PREOPERATIVE DIAGNOSIS: Prostate cancer.
POSTOPERATIVE DIAGNOSES: Prostate cancer and hematuria.
OPERATIONS PERFORMED:
1. Cryosurgical ablation of the prostate.
2. Transrectal ultrasound of prostate for volume determination.
3. Cystoscopy with insertion of urethral warmer device.
SURGEON: John Doe, MD
ANESTHESIA: General.
ANESTHESIOLOGIST: Jane Doe, MD
ESTIMATED BLOOD LOSS: Less than 50 mL.
DRAINS: A 16-French Foley catheter.
SPECIMENS: None.
INDICATIONS: This is a (XX)-year-old male who was found to have prostate cancer with a Gleason score of 3 + 4 = 7, which was found bilaterally at the apex, mid portion, and base. All sites were involved and 9 of 12 cores were positive for cancer. The maximum size of carcinoma was 8 mm; 15% of the tissue was involved. The Gleason score was 3 + 4 = 7 with 30% to 40% Gleason grade 4. The patient’s PSA level was elevated at 7.32. Rectal exam revealed a nodule at the right base extending towards the seminal vesicle. This patient has decided to undergo cryosurgical ablation as treatment for curative intent of his prostate cancer.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and general anesthesia was given. He was then placed in lithotomy position and shaved over the perineum and also over the suprapubic area, in anticipation of possible suprapubic cystostomy tube placement. The patient was prepped in standard fashion and sterile drapes were applied. A transrectal ultrasound probe was then inserted into the rectum. Transrectal ultrasound of the prostate was then performed for volume determination. Measurements were made of the prostate, yielding a height of 47 mm, width of 36 mm, and length of 44 mm. The calculated volume is acceptable for cryosurgical ablation. The patient was also determined not to need a suprapubic catheter for postoperative drainage because of his relatively small prostate size. The prostate was carefully mapped and plans were made to insert 7 IceRod cryotherapy needles by ultrasound guidance for the cryosurgical ablation. It should be noted that during the transrectal ultrasound procedure, aerated KY jelly was injected into the urethra, so that the urethra could be visualized by ultrasound.
Cryotherapy needles were then placed, beginning by placing two needles in the anterior row on channel 1, two needles were then placed in the middle row on channel 2, two lateral needles were placed in the posterior row with the right needle on channel 3 and the left needle on channel 4, a midline needle was placed in the posterior row on channel 5. A temperature probe labeled T1 was placed into the Denonvilliers fascia at the level of the insertion of the rectourethralis muscle. A T2 temperature probe was placed at the level of the external urethral sphincter. Each needle tip was advanced until the tip reached the proper location, as confirmed by both transverse and sagittal ultrasound views.
Cystoscopy was then performed with the flexible cystoscope to confirm that no needles passed through the prostate into the bladder and also to confirm that no needles had penetrated the prostatic urethra. At the end of the cystoscopic procedure, a Super Stiff guidewire was passed through the scope and left in the bladder. The scope was then back-loaded off the wire. The urethral warmer device was placed over the guidewire into the bladder. This was connected to continuous warm irrigating solution, which was kept at 43 degrees throughout the rest of the case.
Cryosurgical ablation of the prostate was then performed using the Galil SeedNet argon-based cryotherapy unit. The needles were activated sequentially from the anterior row to the middle row to the posterior row, and the progress of the cryotherapy was followed by ultrasound and by monitoring the thermal sensors. After the first freezing cycle, the Denonvilliers fascia reached a minimal temperature of -14 degrees centigrade. The external sphincter temperature probe reached a temperature of 1 degree centigrade. An active thaw cycle was then performed. When all areas of the prostate became isoechoic and temperature in all thermal sensors had reached above 30 degrees centigrade, the second freezing cycle was commenced. Once again, the prostate was completely frozen and the freezing was followed all the way down to the level of Denonvilliers fascia. The T1 probe was noted to reach a temperature of -9 degrees centigrade. The T2 probe in the external urethral sphincter reached a low temperature of 4 degrees centigrade.
Active thaw was then performed and all temperature and cryotherapy needles were removed. A passive thaw cycle was then continued for an additional 20 minutes. At that point, the urethral warming device was removed, a 16-French Foley catheter was passed through the urethra into the bladder and 10 mL was inflated into the catheter balloon. The catheter was connected to gravity drainage. Rectal exam confirmed that the rectal mucosa was intact and freely mobile. Compression was applied through a surgical towel onto the perineum until bleeding had stopped at the needle puncture sites. An ABD pad with triple antibiotic ointment was then placed over this area and secured with paper tape. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
