Re: Bladder & Urethra Anatomy

[Guest guest]

Say What???

" He stated that any shrinkage was

not due to a shortening of the urethra. "

What, pray tell, did he attribute the penile shortening to????

It was longer before surgery, right???

OK, I'm done here!

>

> http://www.napa.ufl.edu/oldnews/bladder.htm

>

> Very interesting reading... I'll be sure to show this to my urologist.

>

> I specifically asked my urologist about these issues. My question was

> originally about penile shrinkage. He stated that any shrinkage was

> not due to a shortening of the urethra. " What goes on inside the

> pelvic floor area is not reflected by what goes on outside the body. "

> In other words, during an erection, after prostate surgery, the

> bladder neck is not being pulled by a shortened urethra.

>

> He also stated that the bladder is very loosely tethered, and that as

> soon as the prostate is removed, the bladder drops a bit, and so the

> urethra can easily be reattached to the bladder neck without any

> pulling.

>

> In any event, our Man-to-Man PCa support group is hosting another

> urologist on June 19th, and I'll be sure to grill him some more about

> these issues.

>

> Ron

>

[Guest guest]

>> Say What???

>> " He stated that any shrinkage was

> not due to a shortening of the urethra. "

>> What, pray tell, did he attribute the penile shortening to????

>> It was longer before surgery, right???

>> OK, I'm done here!

The urologist stated that penile shortening is due to an insufficient

blood flow and atrophy. This is why he prescribes a low dose of

Cialis and the vacuum appliance as soon as possible, as part of a

rehabilitation regime.

Don't shoot the messenger!

Ron

[Guest guest]

Dr. Scardino, Chairman of the Department of Urology at

Memorial Sloan-Kettering Cancer Center in New York City, in his

book " Dr. Scardino's Prostate Book " (which I highly

recommend), has some lengthy (no pun intended) commentary on this

question which I quote below for those who are concerned about this

issue. I hope this will clarify matters to some degree.

" Removing the prostate does not pull the penis into your body and

make it shorter. The penis and urethra are fixed to the bones of

the pelvis and cannot be dislodged. When the prostate is removed,

the bladder is brought down and sewn to the urethra. The urethra is

not pulled up with an effect like a retracted hose! "

" Still, some men observe that their penis seems smaller or shorter

after surgery. I'm aware of three reasons for this -- two

misleading and one real. If there is intense scarring between the

lower part of the abdominal incision and the penis, as the scar

retracts, the penis may be pulled toward the pubic bone and appear

shorter. Alternatively, after the operation, some men gain weight

for a variety of reasons, including sexual frustration. Fatty

deposits over the pubic area can cover part of the penis, making it

appear smaller. In both instances, there is no actual shortening,

though the penis looks shorter to the patient. When erection

occurs, the penis fills out and functions normally. "

" Genuine penile shortening can result from the long-term effects of

damaged nerves and the absence of erections, not directly from the

removal of the gland. While the mechanism remains a mystery, in

some men the delicate vascular channels of the penis atrophy and

become hard and inelastic (fibrotic). Fibrous tissue does not

expand when the penis fills with blood, so the organ remains shorter

and erections may not be as firm. Some men report curvature of the

penis with erections, or a penis that is rigid near the body but

softer near the tip. "

Scardino goes on to say that the fibrosis mentioned in the prior

paragraph is an area of intense research.

>

> >> Say What???

> >> " He stated that any shrinkage was

> > not due to a shortening of the urethra. "

> >> What, pray tell, did he attribute the penile shortening to????

> >> It was longer before surgery, right???

> >> OK, I'm done here!

>

> The urologist stated that penile shortening is due to an

insufficient

> blood flow and atrophy. This is why he prescribes a low dose of

> Cialis and the vacuum appliance as soon as possible, as part of a

> rehabilitation regime.

>

> Don't shoot the messenger!

>

> Ron

>

[Guest guest]

My apologies to Ron, I was out of line. But the point is the surgery

was the root cause of the " shrinkage. "

The following site supports Donna's statement and is good info.

http://www.phoenix5.org/sexaids/basics/penile/menushrink.html

>

> >> Say What???

> >> " He stated that any shrinkage was

> > not due to a shortening of the urethra. "

> >> What, pray tell, did he attribute the penile shortening to????

> >> It was longer before surgery, right???

> >> OK, I'm done here!

>

> The urologist stated that penile shortening is due to an insufficient

> blood flow and atrophy. This is why he prescribes a low dose of

> Cialis and the vacuum appliance as soon as possible, as part of a

> rehabilitation regime.

>

> Don't shoot the messenger!

>

> Ron

>

[Guest guest]

Sorry guys..YOUR wrong on your idea of what causes the penile shortening. You have two separate issues mixed up. As I always do, I first go and research the procedure, collect data, review hundreds (yes a hundred plus) web sites and gave copies of some of the comment on penile shorting to my Urological surgeon and to my family doc. to read and comment. Both chuckled! Especially at gaining weight and making it look short. Everyone I know that had surgery lost weight. I went from 200 lbs (5'11") down to 175 lbs and now stabilized at 185 lbs. Here is the scoop. First watch this Video http://www.prostatecentre.ca/surgery_basics.html This site had video animations of the 4 main treatments and video comments made by/of patients that had each type. First:

Short Joint after effect: This video animation at the url listed above agrees with what the surgeon & Family doc. said. When the prostate is removed, that length (plus just a bit more) of the urethra is obviously gone. The urethra is then PULLED up to an attached to the bladder. The Bladder is not dropped down AS ONE PERSON SAID. This would be a major addition to the surgery. It would only be done if some other issue with the bladder existed. This WILL Cause the Drawstring effect causing the "infamous Turtle-head". The INITIAL decrease in penis length OF YOUR NORMAL FLACCID Length, which is all your going to have for a month to two months is a combination effect: 1) Most from the urethra being reduced in length and 2) the poor "little thing" has had it feelings hurt (nerves abused and blood vessels constricted.) This mainly prevents erections NOT THE Flaccid length. I hated that mad

search to find the damn thing while standing at the urinal! I'll admit that a couple of times I had to undo my belt and do a more aggressive Search & Rescue to urinate. The second part of the issue: Erections, degree of stiffness, Up-Time and sensations: "Use it or Lose it!" is a fact!!!!! Did you know that research over the last 20 + years explain why and the NEED for guys to get nocturnal erections. This is how the body maintains a healthy supply of oxygen and keeps the spongy tissue inside the penis and the arteries and veins in the penis flexible, expandable and responsive. In fact guys with high stress levels the have ED during the day often have great erections during the night. One way to confirm a guy's ED problem is stress related is to put a sensor on his penis and measure the frequency and firmness of erections during sleep. But back to the purpose of this

discussion..... For several months after surgery...our little friend is "out of practice" and needs a jump start. In the old days...break out the "Penis Pump" or go to the pre-teen days and call upon "the Hand". Now-a-days Cilias or Viagra is given at 30 to 60 days after surgery to get the penis to "retrained" and tissues expanded. It helps to have a very understanding open minded wife who is willing to be a "physical/sexual therapist". For me these pills would get me to the state of a wilting cucumber. Not firm enough to do anything useful or for such a short period that it only got our hopes up and then bummer! My urologist then said there is a fail safe method to power this puppy back to life. Up side...never fail and pump it up.....down side...have to self inject into the side of my penis. Well...I choose to give the pills another month...I just could

not see sticking a needle into my .....! I noticed that during the night I'd have world class erections that I'd love to have had in college! However during the day...not what was needed. Diagnosis..my job stress was not only messing my mind but my recovery and sex lift up. Time to Inject. Tri-Mix injections: Talk about the miracle! I swear it made me one inch longer that pre-surgery and capable of putting holes in walls! I did this for 6 months and now Viagra or Cilias achieve the standard result but more important. If relaxed and not under stress from work...I need nothing other that to smell my wife's perfume. This validates the Use it or Lose it. Tri-Mix and other drug http://www.erectilerestoration.com.au/Injection-Therapy.html Recap: Shorting of length: due to the Urethra having been shortened and pulled up to the bladder! Reduction in thickness: Yes this is due to lack of blood in the spongy tissue responsible for getting and keeping and erection. This is the Use or Lose aspect. Be bold and exercise your "manhood". It's health is in your hands! I'm now at nearly 4 year out. PSA: Not detectable Erections: World Class and back to full size! Note it took 2 years for the full length and thickness to return. Incontinence: When I lift weights or get very tired on 5 to 8 hour hikes going up a steep incline in the Rockies, I do have slight leakage upon exertion. I have collected a number of other web sites of interest to people that tell about the Pro and

cons of each type of procedure. Surgery is (despite 2 posters comments) THE GOLD Standard against which all other compare Risk, rewards and long term survival AND Quality of life. Only Facts based on the ETHICAL use of science shall be my guide in educating those who seek knowledge.

We won't tell. Get more on shows you hate to love(and love to hate): Yahoo! TV's Guilty Pleasures list.

[Guest guest]

Mel, You are absolutely right in the fact that cutting out the

prostate will pull the urethra up, thus shortening our little? guy;

EXCEPT that there ARE surgeons that DO add that extra layer of

complexity to an already extremely complex procedure, and " drop " the

bladder in an effort to reduce the shortening effect (and perhaps

reduce the strain on a fragile joining of the severed ends of the

urethra??). This is sometimes done by either robotic or standard RP

surgeons. The following is a clip from a description of one such

robotic surgeon's description: (note step # 2). Reading through this

and looking at videos of the procedure actually gave me a chill.

Faced with a life threatening situation, I would put my life in the

hands of these wonderfully skilled surgeons. But if not immediately

life threatening, and I have a choice that will avoid such invasion of

my body, I would avoid it. That is just ME.

Robotic Laparoscopic Prostatectomy

1) Posterior Dissection

The first step of Dr. Hu's robotic assisted laparoscopic radical

prostatectomy is to dissect out the seminal vesicles and the vas

deferens on both sides. Aggressive cancers can invade these

structures which store and transmit ejaculate to the prostatic

urethra. After dividing the vas deferens, which results in a

functional vasectomy, Dr. Hu also opens Denonviller's fascia and

dissect the prostate off of the rectum posteriorly.

2) Dropping the Bladder

Next, Dr. Hu dissects the bladder away from the anterior abdominal

wall to enter the retropubic space by incising the peritoneum lateral

to the medical umbilical ligaments on both sides and then dividing the

medical umbilical ligaments and the urachus. He uses the pubic bone

as a landmark and follows the natural tissue planes anatomically.

3) Opening the Endopelvic Fascia

The prostate is invested by a connective tissue known as the

endopelvic fascia and pelvic floor muscle fibers. Dr. Hu opens this

fascia and gently sweeps the pelvic floor muscle fibers away from the

prostate.

4) Apical Dissection

Dr. Hu continues to sweep off the pelvic floor muscles off of the apex

or distal tip of the prostate, using as little thermal energy as

possible to preserve continence. He then divides the puboprostatic

ligaments, which fix the prostate to the pubic bone.

5) Bladder Neck division

Dr. Hu dissects the bladder off of the prostate, anatomically

preserving the small caliber of the bladder neck. The catheter is

pulled back into the prostatic urethra before dividing the posterior

bladder neck. Division of the posterior bladder neck allows Dr. Hu to

dissect into the space he created in the 1st step or the posterior

dissection.

6) Nerve-Sparing

The neurovascular bundles lie posterior and lateral to the prostate on

both sides. Dr. Hu has incised the thin layer of connective tissue

overlying the prostate to peel the neurovascular bundles away from the

prostate on both sides. The decreased blood loss and magnification of

robotic assisted laparoscopic prostatectomy aid greatly with nerve

sparing to preserve erectile function. Dr. Hu uses the bipolar

forceps in his left robotic arm, which precisely controls bleeding on

the prostate; however, he avoids any energy on the neurovascular

bundles to prevent thermal damage.

7) Division of the urethra

Dr. Hu dissects the neurovascular bundles off of the urethra before he

divides the urethra. The catheter is pulled back prior to dividing

the posterior urethra, and the prostate is freed entirely. Dr. Hu

then begins the reconstruction, suturing the small, anatomic bladder

neck down to the urethral stump.

8) Completion of the Anastomosis

Dr. Hu continues the anastomosis, or reconstruction of the bladder

neck to the urethra. He has placed bio-degradeable material behind

the bladder, which stimulates the clotting cascade. The wrist-like

movement of the robotic instruments aids precise needle placement.

Dr. Hu fills the bladder to ensure that there is no leakage from his

repair.

9) Pelvic Lymph Node dissection

For men with moderate and high risk characteristics, Dr. Hu performs a

lymph node dissection that is identical to his technique for open

surgery. First, he identifies the external iliac vein and dissects

underneath it to the pelvic side wall, teasing off the lymph node

packet. Next, he identifies and preserves the obturator nerve and

vessels before dissecting out the lymph node completely, which is

removed through a 12 mm laparoscopic port.---

The site from which this was taken is here:

http://www.brighamandwomens.org/urology/Services/Minimally_InvasiveVideos.aspx

To all: Again, this is just my own personal reaction to radical

prostate surgery for cancer. I completely understand those that have

decided that they want the physical analysis of the removed prostate

to determine the extent of their disease. BUT:

I am a retired engineer, and dealt with possible " failure points " in

complex space launch vehicles from 1958 until my retirement in 1995,

and my evaluation of this procedure from a non-medical layman's

viewpoint, is that it is fraught with potential failure points. The

skill of the surgeon is paramount. If I had to have RP done, I would

travel as far as it took to find the most skilled and experienced

surgeon that I could find to do this to me.

Fuller

[Guest guest]

>snip<

> The urethra is then PULLED up to an attached to the bladder. The

>Bladder is not dropped down AS ONE PERSON SAID. This would be a

>major addition to the surgery. It would only be done if some other

>issue with the bladder existed.

Mel, I am that person. I not only said it, I experienced it. Unless

my surgeon is lying to me and Dr. Walsh at s Hopkins is also

lying, their procedure brings the bladder down -I never used the

word " dropped " -to meet the urethra. (see my previous post) I had

no " other bladder issue " . I'm not a surgeon but as far as I know,

this is standard procedure …perhaps the method you describe is a

shortcut (no pun intended) for a less experienced surgeon? Bladders

and urethras are not machined parts that have to be fitted like pipe

sections. As you said earlier, the body is very flexible and

stretchable. For a week after my robotic procedure there was a lot

of painless swelling and bruising that made me APPEAR shorter but

once the swelling was gone and catheter out, everything looked

completely normal. I never experienced or heard of the " search and

rescue " you described. I even felt silly that I had considered taking

before and after pictures just in case.

I am a bit dismayed at your enthusiastic support for RP; the rest

your post gives one hope that everything will return to normal. But

you neutralize that positive message by leading off with the " short

joint " talk that serves only to add one more fear to the boatload of

fears a guy has to confront in deciding on a treatment. I will allow

that you and others may have experienced this but I would consider it

the exception, and not the rule. I think you're mistaken to assume

all RP procedures are the same and declare that I'm wrong because you

had a different experience or were told something else.

Yours sincerely,

Tony Higgins

[Guest guest]

>

> Mel, You are absolutely right in the fact that cutting out the

> prostate will pull the urethra up, thus shortening our little? guy;

> EXCEPT that there ARE surgeons that DO add that extra layer of

> complexity to an already extremely complex procedure, and " drop " the

> bladder in an effort to reduce the shortening effect (and perhaps

> reduce the strain on a fragile joining of the severed ends of the

> urethra??). This is sometimes done by either robotic or standard RP

> surgeons.

<snip>

YES!! This is what my surgeon did. I think it's fairly standard and

not a " fringe " or super advanced technique as others have implied.

Walsh described it in 2000 without even mentioning robotics.

> I am a retired engineer, and dealt with possible " failure points " in

> complex space launch vehicles from 1958 until my retirement in 1995,

> and my evaluation of this procedure from a non-medical layman's

> viewpoint, is that it is fraught with potential failure points.

<snip>

Testing launch vehicles sounds like trying new designs about which

little is known. It's very hard to predict where the risks are

because you're in unknown territory. As complicated as the human

body is, I think it has been studied far more than anything man-

made. It's not new, it's been around for a long time, and there is

only one version. Though there is bound to be some variation patient

to patient, surgery to surgery, the content and structure is the same

each time. As a surgeon does more procedures, the range of variation

he/she sees eventually approaches that of the whole population. Added

experience reduces the risk and potential failure points become well

known.

>The

> skill of the surgeon is paramount. If I had to have RP done, I would

> travel as far as it took to find the most skilled and experienced

> surgeon that I could find to do this to me.

<snip>

-or you could look in your own back yard (Rochester, NY) as I did.

Surgery was my last choice but I was told by a radiation oncologist

that any radiation treatment had the same or greater likelihood of

side effects for me, at my age, with my numbers, as surgery. So, I

found a very experienced surgeon and took care of it. -no regrets.

Best regards,

Tony Higgins

[Guest guest]

Tony, Good for you. You did your research, made the choice that was

right for you, found the experienced surgeon, and came out with good

results. That is all any of us can ask for!

We are all different, with different viewpoints, backgrounds and

perhaps even fears. In my case I wanted to avoid " the knife " and the

potentials for problems.

Best to you,

Fuller

[Guest guest]

You say that, " When the prostate is removed, that length (plus just

a bit more) of the urethra is obviously gone. The urethra is then

PULLED up to an attached to the bladder. The Bladder is not dropped

down AS ONE PERSON SAID. This would be a major addition to the

surgery. It would only be done if some other issue with the bladder

existed. "

Well, I looked at the video animation and,of course, such simplified

animations prove nothing. I'm sure you have a fine family doctor,

but he doesn't do 150 RPs per year like the Chairman of the

Department of Urology at Memorial Sloan Kettering Cancer Center who

states unequivocally; " Removing the prostate does not pull the penis

into your body and make it shorter. The penis and urethra are fixed

to the bones of the pelvis and cannot be dislodged. When the

prostate is removed, the bladder is brought down and sewn to the

urethra. The urethra is not pulled up with an effect like a

retracted hose. " In the foregoing quote, he has the word " not " in

the last sentence in italics (for emphasis) in his book, which I am

unable to do here.

Anyway, I have said before than this whole controversy over length

is pretty silly. The important thing is functionality and you seem

to have recovered according to plan. Congratulations! By the way,

while I have found that Viagra and Cialis are helpful to some

degree, I have had problems with side effects (headaches and upset

stomach, in particular) and finally gave up on using these drugs on

a regular basis. I have not tried Levitra although have heard that

it is more like Viagra as far as side effects.

>

> Sorry guys..YOUR wrong on your idea of what causes the penile

shortening. You have two separate issues mixed up.

>

> As I always do, I first go and research the procedure, collect

data, review hundreds (yes a hundred plus) web sites and gave copies

of some of the comment on penile shorting to my Urological surgeon

and to my family doc. to read and comment. Both chuckled!

Especially at gaining weight and making it look short. Everyone I

know that had surgery lost weight. I went from 200 lbs (5'11 " ) down

to 175 lbs and now stabilized at 185 lbs.

>

> Here is the scoop. First watch this Video

http://www.prostatecentre.ca/surgery_basics.html

> This site had video animations of the 4 main treatments and

video comments made by/of patients that had each type.

>

> First: Short Joint after effect:

> This video animation at the url listed above agrees with what

the surgeon & Family doc. said. When the prostate is removed, that

length (plus just a bit more) of the urethra is obviously gone. The

urethra is then PULLED up to an attached to the bladder. The Bladder

is not dropped down AS ONE PERSON SAID. This would be a major

addition to the surgery. It would only be done if some other issue

with the bladder existed. This WILL Cause the Drawstring effect

causing the " infamous Turtle-head " . The INITIAL decrease in penis

length OF YOUR NORMAL FLACCID Length, which is all your going to

have for a month to two months is a combination effect: 1) Most from

the urethra being reduced in length and 2) the poor " little thing "

has had it feelings hurt (nerves abused and blood vessels

constricted.) This mainly prevents erections NOT THE Flaccid

length.

>

> I hated that mad search to find the damn thing while standing at

the urinal! I'll admit that a couple of times I had to undo my belt

and do a more aggressive Search & Rescue to urinate.

>

> The second part of the issue: Erections, degree of stiffness, Up-

Time and sensations:

>

> " Use it or Lose it! " is a fact!!!!! Did you know that

research over the last 20 + years explain why and the NEED for guys

to get nocturnal erections. This is how the body maintains a

healthy supply of oxygen and keeps the spongy tissue inside the

penis and the arteries and veins in the penis flexible, expandable

and responsive. In fact guys with high stress levels the have ED

during the day often have great erections during the night. One way

to confirm a guy's ED problem is stress related is to put a sensor

on his penis and measure the frequency and firmness of erections

during sleep. But back to the purpose of this discussion.....

>

> For several months after surgery...our little friend is " out of

practice " and needs a jump start. In the old days...break out

the " Penis Pump " or go to the pre-teen days and call upon " the

Hand " . Now-a-days Cilias or Viagra is given at 30 to 60 days after

surgery to get the penis to " retrained " and tissues expanded. It

helps to have a very understanding open minded wife who is willing

to be a " physical/sexual therapist " .

>

> For me these pills would get me to the state of a wilting

cucumber. Not firm enough to do anything useful or for such a short

period that it only got our hopes up and then bummer! My urologist

then said there is a fail safe method to power this puppy back to

life. Up side...never fail and pump it up.....down side...have to

self inject into the side of my penis. Well...I choose to give the

pills another month...I just could not see sticking a needle into

my .....! I noticed that during the night I'd have world class

erections that I'd love to have had in college! However during the

day...not what was needed. Diagnosis..my job stress was not only

messing my mind but my recovery and sex lift up. Time to Inject.

>

> Tri-Mix injections: Talk about the miracle! I swear it made

me one inch longer that pre-surgery and capable of putting holes in

walls! I did this for 6 months and now Viagra or Cilias achieve

the standard result but more important. If relaxed and not under

stress from work...I need nothing other that to smell my wife's

perfume. This validates the Use it or Lose it.

>

> Tri-Mix and other drug

> http://www.erectilerestoration.com.au/Injection-Therapy.html

>

>

> Recap:

> Shorting of length: due to the Urethra having been shortened and

pulled up to the bladder!

>

> Reduction in thickness: Yes this is due to lack of blood in the

spongy tissue responsible for getting and keeping and erection.

This is the Use or Lose aspect.

>

> Be bold and exercise your " manhood " . It's health is in your

hands!

>

> I'm now at nearly 4 year out.

> PSA: Not detectable

> Erections: World Class and back to full size! Note it took 2

years for the full length and thickness to return.

> Incontinence: When I lift weights or get very tired on 5 to 8

hour hikes going up a steep incline in the Rockies, I do have

slight leakage upon exertion.

>

> I have collected a number of other web sites of interest to

people that tell about the Pro and cons of each type of procedure.

Surgery is (despite 2 posters comments) THE GOLD Standard against

which all other compare Risk, rewards and long term survival AND

Quality of life.

>

>

>

>

>

> Only Facts based on the ETHICAL use of science shall be my guide

in educating those who seek knowledge.

>

> ---------------------------------

> We won't tell. Get more on shows you hate to love

> (and love to hate): Yahoo! TV's Guilty Pleasures list.

>

[Guest guest]

At last something we agree on! You say, " The skill of the surgeon

is paramount. If I had to have RP done, I would travel as far as it

took to find the most skilled and experienced surgeon that I could

find to do this to me. " When I saw the complexity of this surgery,

I decided that I had to have it done by the very best surgeon I

could find. So I called the office of Dr. Walsh at s

Hopkins (who is the surgeon at the top of everybody's list) but was

told he had a six-month waiting list just to get an appointment!

[Note: Kerry had his surgery done by Dr. Walsh, and I noted

that the time that passed between his diagnosis (by someone else)

and his surgery was much less than six months.] So I chose one of

his most experienced colleages at Hopkins who trained under him, Dr.

H. Ballentine , whose writings I was familiar with as well.

It turned out to be an excellent choice.

Surprisingly, my decision to go from my home in New York to

Baltimore for the surgery cost me very little, even though I assumed

at the start that it would cost a small fortune to leave the local

area. I was willing to pay through the nose, but it turned out that

my insurer, United Healthcare, considered Hopkins to be " in

network. " Not counting travel expenses (which were modest since I

usually travel on Amtrak and I got a good hotel rate), I ended up

paying only about $325 out of pocket. That is all that the RP by

one of the world's top surgeons, plus three days in the U.S.'s top-

ranked hospital, cost me. I was lucky to have had a great plan. In

contrast, I am now under a Cigna plan and I recently paid $375 out

of pocket for a broken toe, since I went out of network and there

was a $500 deductible. Insurance never ceases to amaze me.

>

> Mel, You are absolutely right in the fact that cutting out the

> prostate will pull the urethra up, thus shortening our little? guy;

> EXCEPT that there ARE surgeons that DO add that extra layer of

> complexity to an already extremely complex procedure, and " drop "

the

> bladder in an effort to reduce the shortening effect (and perhaps

> reduce the strain on a fragile joining of the severed ends of the

> urethra??). This is sometimes done by either robotic or standard RP

> surgeons. The following is a clip from a description of one such

> robotic surgeon's description: (note step # 2). Reading through

this

> and looking at videos of the procedure actually gave me a chill.

>

> Faced with a life threatening situation, I would put my life in the

> hands of these wonderfully skilled surgeons. But if not immediately

> life threatening, and I have a choice that will avoid such

invasion of

> my body, I would avoid it. That is just ME.

>

> Robotic Laparoscopic Prostatectomy

>

> 1) Posterior Dissection

> The first step of Dr. Hu's robotic assisted laparoscopic radical

> prostatectomy is to dissect out the seminal vesicles and the vas

> deferens on both sides. Aggressive cancers can invade these

> structures which store and transmit ejaculate to the prostatic

> urethra. After dividing the vas deferens, which results in a

> functional vasectomy, Dr. Hu also opens Denonviller's fascia and

> dissect the prostate off of the rectum posteriorly.

>

> 2) Dropping the Bladder

> Next, Dr. Hu dissects the bladder away from the anterior abdominal

> wall to enter the retropubic space by incising the peritoneum

lateral

> to the medical umbilical ligaments on both sides and then dividing

the

> medical umbilical ligaments and the urachus. He uses the pubic

bone

> as a landmark and follows the natural tissue planes anatomically.

>

> 3) Opening the Endopelvic Fascia

> The prostate is invested by a connective tissue known as the

> endopelvic fascia and pelvic floor muscle fibers. Dr. Hu opens

this

> fascia and gently sweeps the pelvic floor muscle fibers away from

the

> prostate.

>

> 4) Apical Dissection

> Dr. Hu continues to sweep off the pelvic floor muscles off of the

apex

> or distal tip of the prostate, using as little thermal energy as

> possible to preserve continence. He then divides the puboprostatic

> ligaments, which fix the prostate to the pubic bone.

>

> 5) Bladder Neck division

> Dr. Hu dissects the bladder off of the prostate, anatomically

> preserving the small caliber of the bladder neck. The catheter is

> pulled back into the prostatic urethra before dividing the

posterior

> bladder neck. Division of the posterior bladder neck allows Dr.

Hu to

> dissect into the space he created in the 1st step or the posterior

> dissection.

>

> 6) Nerve-Sparing

> The neurovascular bundles lie posterior and lateral to the

prostate on

> both sides. Dr. Hu has incised the thin layer of connective tissue

> overlying the prostate to peel the neurovascular bundles away from

the

> prostate on both sides. The decreased blood loss and

magnification of

> robotic assisted laparoscopic prostatectomy aid greatly with nerve

> sparing to preserve erectile function. Dr. Hu uses the bipolar

> forceps in his left robotic arm, which precisely controls bleeding

on

> the prostate; however, he avoids any energy on the neurovascular

> bundles to prevent thermal damage.

>

> 7) Division of the urethra

> Dr. Hu dissects the neurovascular bundles off of the urethra

before he

> divides the urethra. The catheter is pulled back prior to dividing

> the posterior urethra, and the prostate is freed entirely. Dr. Hu

> then begins the reconstruction, suturing the small, anatomic

bladder

> neck down to the urethral stump.

>

> 8) Completion of the Anastomosis

> Dr. Hu continues the anastomosis, or reconstruction of the bladder

> neck to the urethra. He has placed bio-degradeable material behind

> the bladder, which stimulates the clotting cascade. The wrist-like

> movement of the robotic instruments aids precise needle placement.

> Dr. Hu fills the bladder to ensure that there is no leakage from

his

> repair.

>

> 9) Pelvic Lymph Node dissection

> For men with moderate and high risk characteristics, Dr. Hu

performs a

> lymph node dissection that is identical to his technique for open

> surgery. First, he identifies the external iliac vein and dissects

> underneath it to the pelvic side wall, teasing off the lymph node

> packet. Next, he identifies and preserves the obturator nerve and

> vessels before dissecting out the lymph node completely, which is

> removed through a 12 mm laparoscopic port.---

>

> The site from which this was taken is here:

>

http://www.brighamandwomens.org/urology/Services/Minimally_InvasiveVi

deos.aspx

>

> To all: Again, this is just my own personal reaction to radical

> prostate surgery for cancer. I completely understand those that

have

> decided that they want the physical analysis of the removed

prostate

> to determine the extent of their disease. BUT:

>

> I am a retired engineer, and dealt with possible " failure points "

in

> complex space launch vehicles from 1958 until my retirement in

1995,

> and my evaluation of this procedure from a non-medical layman's

> viewpoint, is that it is fraught with potential failure points. The

> skill of the surgeon is paramount. If I had to have RP done, I

would

> travel as far as it took to find the most skilled and experienced

> surgeon that I could find to do this to me.

>

> Fuller

>