Aira Hospital

The perineal approach was described by Dr Ghadvi. Technically it is a bit more difficult than the transvesical approach, but does not need postoperative irrigation, which is a tremendous advantage when staff and sterile irrigation fluid is scarce. In this method the empty prostatic cavity is packed with gauze to prevent bleeding. Thus close and uninterrupted attention of the staff is not necessary as when irrigation is used, and there are no expenses for purchasing or production of sterile irrigation fluid.

I used this technique the first year or two after arriving at Aira Hospital, but as the complications, in particular urinary incontinence, are much more frequent – at least in my hands – I have switched back to the transvesical approach.

 Only a few instruments are needed, the most important is a sound, a ring forceps and a gauze pack.

 

The patient is placed in lithotomy position after spinal anesthesia. The sound is placed in the urethra with the tip in the bladder. In that way you will be sure that there is no stricture. The sound will also help guiding the index finger into the right position for breaking open the prostatic capsule.                 

 

An oblique perineal incision to the left of the midline is made. The triangular space between the transverse perineal, bulbocavernosus and ischiocavernosus muscles is made. Through that triangle the prostate is approach and the capsule is opened with either scissors or the index finger.

 

 With the sound as a guide the prostate capsule is broken and the prostatic adenoma enucleated with the index finger. As the risk of rectal perforation is greater than with the transvesical approach it is an advantage to have the left index finger placed in the rectum while enucleating the adenoma. Don’t forget to change glove in that case.

 

A Fooley cather No 20-22 with a 30 cc balloon is placed into the bladder and the prostate cavity is packed with gauze. The wound can be approached by some interrupted sutures (optional)

 

Give Furosemide 20 mg i.v. and irrigate vigorously until there is an unhindered flow of urine.

 

Connect with a urine bag – or any tubing if urine bag is not available. Mobilize immediately.

 

Be sure that the patient has a high oral fluid intake. Furosemide 20 mg i.v. QID will secure a high urinary output.

The pack is removed after 24-48 hours depending on the amount of bleeding. The urine should be clear and flowing freely before its removal. If the wound was sutured the stitches are removed after 7 days, and the catheter after 12-14 days.