Surgical Anatomy of Prostate

Surgical Anatomy of Prostate.

1. Surgical Anatomy of Prostate For the students of Gulf Medical University, Ajman, MBBS Dr. Seyed Morteza Mahmoudi , MBBS Gulf Medical University, Ajman

2. Contents Surgical Anatomy Relations Coverings Lobes Arteries and veins Lymphatic and nerves Prostate Surgeries Complications Injuries Urinary incontinence Erection and Ejaculation

3. http:// vimeo.com/55246215

4. Shape and Location

5. Relations

6. Capsules

7. Relations Anteriorly 1) Symphysis pubis 2) Retropubic space (cave of Retzius ) 3) Puboprostatic ligaments 4) Santorini venous plexus Posteriorly 1)Rectal ampula 2) Denonvilliers fascia 3) Dorsal venous plexus 4)Prostatic nervous plexus

8. Relations Laterally 1) Levator ani muscle ( levator prostatae ) 2)Parietal and visceral layers of pelvic peritoneum 3) Neurovascular triangle Superiorly 1)Neck of the bladder 2)Sphincter vesicea (internal urethral sphincter) Inferiorly 1) Urogenital diaphragm 2) Sphincter urethrea (External urethral sphincter)

9. Lies between the neck of the bladder and the urogenital diaphragm Lies anterior to the rectum through which it normally can be palpated

10. Surrounds the first part of the male urethra & ejaculatory ducts cone-shaped with its base directed toward the bladder apex resting on the superior fascia of the urogenital diaphragm

11. Surrounded by connective tissue true capsule and condensation of pelvic fascia (false capsule), -separated by the prostatic venous plexus In prostatectomy-both capsules with the venous plexus are retained and the gland is enucleated. Capsules

12. Arterial Blood supply Inferior vesical A Middle rectal A Internal pudendal A

13. Venous Blood supply Prostatic plexus >> vesical plexus>>internal iliac V Communication with Batson’s plexus of paravertebral veins>>vertebral venous plexus may be responsible for spread of cancer metastasis into vertebral bodies or intracranial invasion.

14. Lymphatic Drainage The lymphatic drainage of the prostate primarily drains to the obturator and the internal iliac lymphatic channels. There is also lymphatic communication with the external iliac, presacral , and the para -aortic lymph nodes.

15. Innervations Pelvic plexuses formed by: parasympathetic, visceral efferent, and preganglionic fibers that arise from the sacral levels(S2-S4) and the sympathetic fibers from the thoracolumbar levels (L1-L2). Located beside the rectum The parasympathetic nerves end at the acini and lead to prostatic secretion. The sympathetic nerves lead to contraction of the smooth muscle of the capsule and the stroma .

16. Inferior hypogastric plexus (also called the pelvic plexus) Contributions from: Sympathetic Sacral splanchnic nerves - post ganglionic Lumbar splanchnic nerves Parasympathetic Pelvic splanchnic nerves Sensory Visceral afferent fibers Vesical , prostatic, rectal, Supplies 1-pelvic organs

17. Parasympathetic – efferent visceral branches Pelvic splanchnic nerves • Are also known as nervi erigentes • Are visceral branches of the ventral rami of the S2, S3, S4 spinal nerves • Comprise the sacral parasympathetic outflow • Mediate the parasympathetic influences on defecation, micturition , and erection • Join the inferior hypogastric (pelvic) plexus Only parasympathetics to ascend in pelvic mesocolon & reach the inferior mesenteric plexus - distributed to the descending and sigmoid colon (caudal to the left colic flexure)

18. Sacral sympathetic trunk • Is continuous with the lumbar sympathetic trunk over the sacral promontory posterior to the common iliac vessels

19. Lobes Anterior Lateral Posterior Median

20. Anterior lobe Lies anterior to the urethra and is mostly muscular containing little glandular tissue

21. Posterior lobe Lies posterior to the urethra and inferior to the plane of the ejaculatory ducts.

22. Paired lateral lobes between the anterior and posterior lobes lateral to the urethra and form the bulk of the gland

23. Middle lobe (median lobe) Lies posterior to the urethra and superior to the plane of the ejaculatory ducts when enlarged results in obstruction of the urethra at the neck of the bladder

24. Opens by 25 to 30 ducts into the prostatic sinus, a recess in the prostatic urethra alongside the colliculus seminalis

25. Internal features of the prostatic urethra Prostatic sinus

26. The urethral crest is the longitudinal ridge in the posterior wall of the prostatic urethra. The colliculus seminalis is a smooth enlargement of the urethral crest. — It receives the openings of the paired ejaculatory ducts & prostatic utricle. — It is also called the verumontanum.

27. The prostatic sinus - depression on each side of the colliculus seminalis - receives the openings of the prostatic ducts. The prostatic utricle -a blind pouch that opens at the apex of the colliculus seminalis. It is thought to be the remnant of the fused paramesonephric ducts - the male homologue of the uterus and upper vagina.

28. Zonal Classification of Prostate Transitional zone- Median lobe Central zone Peripheral zone Anterior fibromuscular stroma- Anterior lobe Posterior & Lateral lobes

29. Transitional zone surrounds urethra proximal to the ejaculatory ducts. Main site of BPH.

30. Central zone surrounds ejaculatory ducts and projects under the bladder base narrows as it approaches the opening of the ejaculatory ducts into the verumontanum. Site of origin of about 10% of carcinomas. 

31. Peripheral zone constitutes the bulk of apical, posterior and lateral aspects of the prostate Approximately 70% of the prostate gland lies in the peripheral zone. This zone does not undergo benign hyperplasia Site of origin of 70% of all prostate carcinoma

32. Anterior fibromuscular stroma- nonglandular region- located in the anteromedial portion of the gland extends from bladder neck to striated urethral sphincter.

33. Periurethral glands - 1% of prostatic glandular tissue . Located in the smooth muscle of the urethra in the preprostatic sphincter. Benign hyperplasia in the periurethral glands leads to an enlarged middle lobe. 

34. Uvula is a projection of the trigone , prominent in males formed by Median lobe of prostate Projects into the interior and causes obstruction to easy flow of urine in BPH

35. PR Structures felt Anteriorly Terminal phalanx: Rectovesical pouch Posterior surface of bladder Seminal vesicles Vasa defrentia Middle phalenx : Rectoprostatic fascia Prostate Proximal phalanx: Perineal body Urogenital diaphragm Bulb of the penis Laterally Ischiorectal fossa and ischial spines

36. Routs of Prostate Cancer Spread

37. Routs of Prostate Cancer Spread Local Spread: Seminal vesicle Trigone of bladder Distal urethral sphincter Rectal wall Blood stream Pelvic bone and lower lumbar vertebrae Intracranial cavity Lymphatic Retroperitonial lymph nodes Mediastinal lymph nodes Supraclavicular lymph nodes

38. BPH Surgeries TURP Open Prostatectomy Retropubic Prostatectomy Perineal Prostatectomy Transvesical Prostatectomy Laparoscopic Prostatectomy Robotic Laparoscopic Prostatectomy Intraurethral stents Newer treatments Laser treatment – Transurethral microwave therapy (TUMT) Transurethral needle ablation of the prostate (TUNA) High-intensity ultrasonographic energy therapy - Currently in the clinical trial stage

39. http:// www.youtube.com/watch?v=B1bAvN_esiI

40. http:// www.youtube.com/watch?v=JWFf8CDw0m0

41. http:// www.youtube.com/watch?v=5Exd86dbT68

42. Complications General complications of surgery Local injuries Bladder, rectum, sphincters, Incontinence Retrograde ejaculation Urethral stricture Bladder neck stenosis Erectile dysfunction ( impotance ) Sterility