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ARTICLES |
SELF-RETRACTION CLAMP FOR DISSECTION OF THE POSTERIOR PROSTATIC FOSSA DURING
RADICAL RETROPUBIC PROSTATECTOMY
Aria F. Olumi, M.D.
Brigham & Womenís Hospital, Harvard Medical School
Boston, MA 02115
Introduction
Dissection of the posterior prostatic fossa is a critical part of radical retropubic
prostatectomy (RRP). Two main goals during this portion of surgery are 1. to identify
the correct plane on the anterior wall of the rectum to ensure all layers of Denonvilliers
fascia are excised, and 2. to avoid trauma to the neurovascular bundle 1.
After resection of the anterior urethra, the Foley catheter is brought through, clamped
and divided, followed by incision of the posterior urethral wall. With the aid of
a hemostat clamp on the divided Foley catheter, the prostate is retracted cranially
to dissect the lateral pelvic fascia and identify the neurovascular bundle. However,
manual cranial retraction of the prostate is imprecise; too much retraction can damage
the neurovascular bundle, and too little retraction does not delineate the fascial
planes between the prostate and the rectum. Therefore, a self-retraction prostate
clamp was designed to enable the surgeon to apply constant traction on the Foley
catheter during dissection of the posterior prostatic fossa during RRPa.
Technique
The clamp is divided into three portions, segments A and B connected by a 20
cm ball-bearing chain(Figure
1). Prior to resection of the Foley catheter, the catheter is clamped with segment
A of the retraction device. Segment A of the retraction clamp secures the catheter
without sliding and the toothed segment (arrow
Figure 1) limits the maximum applied pressure on the Foley catheter in order
to avoid damaging the balloon port. Segment B is attached to the Bookwalter ring
or the Balfour retractor. The tension on the chain is adjusted by cocking the ball-bearing
chain in the notched screw of segment B (dashed arrow Figure
1, and Figure 2). By
using the self-retraction device, the clamp is adjusted on the Bookwalter or the
Balfour ring only twice (once for each posterior prostatic pedicle). The rest of
the adjustments simply are by varying the length in the "ball-bearing"
chain as the dissection of the posterior prostatic fossa is continued cranially.
The length of the ball-bearing chain is adjusted to vary the applied traction on
the lateral pelvic fascia and the neurovascular bundles, as resection of the prostate
gland proceeds cranially. In addition to applying constant steady traction on the
posterior prostate gland during RRP, this traction device frees the surgeonís hand
from manually retracting the Foley catheter.
Conclusion
In conclusion, a self-retraction clamp has been designed to apply constant steady
traction on the prostate gland during dissection of the posterior prostatic fossa.
The constant adjustable traction delineates the surgical planes between the prostate
and the rectum. In addition, the surgeonís hand is freed from manually retracting
the Foley catheter during dissection of the posterior prostatic fossa.
Reference
1. Walsh, P.C.: Anatomic Radical Retropubic Prostatectomy: In: Campbell's Urology
7th edition. Edited by P. C. Walsh, A. B. Retik, T. A. Stamey, and E. D. Vaughan
Jr., Philadelphia: W. B. Saunders, vol. 3, chapt. 86, pp. 2565-88, 1997.
a The prostate self-retraction clamp can be purchased from: J Hugh
Knight Instrument Company, 226 S. Villere St., New Orleans, LA 70112, (504) 524-2797
