the widest functionality. It can be used to treat patients with overweight, weighed down by the presence of vascular prostheses of the iliac vessels, who underwent numerous operations on the organs of the abdominal cavity.

The technical result is achieved by performing all stages of the operation from one perineal access, as well as the sequence of stages and technology of surgical techniques from this access proposed by the authors.

Surgery from one perineal access became possible due to the relationship established by the authors between the size of the exit from the pelvis and the type of physique.

It was found that the largest sizes of exit from the small pelvis in individuals with a brachymorphic body type, the smallest - in individuals with a dolichomorphic type with a statistically significant Student t-test (p <0.05% 95% significance level).

The correlation analysis showed a statistically significant inverse correlation: a change in the size of the exit from the pelvis, depending on the type of physique. The indicated regularity was established by the authors on the basis of the results of anatomical and topographic examination of the prostate gland, neurovascular bundles, external iliac lymph nodes, taking into account the data of anthropometry studies carried out on 20 male corpses, as well as data from clinical, laboratory, histomorphological and anthropometric studies of 11 patients, selectively selected for perineal radical prostatectomy and pelvic lymphadenectomy. The studies were carried out with the aim of developing the surgical tactics of lymphadenectomy from the perineal access, during which the indicated dependence was unexpectedly revealed.

The method developed by the authors can be applied in individuals with a brachymorphic and mesomorphic type of physique, which are large enough for a successful operation without risk of complications of the small pelvis. Persons of a dolichomorphic body type having the smallest exit sizes from the small pelvis, this operation is contraindicated in the proposed method. When performing an operation in individuals of this type of physique, the operational review and the area of the surgical field are significantly reduced, which dramatically increases the risk of intraoperative injury. Preliminary determination of the patient’s body type and, accordingly, the size of the exit from the pelvis allows determining indications or contraindications for the operation, excluding it for persons of the dolichomorphic body type. This makes it possible to choose the appropriate tactics for the operation for the patient, depending on his constitution. At the same time, the operation according to the proposed method in persons with sufficient sizes of exit from the pelvis provides a favorable prognosis and a good clinical result.

For the first time, the following sequence of operations was proposed from one perineal access: first, a prostatectomy is performed, then a lymphadenectomy, and then the formation of the bladder neck and the application of a vesicourethral anastomosis.

Performing a prostatectomy before lymphadenectomy, which precedes the stage of formation of the bladder neck and imposing a vesicourethral anastomosis, allows maximizing operative visibility, greatly facilitating access to the lymph nodes of the external iliac vessels and obturator fossa, carefully performing lymphadenectomy, significantly reducing the duration and morbidity of the operation, and reducing the number of operations postoperative complications.

Implementation of traction and mobilization of the prostate gland using a device previously developed by the authors provides optimal conditions for its isolation, reduces the complexity of this procedure, reduces trauma and excludes the possibility of intraoperative bleeding from the dorsal venous complex due to damage during prostate secretion. Along with this, the necessary mobility of both its lobes is created, which greatly facilitates the process of its mobilization, and subsequently the allocation of lymph nodes of the external iliac vessels and the obturator fossa.

After removal of the prostate gland, the perineal muscles are set aside. Lymphadenectomy begins on the right side of the surgical wound, the right half of the endopelvic fascia separating the perineum from the pelvic cavity is separated. Due to the high risk of damage to a part of the trunk of the obturator nerve closely adjacent to the fascia, the authors developed a new technique: dissection of the endopelvic fascia is performed from the edge to the center, which reduces damage to the obturator nerve. Further, the selection and dissection of the elements of the obturator fossa are performed in a certain sequence proposed by the authors: first, the obstructive nerve is isolated, then the external iliac vein and the external iliac artery. This allows you to remove the obturator nerve, which is located somewhat anteriorly and laterally with respect to the external iliac vessels, which facilitates access to the vessels and thereby reduces the likelihood of damage to them. A prerequisite for performing these techniques is visualization - clear visual control of the surgical field, which helps prevent intraoperative injury.

All the above methods of the proposed method can improve the results of surgical treatment of patients with localized forms of prostate cancer in the form of reducing the number of complications, relapses of the disease and improving the quality of life of patients after surgery.

The method is as follows.

Prior to the operation, the type of physique of the patient is determined by anthropometric studies.

Assessment of body type is carried out by determining body indices: relative body length index (IODT) - the percentage of the distance from the jugular notch to the bosom to the body length; the relative width of the pelvis (IOSHT) - the percentage of the width of the pelvis to the length of the lower extremity, measured from the crest point to the calcaneal tuber; relative shoulder width index (IOS) - the percentage of shoulder width relative to body length.

The value of the indices for the mesomorphic type of physique is - X + Sx, for the brachymorphic type> X + Sx, for the dolichomorphic type <X + Sx, where X is the arithmetic mean of the index in the group, and Sx is the arithmetic mean error.

The objectivity of the obtained index values: IODT, IOSHT, is additionally controlled by comparing them with the Brugsch index - the percentage of the circumference of the chest to the length of the body. In individuals of the mesomorphic, dolichomorphic and brachymorphic types, the Brugsch index is respectively 50-55%, <50% and> 55% (Bunak V.V. Normal constitutional types in the light of data on the correlation of individual signs. // Scientific notes of Moscow State University. - Ed. Moscow State University - 1940. - Issue 34. - P.101; Anthropometry. - M .: Uchpedgiz, 1971. - P.368).

Perineal radical prostatectomy and pelvic lymphadenectomy from one perineal access are performed when a patient has a mesomorphic or brachymorphic physique. Persons with these types of physique have sufficient output from the pelvis, which can significantly reduce the risk of trauma, intra- and postoperative complications, successfully perform the operation and obtain a stable clinical effect.

Persons with a revealed dolichomorphic body type, having, in accordance with the regularity established by the authors, the smallest sizes of exit from the small pelvis, insufficient for the possibility of radical prostatectomy and pelvic lymphadenectomy from one crotch access, it is contraindicated.

The operation is performed under combined analgesia: cerebrospinal anesthesia and endotracheal anesthesia.

One of the main requirements for successful operation is the correct placement of the patient on the operating table.

The patient is placed in a supine position so that when the legs are bent at the hip and knee joints and the pelvis is raised, the plane of the crotch is as parallel as possible to the plane of the operating table. To do this, put supports under the legs, and a roller under the basin. The bend angle between the plane of the operating table and the plane of the pelvis should be at least 60 °.

The operation is carried out in a certain sequence. First, a radical prostatectomy is performed.

The anus area is isolated with a special sterile sticker with a rubber fingertip, which is inserted into the rectum for subsequent manipulations. The Katadzhel gel is injected into the urethra. A long Yang or Lousley retractor is inserted through the urethra into the bladder so that its angle is located in the onion section of the urethra and is palpated at the apex of the prostate gland. The second assistant holds the retractor with his right hand.

Using a cross-finkler access (Young's access), a U-shaped perineal incision is made, drawing it inside from the subcutaneous, superficial and deep parts of the external anal sphincter, using sciatic tubercles as reference points. Grabbing the tip of the formed skin flap with an Allis clamp, cut the surface fascia along the incision line with an electric knife. As a guide, the angle of the retractor located in the bulbous section of the urethra is palpated. At the base of the flap, in the area of the wound angles, index fingers on both sides of the incision penetrate through the superficial perineal fascia into the sciatic-rectal fossa to a depth of 3.5 cm under the external anal sphincter in the upward and anterior directions along the rectum wall, which is crossed by an electric knife, exposing the rectum wall guts. Then the index finger is inserted through the fingertip into the rectum, under its control, the external anal sphincter is dissected from the rectal fascia. By removing the fibers of the muscle that raises the anus, to the sides and upwards, they continue to isolate the wall of the rectum to the rectal-urethral muscle located in the midline. A long prostatic retractor is advanced into the bladder, its lobes are bred.

The prostate is removed into the wound, palpation determining the apex of the gland. The wall of the rectum is separated with a blunt and sharp path. They capture the rectal-urethral muscle with tweezers, exposing the surface of the fascia of Denonville, covering the prostate near the apex. Vascular scissors cross the junction of the muscle with the wall of the rectum.

The back leaf of the fascia of Denonvilliers, along which the neurovascular bundles pass, is separated from the front leaf.

After dissection of the fascia, Denonvilliers secrete the lateral surface of the prostate gland.

In the area of the urethral-prostate zone, by palpating the retractor, a pelvic fascia is cut into a vertical section to the proximal part of the membranous part of the urethra. In the area of the prostate apex, urethra is excreted. The long retractor is removed. The proximal part of the urethra is crossed. Then, through the prostatic end of the crossed urethra, a device for traction and mobilization of the prostate gland (RU 50099, IPC: АВВ 17/00, 2005) is introduced into the bladder cavity, containing a handle with three rods installed in it, the working ends of which are made in the form of lobes, two side rods are mounted rotatably around their axis and provided with handles. The blades are moved apart with the help of handles so that they are tightly in contact with the base of the prostate gland, as if capturing it. Holding the handle, the prostate gland is tightened. The manipulation is repeated until the lateral lobes are fully mobilized. After that, the blades are folded using the handles, and the device is removed.

On the urethra through the prostate, a dissector is brought to the neck of the bladder and a mucous membrane is cut above it. The clamp captures the end of a soft rubber catheter with a diameter of 14-16F and pulls it through the urethra. The ends of the catheter are clamped in the form of a “catheter loop”, and subsequently used for traction of the prostate.

After mobilization of the dorsal surface of the prostate and exposure of the base of the seminal vesicles (SP) and the vas deferens using the "catheter loop" produce their selection. The vas deferens cross and ligate, thereby increasing the mobility of the prostate.

Dull and sharp way produce mobilization of seminal vesicles to the proximal sections. In the area of the apex of the seminal vesicles, clips are applied to the vesiculate arteries. Make the intersection of the neck of the bladder at its junction with the prostate gland. Bleeding from small vessels is stopped by dressing and / or coagulation. An examination of the mucous membrane of the bladder is carried out and the localization of the mouths of the ureter is determined. With difficult visualization of the mouths, the anesthesiologist intravenously injects 5 ml of indigo carmine, or catheterizes them, after which the fully isolated prostate gland is removed with seminal vesicles.

After this, pelvic lymphadenectomy is performed, they begin on the right side. The perineal muscles are pulled to the side with hooks compatible with the Omni-tract retractor. The right half of the endopelvic fascia, which separates the perineum from the pelvic cavity, is separated with a blunt and sharp path. At the entrance to the pelvic cavity under visual control, its dissection is performed, the adjacent part of the obturator nerve is isolated, which is taken away literally. Then, under the strictest visual control, the pelvic fatty tissue adjacent to the obturator fossa is separated. Its individual elements are exposed and sequentially extracted (thoroughly and in detail): the obturator nerve, the external iliac vein and the external iliac artery. The obturator nerve is diverted somewhat laterally. After that, lymph nodes are sequentially isolated and removed - at the beginning along the external iliac vessels, then - in the region of the obturator fossa.

Similarly to the above technique, lymphodissection of the external iliac lymph nodes on the left side is performed.

After performing perineal pelvic lymphadenectomy, the final stages of the operation are continued - the neck of the bladder is formed and the urethroscopic anastomosis is applied.

Alice clamp is applied to the posterior lip of the bladder with the help of which it is lifted and the front leaf of the fascia of the seminal vesicles is exposed. A silicone Foley 20-22F catheter is passed through the external opening of the urethra and brought out through the crossed end of the distal urethra and grab both ends with a soft clip. With the help of the loop formed, the urethra is tightened so that the posterior semicircle of the membranous part can be seen. Given the fact that the diameter of the opening of the cystic neck is larger than the urethra, the neck of the bladder is formed - it is sutured vertically, similar to the "racket handle" with its subsequent vesicalization.

According to the imaginary dial, 6 sutures for the vesicourethral anastomosis are placed on the formed bladder neck and the intersected detailed part of the membranous urethra according to the imaginary dial: at 13, 17, 19, 21 and 24 hours and they are taken onto the holders using soft mosquito-type clamps.

A silicone Foley 18-20F catheter is inserted into the bladder cavity. Foley catheter balloon is filled up to 15-20 ml. Under visual control, carefully without tension, pull the neck of the MP to the distal end of the urethra, begin to sequentially tie the sutures of the vesicourethral anastomosis from the posterior semicircle.

At the end of the operation, for control, through the Foley catheter, the bladder is filled and checked for leaks. If necessary, impose additional seams.

Control for hemostasis and integrity of the rectal wall. Active drainage is established in the area of the anastomosis, which is removed through the corner of the wound. Sutured by interrupted sutures of the edge of the muscle that raises the anus. The tendon center is sutured. Subcutaneous tissue is brought together by several interrupted sutures. Metal staples are applied to the skin using a mechanical skin stapler. A gauze dressing is applied to the wound, which is fixed with a special adhesive film.

Example: Patient L., 67 years old, was admitted to the hospital of the Urology Clinic to perform a transrectal multifocal biopsy due to an elevated level of blood PSA to 6.54 ng / ml.

From concomitant diseases: ischemic heart disease, atherosclerotic cardiosclerosis, GB 2 tbsp. Data on pathology from the respiratory system and musculoskeletal system were not identified.

Mesomorphic body type.

Assessment of body type was carried out by determining body indices: IODT, IOSHT and IOSHP.

Mesomorphic body type = X + Sx

Body type objectivity was additionally controlled by comparing the values of the IODT, IOSH T, and IOSHP indices with the Brugsch index (V.V. Bunak Normal constitutional types in the light of data on the correlation of individual characteristics. // Uchenye zapiski MSU. - Ed. Moscow State University - 1940. - issue 34. - P.101; Anthropometry. - M .: Uchpedgiz, 1981. - P.368).

The Brugsch index is equal to 53%.

On examination: no complaints. The condition is satisfactory. Proper mesomorphic physique, moderate nutrition. The skin and visible mucous membranes are clean, normal in color. In the lungs, vesicular breathing is carried out in all departments. NPV - 18 per min.

HELL 130/90 mm Hg Pulse - 72 in 1 min. Heart sounds are muffled, rhythmic. The tongue is wet, clean. The abdomen is enlarged due to subcutaneous fat. In the right iliac region, the postoperative scar is up to 6 cm. On palpation, the abdomen is soft, painless. There are no symptoms of peritoneal irritation. Peristalsis is sonorous. The bowel movement is normal.

The kidney area is not changed. The kidneys are not palpable. Palpation of their area is painless on both sides. The symptom of striking is negative. Diuresis is adequate. Organs of the scrotum without features.

Rectal: sphincter in good shape. The gland is painless, moderately enlarged, elastic consistency, with a clear contour. The interlobar groove is smoothed, the mucosa above the gland is mobile. In the right lobe on the periphery, a focus of compaction is determined up to 2.5 cm, the mucous membrane above the focus is mobile.

Fluorography - pathological changes in the lung tissue and heart were not detected. The function of external respiration (HFD) - indicators of personal ventilation are normal.

Ultrasound of the abdominal cavity and urinary system

Liver sagittal size - 121 mm, without focal changes.

The kidneys are of normal shape, the position values are mobile, the contour is wavy, the parenchyma is homogeneous, not changed. Concrements and disturbances of urodynamics are not revealed. A bladder with a clear, even outline. The content is homogeneous in the cavity without additional formations.

Transrectal ultrasound examination of the prostate gland: prostate 44 × 39 × 38 mm. The prostate volume is 35 cm ³ with a clear, even contour, of a homogeneous echostructure; a hypoechoic area is determined along the periphery of the right lobe. With central Doppler mapping in the area of the hyporechogenic area, hypervascularization is determined. Seminal vesicles are intact, without features.

A 12-point transrectal multifocal biopsy was performed on the patient under transrectal ultrasound guidance. A histomorphological study of the biopsy of prostate tissue was carried out in the Department of Pathomorphology of the Research Institute of Oncology. P.A. Herzen.

According to the obtained histomorphological conclusion: 4 columns revealed prostate adenocarcinoma with damage to up to 40% of the tissue of the biopsy column - 3 in the right lobe (2, 3, 5) and 1 (12) in the left lobe. Gleason's sum was 7 = 3 + 4.

According to the results of the examination, the patient was diagnosed with a clinical diagnosis: Moderately differentiated prostate adenocarcinoma kT2cNxM0.

After establishing the final diagnosis, the patient was operated on by the proposed method. The patient was performed simultaneously - in one stage, radical prostatectomy and pelvic lymphadenectomy from the perineal access.

The operation was performed under combined anesthesia: spinal anesthesia and endotracheal anesthesia.

The patient is laid in a supine position so that when the legs are bent at the hip and knee joints and the pelvis is raised, the plane of the crotch is as parallel as possible to the plane of the operating table. To do this, stands are placed under the legs, and a roller under the basin.

According to the initially proposed method, the prostate gland was mobilized and removed. Then the lymph nodes of the external iliac vessels and obturator fossae were removed on both sides. After performing perineal pelvic lymphadenectomy, the final stages of the operation were continued: the formation of the bladder neck and the application of the urethroscopic anastomosis.

This method was applied at the 20th urological department of the City Clinical Hospital named after S.P. Botkin in the treatment of 11 patients with localized prostate cancer. The observation period ranged from 3 months to 1.5 years. The use of this method provided optimal conditions for the isolation of the prostate gland and external iliac lymph nodes, which reduced the complexity of the operation and also reduced the time of the operation and minimized the trauma of the surrounding tissues of the surgical wound and the number of intra- and postoperative complications.

The duration of the operation was 150 minutes. Blood loss - 300 ml.

There were no intra- and postoperative complications.

The postoperative period was uneventful. The patient is activated on the first day after surgery. Prescription of narcotic analgesics was not needed. The patient was discharged 8 days after surgery. The urethral catheter was removed after 2 weeks on an outpatient visit.

The follow-up was 1 year. Relapses were not detected. I did not complain.

Claims (1)

A method of radical surgical treatment of local prostate cancer, characterized in that the patient’s physique is first determined by anthropometric examination and, when a mesomorphic or brachymorphic physique is established, they perform perineal radical prostatectomy and pelvic lymphadenectomy from one perineal access, first they perform radical prostatectomy, whereupon a long retractor is introduced into the bladder, U- through sphincteric access a perineal incision in the perineum, its tendon center is crossed, the rectal wall is secreted to the rectum-urethral muscle, the prostate gland is taken out into the wound, the rectal wall is separated, the surface of the fascia of Denonville is exposed, and after its dissection, the lateral surfaces of the prostate gland are isolated in the urethral-prostate zone the pelvic fascia is dissected vertically to the proximal part of the membrane part of the urethra, it is extracted, the retractor is removed, and the proximal part of the urethra is intersected, p After which, a device for traction and mobilization of the prostate gland is introduced into the bladder strip, containing a handle with three rods installed in it, the working ends of which are made in the form of blades, and two side rods are equipped with handles, with the help of which the blades are moved apart so that they are in close contact with the base of the prostate gland, holding it, holding on to the handle, the gland is pulled up, repeating the manipulation until the mobilization of the lateral lobes is complete, after mobilization of the dorsal surface of the gland and exposure of the base of the seminal vesicles and vas deferens, they are secreted and mobilized, they cross the neck of the bladder at its junction with the prostate gland, the fully isolated prostate gland with seminal vesicles is removed, then lymphadenectomy is performed, starting from the right side, the perineal muscles are taken to the side, right half of the endopelvic fascia is separated, at the entrance to the pelvic cavity under visual control, it is dissected, the adjacent part of the obturator nerve is isolated which is laterally removed, then under visual control the pelvic fatty tissue adjacent to the obturator fossa is separated, its individual elements are exposed and secreted in a certain sequence: first, the obturator nerve, then the external iliac vein and the external iliac artery, the obturator nerve lateral, after which lymph nodes are sequentially isolated and removed: first along the external iliac vessels, then in the region of the obturator fossa, similar m lymphadenectomy manner produce external iliac lymph nodes on the left side, and then perform final stages of operation - the formation of the bladder neck and overlay uretrosheechnogo anastomosis.