Perineal Technique Research Articles

The Endoscopic Perineal Approach to the Presacral Space: An Excision Biopsy

Presacral tumors in adulthood are rare. Several surgical difficulties exist, because of limited access of the presacral area. The patient in this report was a 72-year-old man without comorbidities referred by the urologist because of a presacral mass. Standard diagnostic evaluation disclosed no conclusive diagnosis. The perineal endoscopic approach was used to reach the presacral space. An excision biopsy, using this new technique, was performed to obtain a conclusive diagnosis. This perineal endoscopic excision biopsy was performed without complications. Postoperative pathology showed a lipoma. The patient was discharged in good health 2 days after the procedure. We concluded that this new perineal endoscopic technique is a safe, feasible approach for reaching the presacral space to resect a tumor, acquire a histologic diagnosis of an unknown tumor, or both.

Samenblasenerhaltende radikale perineale Prostatektomie

The early and mid-term oncological and functional results of a seminal vesicle sparing modification of perineal nerve sparing radical prostatectomy (SV-RPP) was compared to the classical perineal (RPP) and retroperitoneal (RRP) approaches. From July 2003 to December 2007, 702 radical prostatectomies (417 RPP, 285 RRP) were performed by 3 surgeons (mean follow-up 17 months, range 0-48 months). RPP was chosen under the following conditions: PSA<10 ng/ml, Gleason sum<7 and volume<50 ml. A seminal vesicle sparing technique (SV-RPP) was used in 47% of the RPPs. With a significantly shorter average operation (OR) time (SV-RPP 90 min, RPP 144 min, RRP 165 min), transfusion rate (SV-RPP 3%, RPP 9.1%, RRP 11.9%) and rate of anastomotic leaks at day 10 (SV-RPP 6.4%, RPP 10.3%, RRP 27.8%) the pT2 positive surgical margin rate with SV-RPP (3.4%) was significantly lower than with RPP (9.6%) and RPP (8.4%). For pT2-R0 tumors PSA relapse>0.2 ng/ml occurred in 12.5%, 13.6% and 8.2%, respectively (not significant). Continence rates (0-1 pad) for SV-RPP were significantly better compared to RPP and RRP after 4 weeks (59.3%, 41.0% and 45.4%, respectively) and 12 months (95.7%, 86.4% and 86.8%, respectively) SV-RPP represents an improved perineal technique with respect to intraoperative and postoperative complications whilst maintaining an oncological outcome comparable to RPP and RRP. Leaving seminal vesicles in situ did not result in increased PSA relapse rates.

Chirurgische Therapieoptionen beim Rektumprolaps - Indikation, Technik und Ergebnisse

Two different approaches can be distinguished in the surgical treatment of rectal prolapse, i. e. the transabdominal route and the perineal procedures. The following article deals with both operative options with a detailed discussion of the Delorme's operation and the perineal rectosigmoidectomy, also known as the Altemeier procedure for the perineal techniques. Regarding abdominal operations simple rectopexy is compared with operations including bowel resection including minimally invasive approaches. In general, perineal procedures for full-thickness rectal prolapse cause less morbidity compared with abdominal operations. They are especially indicated in the elderly and /or high-risk patients. Recurrences, on the other hand, are usually encountered more often following local techniques as compared with abdominal operations. It can be concluded that perineal as well as abdominal procedures remain important options in the surgical treatment of rectal prolapse and should be part of the armamentarium of colorectal surgeons.

Minimal invasive perineal radical prostatectomy

15566 Background: Radical perineal prostatectomy (RPP) has experienced a reappraisal as excellent surgical treatment option for patients with localized prostate cancer which is competing well with the retropubic (RRP), endoscopic and robotic approaches. Herein we report a new and improved minimal invasive technique of an intrafascial, nerve-sparing and seminal vesical sparing RPP. Methods: From July 2003 to July 2006, 507 radical prostatectomies (317 RPP, 190 RRP) have been performed by 3 surgeons. RPP selection criteria: PSA ≤ 10 ng/ml, Gleason sum ≤ 7, volume ≤ 50 ml. A minimal invasive technique (MI-RPP) was used in 146 of 317 RPP (46%) in order to potentially improve on the results of classical RPP. “Minimal invasive” was defined as an approach with reduced mobilisation of the rectum, intended bilateral nerve-sparing with intrafascial preparation and leaving the seminal vesicals in situ. This approach was compared to classical RPP and to RRP. Perioperative and follow-up data using validated questionnaires were centrally registered using an on-line internet-based prostate cancer data bank provided by the Tumorzentrum Berlin. Results: With a median follow-up of 12 months (0–24), the oncological outcome of patients with MI-RPP was not different to RPP or RRP (comparable T-stages). PSA relapse in MI-RPP, RPP, and RRP in pT2R0 was seen in 10.2%, 14.7%, and 9.7% respectively (n.s.). Continence rates (0–1 pad/d) at 4 weeks were 61.7%, 45.0%, and 43.8%, respectively. This improved at 12 months to 96.3%, 85.7%, and 85.6%, respectively (p &lt; 0,023; p &lt; 0,005). MI-RPP, RPP, and RRP showed pT2 in 70.5, 69.6, and 57.3% with R1pT2 in 1.9, 6.7, and 9.2%, resp. Nerve-sparing was performed in 90.4, 62.0, and 57.4% with median OR times of 90, 141, and 163 min. Catheter removal after more than 13 d was seen in 6.6, 13.6, and 33.3%, resp. Conclusions: MI-RPP represents an improved perineal technique regarding intraoperative and postoperative complications maintaining comparable oncological outcome to RPP and RRP. Leaving seminal vesicals in place did not increase PSA relapse rates. Since OR time is significantly less and early recovery is superior, MI-RPP should be the recommended first-line perineal approach to patients with low risk prostate cancer. At the time of the meeting, data of more than 600 patients will be presented. No significant financial relationships to disclose.

Radical Perineal Prostatectomy: Initial Experience of a Single Center and Comparison with the Retopubic Technique

The Authors present a comparison between the first 13 radical perineal prostatectomies performed in their Center and 14 retropubic radical prostatectomies, in order to describe the experience of a group adopting a new technique besides an already acquired one. The age of the patients ranged from 56 to 74 years (mean 67), the mean follow-up was 12 months. Both technique provided a disease-specific survival of 100% and absence of technique-related complicances. The perineal technique implies, at the beginning, worse –- although acceptable –- results as regards continence and erectile function and better results as regards duration of the hospital stay of the patient.

Failed posterior urethroplasty: lessons learned

Objectives To determine the factors contributing to unsuccessful results after posterior urethroplasty and to establish some guidelines for its prevention. Methods From 1977 through 2000, 130 patients (3 to 58 years old) underwent 145 anastomotic urethroplasty procedures for post-traumatic posterior urethral distraction defects. Bulbo-prostatic anastomosis was performed through the perineum in 105 cases and by a perineo-abdominal transpubic procedure in 40. Factors that might have an impact on the surgical result, such as the size and type of sutures, urethral stents, and use of antibiotics were standardized. The records of all patients with unsuccessful results during a follow-up of 2 to 20 years were analyzed. Results Overall, the results were unsuccessful in 12 cases (8%). A negative result was related to incomplete excision of the scar tissue in 3 cases, inadequate fixation of the prostatic mucosa in 6 cases, and anastomotic tension in 2 cases; 1 patient was lost to follow-up. Previous repair, length of distraction defect, and urinary infection had no statistically significant influence on the result. Conclusions The essential operative details of posterior urethroplasty include complete excision of scar tissue involving the membrano-prostatic region, lateral fixation of pliable prostatic mucosa, and creation of a tension-free anastomosis. If a tension-free anastomosis cannot be achieved through the perineum, the perineo-abdominal progressive approach or the elaborated perineal technique should be used at the same setting. Previous repair, a long distraction defect, and urinary infection do not preclude successful posterior urethroplasty.

Radical prostatectomy by the retropubic, perineal and laparoscopic approach: 12 years of experience in one center.

We retrospectively evaluated the oncological outcome of radical prostatectomy performed by the retropubic, perineal and laparoscopic approaches. From 1988 to 2000, 401 patients underwent radical prostatectomy for localized prostate cancer by the retropubic, perineal or laparoscopic approach. Age, clinical stage, preoperative PSA and Gleason score of positive biopsies were noted. Operating time, complication rate, transfusion rate, length of hospital stay, catheterization time and pathological results were reviewed. Kaplan-Meier analysis was used to evaluate the likelihood of biochemical recurrence (PSA > or =0.2 ng/ml). There were no significant differences between the three groups regarding preoperative characteristics, except for PSA (21.4 ng/ml, 13.2 ng/ml, and 11.6 ng/ml for the retropubic, perineal, and laparoscopic approach, p<0.05) and the frequency of stage T1c tumors (31.7%, 47.1% and 63.5%, respectively, p<0.05). The operating time was significantly longer in the laparoscopic approach (285 min) compared to the retropubic and perineal techniques (197 min and 178 min, respectively). The retropubic approach was associated with a higher transfusion rate (26.2% versus 15.9% and 2.9% with the perineal and laparoscopic approaches), longer bladder catheterization time (15.9 days versus 11.7 days and 6.8 days, respectively), and longer hospital stay (15.2 days versus 8.5 days and 7.4 days, respectively) (p<0.05 for each). With the retropubic, perineal and laparoscopic approaches, medical complication rates were 8.3%, 4.2% and 5.1%, and surgical complication rates were 16.5%, 12.7% and 13.1%, respectively. The rates of pathological stage pT2 tumors were 62.1%, 72.2% and 75.9%, in the retropubic, perineal and laparoscopic groups, respectively. Positive surgical margins in pT2 tumors were noted in 19%, 14% and 22%, respectively. The actuarial 3-year recurrence-free survival rates were not significantly different between the three techniques (75%, 85.2% and 84.1%, respectively; 91.7%, 95.8% and 90.4% among patients with organ-confined tumors). Despite changes in patient selection criteria over time, and the relatively short follow-up, this study showed no significant difference in oncologic outcome between the retropubic, perineal and laparoscopic approaches to radical prostatectomy.

Perineal Urethrectomy for Transitional Urethral Tumours in Bladder Cancer Patients

Transitional cell carcinoma is often multicentric in the urinary tract and urethral tumours are not infrequent in bladder cancer patients. The occurrence of urethral carcinoma is simultaneous or recurrent after radical cystectomy. The management of urethral neoplasms and results of 12 simultaneous and 10 post-cystectomy cases treated with perineal urethrectomy are reported. The Authors debate the role of primary and secondary surgical treatment and the perineal or prepubic technique. One case of urethral recurrence after orthotopic bladder substitution emphasizes that patients must be accurately evaluated to exclude urethral disease before cystoprostatectomy, and monitored for carcinoma of urethral remnant.

Surgical treatment of perineal hernia in the dog.

ABSTRACTIn a nine‐year period 101 dogs which were available for subsequent follow‐up studies, were subjected to perineal hernia surgery. In thirty‐six dogs the hernia was bilateral and, therefore, 137 hernias were initially operated. In 111 operations the standard perineal technique was adopted. In twenty‐six operations the superficial gluteal muscle was reflected and sutured into the hernial defect (‘gluteal flap’). Later, following recurrence of hernia or new development on the second side, a further sixteen operations were done, including three anal splitting procedures. In all cases the deep sutures were of monofilament nylon.A post‐operative follow‐up was carried out for a minimum period of 12 (average 39) months. The operative and post‐operative complications included superficial and deep wound infection, partial or complete sciatic paralysis, rectal prolapse and recurrence of the hernia following breakdown of the repair, as well as occurrence of the hernia on the opposite side.The success rate (75 per cent excluding six immediate post‐operative fatalities) judged by remission of signs and lack of recurrence was higher in the standard technique (81 per cent) than the gluteal flap method (64 per cent). Anal splitting was unsuccessful and resulted in faecal incontinence.The standard technique was slow, sometimes gave limited exposure but was rarely associated with wound breakdown (13 per cent of operations), though sciatic paralysis was only noted in this procedure. The gluteal flap method was longer, gave excellent exposure with no risk of sciatic nerve damage, but was often associated with wound breakdown (58 per cent). Both techniques led sometimes to rectal prolapse. Castration with hernial repair resulted in a lower recurrence rate (13 per cent v. 20 per cent).Castration should be carried out in all cases of perineal hernia.