1. For the students of Gulf Medical University, Ajman, MBBSDr. 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. Capsules Surrounded by connective tissue true capsule and condensation of pelvic fascia (false capsule), -separated by the prostatic venousplexusIn prostatectomy-both capsules with the venous plexus are retained and the gland is enucleated. 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 Batsons plexus of paravertebralveins>>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 primarilydrains 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, visceralefferent, 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, Supplies1-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 thesacral 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 1. Anterior 2.Lateral 3.Posterior 4.Median 20. Anterior lobeLies 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 lobesbetween 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 urethraProstatic 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 theopenings 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 thefused paramesonephric ducts- the male homologue of the uterus and upper vagina. 28. Zonal Classification of Prostate 1. Transitional zone-Median lobe2. Central zone 3. Peripheral zonePosterior & Lateral lobes4. Anterior fibromuscular stroma-Anterior lobe 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 regionlocated in the anteromedial portion of the gland extends from bladder neck to striated urethral sphincter. 33. Periurethral glands1% 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