Ghadvi's lateral perineal prostatectomy

The place of his operation in the hospitals for which we write is not clear, which is why it is in small print. Earlier descriptions of it were incomplete, so that some operators appear to have neglected the critically important step of incising the prostatic capsule, and entering the prostatic urethra inside it, rather than outside it. How common incontinence and stricture are with less skilled operators remains to be determined, and to be compared with the complication rate of Freyer's operation, in the same hands and under the same circumstances. More extensive trials are in progress. Meanwhile, the place of this operation is uncertain, but it may turn out to be a very useful method. At least one contributor has advised its deletion: others disagree.

About 1500 BC Sushruta removed bladder stones through a lateral incision in the perineum. More recently, Ghadvi has adapted this approach to remove the prostate, and it is now used by a number of surgeons in East Africa. It has several advantages: (1) Most importantly, there is no need for postoperative irrigation, and the 15 or 20 bottles of fluid that Freyer's method may need. This makes it very popular with the nurses. (2) There is less bleeding, so that few patients need a blood transfusion. (3) There is very much less risk of clot retention, than with other methods. This is because the balloon of a Foley catheter can be used to compresses a pack in the prostatic cavity most effectively, and with much less tendency for it to slip up into the bladder than with Freyer's method. (4) The operation is quick[md]about 30 minutes. (5) The incision is small and the scar hidden. (6) You seldom need an assistant. (7) You need only the minimum of equipment. (8) It is painless. (9) It has a low mortality rate. (10) Recovery is rapid. (11) There is little danger of injuring the rectum. Preliminary cystoscopy is desirable, but not absolutely necessary. (13) It is well adapted to adversity[md]to overcrowded wards, and the very minimum of equipment and facilities.

Like all operations, it has some disadvantages: (1) Enucleating a prostatic adenoma through the perineum needs more experience than removing one through the bladder[md]you will find it more difficult to be sure what you are feeling at the end of your finger, and preferably you need a very long finger. You should therefore be familiar with Freyer's method before you start. (2) The prostatic capsule cannot be sutured in the depth of the wound, so you have to let it granulate. This means that a postoperative catheter is required for 10 to 14 days, which is the same time as with Freyer's method, but is longer than with Millin's retropubic prostatectomy (5 days), which allows you to suture the prostatic capsule. (3) In the original series of 400 patients temporary incontinence was seen in 10% of cases. About 1% of the series needed a penile clamp 6 months after the operation. The complication rate is thus much the same as with other methods of prostatectomy. The reasons for incontinence with this method, as with the others, is not altogether clear. It may be due to fibrosis in the membranous urethra, or because the hypertrophied lower part of the lateral lobes protrudes through the dilated fibres of the sphincter urethrae. When this happens these overstretched fibres may not regain their tone and their power to compress the urethra. Postoperative incontinence is said to be more common in patients who already have preoperative incontinence with overflow. Ghadvi NP, ''Sushruta's lateral perineal approach for prostatectomy', Proceedings of the Association of Surgeons of East Africa 1978;1:28[nd]32[-3] Loefler IJP, ''Ghadvi's prostatectomy', Proceedings of the Association of Surgeons of East Africa 1983;6:51[nd]52. Fig. 23-28 GHADVI'S LATERAL PERINEAL PROSTATECTOMY. A, the incision. B, a cross sectional view of the structures through which the incision passes. C, a schematic view of the structures through which it passes. D, the capsule of the patient's prostate being incised with scissors. E, insert your finger through the incision. Reach for the top of his prostate and avoid his external sphincter. F, remove the adenoma. G, a diagram of the way bleeding is controlled with a pack in the prostatic cavity. H, the finished operation, showing the urethral catheter, the pack in the wound, and an additional catheter (dotted), should one be needed. Kindly contributed by NP Ghadvi.

GHADVI'S PROSTATECTOMY INDICATIONS. (1) As for Freyer's method. (2) Many patients requiring prostatectomy under difficult circumstances. (3) It is an excellent way of taking a biopsy of the prostate.

CONTRAINDICATIONS. (1) An inexperienced operator doing his first prostatectomy. You will be wise to have done a few operations by Freyer's method first. (2) Carcinoma of the prostate. (3) Dyskinesia and bladder-neck fibrosis (''small fibrous prostate', 23.20). (4) Obesity; if a patient is very obese, you can examine his prostate through his rectum without difficulty, but obese buttocks make it difficult to remove his prostate through his perineum; your finger is not long enough. If you try and have difficulty, you may damage his urethra, and a stricture may follow.

EQUIPMENT. Two haemostats, ovum forceps, a guarded knife as in Fig. 5-6, or pointed scissors; a straight urethral sound. A bladder irrigation syringe, or an ear syringe, or a bottle of saline hanging from a drip stand. 2 Foley catheters, a catheter introducer, a roll of sterile gauze or a uterine pack.

ANAESTHESIA. (1) Ketamine drip (A 8.4). (2) Caudal epidural anaesthesia (A 7.3). (3) Saddle block (A 7.6). (4) General anaesthesia[md]relaxants are not essential (A 11.3). (5) You can premedicate a very old man with pethidine, and then use local infiltration only.

INCISION. Prepare him, put him into an exaggerated lithotomy position. Pass a metal urethral sound up into his bladder, to make sure he has not also got a stricture, and to identify the position of his urethra.

Make a left sided oblique 6 cm incision, as in A, Fig. 23- 28, extending from his subpubic angle to his ischial tuberosity. Anteriorly the incision should be about 1 cm lateral to the median raphe, and extend further from it posteriorly. Incise his subcutaneous tissue and undermine flaps on each side, as far as the bulb of his urethra, and the crura of his penis.

Split Camper's fascia vertically, as it stretches over his ischiocavernosus and bulbocavernosus muscles. Open the groove between these two muscles between the bulb and the crura of his penis. Deep to them, use a pair of scissors to split his perineal membrane. Extend the gap vertically with your index finger. The upper limit of the gap is his subpubic angle, and its lower limit the resistance his deep transversus perinei offers to your finger.

Incise his prostatic capsule with pointed scissors, and push your finger through the incision. Feel for the tip of the sound, and let this guide you to his urethra. Feel for the top of his prostate, split the commissure anteriorly, and try to get your finger underneath it so as to enucleate it (some surgeons don't use scissors or a guarded knife, and push their fingers straight through the prostatic capsule).

Put your right index finger into his prostatic urethra, through the torn capsule of his prostate, and withdraw the sound.

CAUTION ! (1) Don't try to enter his urethra outside his prostatic capsule below his perineal membrane, because this is where his external sphincter is, and you must not tear it. Leaving it intact is the critical step in preserving continence. (2) You must have a sound in place, because this tells you where his urethra is.

With your right hand in his suprapubic region, push his prostate downwards.

Split the anterior commissure of his prostate with a hooking movement of your right index finger, and separate the lobes from the capsule by encircling them, as with Freyer's method.

The incision is small, so you cannot remove his prostate in one piece. Instead, remove it lobe by lobe with ovum forceps.

Your finger will not be long enough to reach far enough into his bladder, to let you remove the intravesical protrusion of his middle lobe. So use a pair of ovum forceps to twist all the remaining portions of his middle lobe from the capsule.

CAUTION ! In all cases put your finger into his bladder to dilate its internal sphincter.

Insert a Foley catheter. Pack his prostatic cavity with a roll of sterile gauze to control bleeding. Wash out his bladder with saline. Suture only his skin. Apply mild traction to the catheter by strapping it to his thigh.

POSTOPERATIVE CARE. Antibiotics are not necessary routinely. As soon as his urine is clear, and not mixed with frank blood, give him intravenous diazepam and remove the pack, usually at 24[nd]48 hours; removing it is not difficult and bleeding is rare. Remove the skin stitches and the urethral catheter between 10 and 14 days.

DIFFICULTIES [s7]WITH GHADVI'S PROSTATECTOMY If a piece of ADENOMA ESCAPES INTO HIS BLADDER, remove it with ovum forceps; if this fails, you will have to do a small suprapubic cystotomy and remove it that way.

If he has BLADDER-NECK FIBROSIS (a ''small fibrous prostate'), you will not be able to get into his prostatic urethra with your finger, so you will have to use a guarded knife, as above. This, if you diagnose it preoperatively, is normally considered a contraindication to this method.

If he has a MALIGNANT PROSTATE, you may be able to enucleate the adenomatous zone, before it has been infiltrated from the peripheral carcinomatous zone. Send a biopsy for histological examination. A preoperative diagnosis of carcinoma is a contraindication to this method. It is likely to bleed much.

If the operation is DIFFICULT, protect his rectum from injury by putting your left index into it, while your assistant stabilizes his prostate by downward and forward suprapubic pressure.

If YOUR FINGER GOES INTO HIS RECTUM insert 2 or 3 stitches of ''0' or ''1' catgut on a curved atraumatic needle through his rectal wall and his prostatic bed. Keep him on a liquid diet for a week. Some surgeons insert no sutures when this happens.

If URINE IS NOT DRAINING into the bag, and his bladder is distending, he has clot retention. Take him to the theatre, remove his skin stitches, and the perineal pack, and evacuate the clot in his bladder through his perineal wound. Remove the clot with ovum forceps. Leave a large three-channel Foley catheter in the wound, repack his prostatic cavity, and irrigate his bladder, as with Freyer's method.

If URINE LEAKS from his wound, it will probably start do so between the 7th and 10th day, after which his fistula will heal spontaneously in 2 weeks. Leave his urethral catheter in place, and cauterize the fistulous track with diathermy. No permanent perineal fistulae have been recorded.

If he is INCONTINENT OF URINE after removing the catheter, reassure him that this is likely to be only temporary, and that he will probably gradually gain control of micturition. If he is unlucky enough to be permanently incontinent, fit him with a penile clamp.

If he starts to develop a STRICTURE, dilate him regularly (23.8).