![CASE REPORT OPEN ACCESS
International Journal of Surgery Case Reports 13 (2015) 8890
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports
journal homepage: www.casereports.com
Surgical access for radical retropubic prostatectomy in the
phenotypically narrow and steep black males pelvis is exacerbated by
a posterior pubic symphyseal protuberance: A case report
William Derval Aikena,
, Warren Chinb
a
Division of Urology, Section of Surgery, Department of Surgery, Radiology, Anaesthesia and Intensive Care, Faculty of Medical Sciences, University of the
West Indies, Mona, Kingston 7, WI, Jamaica
b
Department of Urology, Kingston Public Hospital, South-East Regional Health Authority, Kingston, WI, Jamaica
a r t i c l e i n f o
Article history:
Received 11 April 2015
Received in revised form 16 June 2015
Accepted 20 June 2015
Available online 26 June 2015
Keywords:
Pubic symphysis
Prostate cancer
Radical retropubic prostatectomy
Protuberance
Black men
Male pelvis
a b s t r a c t
INTRODUCTION: Men of African descent are known to have a narrower and steeper pelvis that is associated
with a higher risk of positive surgical margins after radical retropubic prostatectomy. We describe the
additional challenge posed when a very prominent posterior pubic symphyseal protuberance is present
in the pelvis of a Black man during this operation and how to overcome it.
PRESENTATION OF CASE: A 61-year old man of African-descent with organ-con鍖ned prostate cancer
underwent a radical retropubic prostatectomy. He had a very prominent posterior pubic symphyseal
protuberance on a background of a phenotypically narrow and steep pelvis, precluding adequate surgi-
cal access to the prostate. Using a combination of resection of the protuberance, modi鍖cation of patient
position and lighting, coordinated retraction and long instruments, surgical access was achieved.
DISCUSSION: The coexistence of a very prominent posterior pubic symphyseal protuberance in a Black
male with a narrow and steep pelvis poses a surgical challenge in accessing the prostate, particularly the
apex. This can be overcome by surgical resection of the protuberance, patient waist extension by operating
table 鍖exion, use of head lamps or intracavitary lighting, adequate retraction and use of appropriately
long instruments.
CONCLUSION: Surgical access to the prostate, particularly its apex, when performing radical retropubic
prostatectomy in a Black man with a very prominent posterior pubic symphyseal protuberance may be
achieved by a combination of manoeuvres and adjuncts described herein.
息 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
It is known that Black men have a narrower and steeper pelvis
compared to white men and this variation has been shown to inde-
pendently increase the risk of positive surgical margins during
radical retropubic prostatectomy (RRP) for prostate cancer (PCa)
due to the dif鍖culty of apical prostate dissection [1]. Men of all
races on occasions may also have a marked protuberance from the
posterior aspect of the pubic symphysis that is variably composed
of cartilage or bone and it too has been described as increasing the
dif鍖culty of radical prostatectomy [2,3].
When a very prominent posterior pubic symphyseal protuber-
ance is present in a man of African descent with a phenotypically
narrow and steep pelvis, we propose that it makes safe apical
dissection via the retropubic approach virtually impossible due
Corresponding author. Fax: +1 876 970 4302.
E-mail addresses: william.aiken@uwimona.edu.jm, uroplum23@yahoo.com
(W.D. Aiken), chin.urology@gmail.com (W. Chin).
to inability to directly visualize the deeply located apex of the
prostate. The situation is exacerbated when the prostate is large
and/or the patient is overweight or obese. A combination of mod-
i鍖cation of patient position with suf鍖cient retro鍖exion of the
waist, additional light emitting diode (LED) head or intracavitary
lights, resection of the posterior pubic symphyseal protuberance,
adequate retraction and appropriately long instruments is rec-
ommended to safely perform the procedure and maximize good
oncologic control and functional outcomes.
2. Case presentation
A 61-year old Jamaican man of African descent, a farmer from
a rural parish, was referred to the urologist with a diagnosis of
a Gleason 6 adenocarcinoma of the prostate already having been
made on transrectal ultrasound-guided biopsy. He denied having
any co-morbid illnesses or constitutional symptoms and was not
taking any medication. He had no lower urinary tract symptoms
(LUTS) and denied a family history of PCa. Pre-biopsy prostate-
speci鍖c antigen (PSA) was 13 ng/ml. Physical examination revealed
http://dx.doi.org/10.1016/j.ijscr.2015.06.016
2210-2612/息 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).](https://image.slidesharecdn.com/1e1f4e3b-b213-4008-8070-f7a669d8484e-150709030044-lva1-app6892/85/Author-copy_PPSP_RRP_Black-men_WDA-1-320.jpg)
![CASE REPORT OPEN ACCESS
W.D. Aiken, W. Chin / International Journal of Surgery Case Reports 13 (2015) 8890 89
Fig. 1. Intraoperative photograph showing a prominent posterior pubic symphyseal
protuberance viewed from above, limiting access to the prostate.
a well-looking, slightly overweight, middle-aged man who looked
his stated age. Digital rectal examination (DRE) revealed a clinically
benign prostate (cT1c). Treatment options were discussed with the
patient and he chose to have a radical retropubic prostatectomy.
At surgery a sub-umbilical 5 cm midline incision beginning at
the symphysis pubis and extending superiorly was made with the
patient in the supine position and with the bed slightly broken at
the level of the patients iliac crest. The prostate was approached
extraperitoneally in the cave of Retzius but it could not be visualized
in its entirety due to a very prominent posterior pubic symphyseal
protuberance that projected upwards and posteriorly preventing
direct observation of the lower half of the prostate (Fig. 1). Addition-
ally, the patients pelvis was characteristically narrow and deep.
The posterior pubic symphyseal protuberance was resected with
the cutting electrocautery as recommended and described by Kim
et al. [3] and following this the prostate was more readily visual-
ized (Fig. 2) but the region of the apical prostate was still dif鍖cult
to access due to the con鍖guration of the pelvis.
To facilitate visualization of the apical prostate the patients
position was modi鍖ed by further 鍖exion of the operating table
resulting in additional waist extension (Fig. 3) and additional LED
head lights were used to visualize the depths of the pelvis. The
urinary bladder and peritoneal contents were retracted superiorly
using a Balfour retractor with middle blade centered on the in-situ
catheter balloon in鍖ated to 30 ml, thereby exerting upward trac-
tion on the prostate making taut its anterior adventitial coverings.
Finally, with the use of instruments of appropriate length, the api-
cal prostate was accessible, particularly after control and division of
the deep dorsal venous plexus, which was now easier to do with the
improved visualization after the above-mentioned manoeuvres.
The patient made an uneventful recovery and was discharged
home on day three postoperatively with the catheter in-situ, to
return in two weeks for catheter removal. He returned two weeks
later and had the catheter removed and has been completely
Fig. 2. View of the retropubic space after resection of the posterior pubic sym-
physeal protuberance and with a sponge stick depressing the prostate showing
improved access.
Fig. 3. Male model lying supine on 鍖exed operating table demonstrating waist
extension used to improve visualization of prostatic apex.
continent of urine. At 4 months post-surgery he is having penile
tumescence but not full rigidity as yet. He is on Tadala鍖l 5 mg once
daily to encourage early return of erections. Pathological assess-
ment demonstrated a pT2b (organ con鍖ned) tumour with negative
surgical margins. Postoperative PSA is 0 ng/ml.
3. Discussion
In Black men in whom the pelvic cavity is characteristically
narrow and steep, surgical access to the prostate via the retrop-
ubic approach is sometimes challenging. This is especially so for
the prostatic apex and is exacerbated when the prostate is large](https://image.slidesharecdn.com/1e1f4e3b-b213-4008-8070-f7a669d8484e-150709030044-lva1-app6892/85/Author-copy_PPSP_RRP_Black-men_WDA-2-320.jpg)
![CASE REPORT OPEN ACCESS
90 W.D. Aiken, W. Chin / International Journal of Surgery Case Reports 13 (2015) 8890
and/or the patient is overweight or obese. In this situation there is
a documented compromise of oncologic outcome as indicated by
an increased risk of positive surgical margins [1].
If, in addition, a posterior pubic symphyseal protuberance is
present, as was the case here, surgical access is further compro-
mised and then it becomes necessary not only to institute the
several manoeuvres to aid access in the pelvis of the man of
African descent, such as supplemental lighting via head or intra-
cavitary lights, adequate retraction, usually achieved inexpensively
with a regular Balfour abdominal retractor with a malleable or
curved middle blade tautly retracting superiorly the urinary blad-
der with the contained balloon catheter in鍖ated with 30 ml of
water, modifying the supine position by varying degrees of waist
extension accomplished by breaking the operating table and using
instruments of appropriate length; but, speci鍖cally addressing the
posterior pubic symphyseal protuberance is necessary.
Resection of the posterior pubic symphyseal protuberance is
necessary to achieve adequate visualization and surgical access
and is accomplished simply by using electrocautery on cut settings
when the protuberance is cartilaginous in nature [3,4], but on other
occasions it may be necessary to chisel bone, with adequate protec-
tion of the soft tissues, if the protuberance is predominantly bony
and osteophytic in nature as described by Marshall et al. [2]. It
would be dangerous to proceed without 鍖rst having good access
to the prostate and in particular the prostatic apex as doing so
increases the risk of positive surgical margins and may compromise
functional outcomes.
Con鍖icts of interest
The authors have no con鍖icts of interest to declare.
Funding
There was no source of funding for this study.
Ethical approval
Ethics approval was not sought for this case report.
Consent
Written informed consent was obtained from the patient for
publication of this case report and accompanying images. A copy
of the written consent is available for review by the Editor-in-Chief
of this journal on request.
Author contribution
William Aiken conceptualised the paper and wrote the initial
draft.
Warren Chin helped to write the paper and contributed useful
insights.
Both authors have read and approved the 鍖nal manuscript.
Guarantor
William Aiken.
References
[1] C. Von Bodman, M.P. Matikainen, L.H. Yunis, et al., Ethnic variation in
pelvimetric measures and its impact on positive surgical margins at radical
prostatectomy, Urology 76 (5) (2010) 10921096, http://dx.doi.org/10.1016/j.
urology.2010.02.020
[2] F.F. Marshall, S.C. Hortopan, Y. Lakshmanan, Partial resection of symphysis: an
aid in radical prostatectomy, J. Urol. 157 (2) (1997) 578579 (accessed
28.11.14) http://www.ncbi.nlm.nih.gov/pubmed/8996362
[3] S.C. Kim, A.C. Weiser, R.B. Nadler, Resection of a posterior pubic symphyseal
protuberance using the electrocautery device, Urology 55 (4) (2000) 586587
(accessed 28.11.14) http://www.ncbi.nlm.nih.gov/pubmed/10736509
[4] K. Robertson, M. Verghese, S.R. Ghasemian, A.M. Kwart, A novel technique of
exposure during radical retropubic prostatectomy, J. Urol. 167 (5) (2002)
21232124 (accessed 28.11.14) http://www.ncbi.nlm.nih.gov/pubmed/
11956455
Open Access
This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which
permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are
credited.](https://image.slidesharecdn.com/1e1f4e3b-b213-4008-8070-f7a669d8484e-150709030044-lva1-app6892/85/Author-copy_PPSP_RRP_Black-men_WDA-3-320.jpg)
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- 1. CASE REPORT OPEN ACCESS International Journal of Surgery Case Reports 13 (2015) 8890 Contents lists available at ScienceDirect International Journal of Surgery Case Reports journal homepage: www.casereports.com Surgical access for radical retropubic prostatectomy in the phenotypically narrow and steep black males pelvis is exacerbated by a posterior pubic symphyseal protuberance: A case report William Derval Aikena, , Warren Chinb a Division of Urology, Section of Surgery, Department of Surgery, Radiology, Anaesthesia and Intensive Care, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston 7, WI, Jamaica b Department of Urology, Kingston Public Hospital, South-East Regional Health Authority, Kingston, WI, Jamaica a r t i c l e i n f o Article history: Received 11 April 2015 Received in revised form 16 June 2015 Accepted 20 June 2015 Available online 26 June 2015 Keywords: Pubic symphysis Prostate cancer Radical retropubic prostatectomy Protuberance Black men Male pelvis a b s t r a c t INTRODUCTION: Men of African descent are known to have a narrower and steeper pelvis that is associated with a higher risk of positive surgical margins after radical retropubic prostatectomy. We describe the additional challenge posed when a very prominent posterior pubic symphyseal protuberance is present in the pelvis of a Black man during this operation and how to overcome it. PRESENTATION OF CASE: A 61-year old man of African-descent with organ-con鍖ned prostate cancer underwent a radical retropubic prostatectomy. He had a very prominent posterior pubic symphyseal protuberance on a background of a phenotypically narrow and steep pelvis, precluding adequate surgi- cal access to the prostate. Using a combination of resection of the protuberance, modi鍖cation of patient position and lighting, coordinated retraction and long instruments, surgical access was achieved. DISCUSSION: The coexistence of a very prominent posterior pubic symphyseal protuberance in a Black male with a narrow and steep pelvis poses a surgical challenge in accessing the prostate, particularly the apex. This can be overcome by surgical resection of the protuberance, patient waist extension by operating table 鍖exion, use of head lamps or intracavitary lighting, adequate retraction and use of appropriately long instruments. CONCLUSION: Surgical access to the prostate, particularly its apex, when performing radical retropubic prostatectomy in a Black man with a very prominent posterior pubic symphyseal protuberance may be achieved by a combination of manoeuvres and adjuncts described herein. 息 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction It is known that Black men have a narrower and steeper pelvis compared to white men and this variation has been shown to inde- pendently increase the risk of positive surgical margins during radical retropubic prostatectomy (RRP) for prostate cancer (PCa) due to the dif鍖culty of apical prostate dissection [1]. Men of all races on occasions may also have a marked protuberance from the posterior aspect of the pubic symphysis that is variably composed of cartilage or bone and it too has been described as increasing the dif鍖culty of radical prostatectomy [2,3]. When a very prominent posterior pubic symphyseal protuber- ance is present in a man of African descent with a phenotypically narrow and steep pelvis, we propose that it makes safe apical dissection via the retropubic approach virtually impossible due Corresponding author. Fax: +1 876 970 4302. E-mail addresses: william.aiken@uwimona.edu.jm, uroplum23@yahoo.com (W.D. Aiken), chin.urology@gmail.com (W. Chin). to inability to directly visualize the deeply located apex of the prostate. The situation is exacerbated when the prostate is large and/or the patient is overweight or obese. A combination of mod- i鍖cation of patient position with suf鍖cient retro鍖exion of the waist, additional light emitting diode (LED) head or intracavitary lights, resection of the posterior pubic symphyseal protuberance, adequate retraction and appropriately long instruments is rec- ommended to safely perform the procedure and maximize good oncologic control and functional outcomes. 2. Case presentation A 61-year old Jamaican man of African descent, a farmer from a rural parish, was referred to the urologist with a diagnosis of a Gleason 6 adenocarcinoma of the prostate already having been made on transrectal ultrasound-guided biopsy. He denied having any co-morbid illnesses or constitutional symptoms and was not taking any medication. He had no lower urinary tract symptoms (LUTS) and denied a family history of PCa. Pre-biopsy prostate- speci鍖c antigen (PSA) was 13 ng/ml. Physical examination revealed http://dx.doi.org/10.1016/j.ijscr.2015.06.016 2210-2612/息 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
- 2. CASE REPORT OPEN ACCESS W.D. Aiken, W. Chin / International Journal of Surgery Case Reports 13 (2015) 8890 89 Fig. 1. Intraoperative photograph showing a prominent posterior pubic symphyseal protuberance viewed from above, limiting access to the prostate. a well-looking, slightly overweight, middle-aged man who looked his stated age. Digital rectal examination (DRE) revealed a clinically benign prostate (cT1c). Treatment options were discussed with the patient and he chose to have a radical retropubic prostatectomy. At surgery a sub-umbilical 5 cm midline incision beginning at the symphysis pubis and extending superiorly was made with the patient in the supine position and with the bed slightly broken at the level of the patients iliac crest. The prostate was approached extraperitoneally in the cave of Retzius but it could not be visualized in its entirety due to a very prominent posterior pubic symphyseal protuberance that projected upwards and posteriorly preventing direct observation of the lower half of the prostate (Fig. 1). Addition- ally, the patients pelvis was characteristically narrow and deep. The posterior pubic symphyseal protuberance was resected with the cutting electrocautery as recommended and described by Kim et al. [3] and following this the prostate was more readily visual- ized (Fig. 2) but the region of the apical prostate was still dif鍖cult to access due to the con鍖guration of the pelvis. To facilitate visualization of the apical prostate the patients position was modi鍖ed by further 鍖exion of the operating table resulting in additional waist extension (Fig. 3) and additional LED head lights were used to visualize the depths of the pelvis. The urinary bladder and peritoneal contents were retracted superiorly using a Balfour retractor with middle blade centered on the in-situ catheter balloon in鍖ated to 30 ml, thereby exerting upward trac- tion on the prostate making taut its anterior adventitial coverings. Finally, with the use of instruments of appropriate length, the api- cal prostate was accessible, particularly after control and division of the deep dorsal venous plexus, which was now easier to do with the improved visualization after the above-mentioned manoeuvres. The patient made an uneventful recovery and was discharged home on day three postoperatively with the catheter in-situ, to return in two weeks for catheter removal. He returned two weeks later and had the catheter removed and has been completely Fig. 2. View of the retropubic space after resection of the posterior pubic sym- physeal protuberance and with a sponge stick depressing the prostate showing improved access. Fig. 3. Male model lying supine on 鍖exed operating table demonstrating waist extension used to improve visualization of prostatic apex. continent of urine. At 4 months post-surgery he is having penile tumescence but not full rigidity as yet. He is on Tadala鍖l 5 mg once daily to encourage early return of erections. Pathological assess- ment demonstrated a pT2b (organ con鍖ned) tumour with negative surgical margins. Postoperative PSA is 0 ng/ml. 3. Discussion In Black men in whom the pelvic cavity is characteristically narrow and steep, surgical access to the prostate via the retrop- ubic approach is sometimes challenging. This is especially so for the prostatic apex and is exacerbated when the prostate is large
- 3. CASE REPORT OPEN ACCESS 90 W.D. Aiken, W. Chin / International Journal of Surgery Case Reports 13 (2015) 8890 and/or the patient is overweight or obese. In this situation there is a documented compromise of oncologic outcome as indicated by an increased risk of positive surgical margins [1]. If, in addition, a posterior pubic symphyseal protuberance is present, as was the case here, surgical access is further compro- mised and then it becomes necessary not only to institute the several manoeuvres to aid access in the pelvis of the man of African descent, such as supplemental lighting via head or intra- cavitary lights, adequate retraction, usually achieved inexpensively with a regular Balfour abdominal retractor with a malleable or curved middle blade tautly retracting superiorly the urinary blad- der with the contained balloon catheter in鍖ated with 30 ml of water, modifying the supine position by varying degrees of waist extension accomplished by breaking the operating table and using instruments of appropriate length; but, speci鍖cally addressing the posterior pubic symphyseal protuberance is necessary. Resection of the posterior pubic symphyseal protuberance is necessary to achieve adequate visualization and surgical access and is accomplished simply by using electrocautery on cut settings when the protuberance is cartilaginous in nature [3,4], but on other occasions it may be necessary to chisel bone, with adequate protec- tion of the soft tissues, if the protuberance is predominantly bony and osteophytic in nature as described by Marshall et al. [2]. It would be dangerous to proceed without 鍖rst having good access to the prostate and in particular the prostatic apex as doing so increases the risk of positive surgical margins and may compromise functional outcomes. Con鍖icts of interest The authors have no con鍖icts of interest to declare. Funding There was no source of funding for this study. Ethical approval Ethics approval was not sought for this case report. Consent Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Author contribution William Aiken conceptualised the paper and wrote the initial draft. Warren Chin helped to write the paper and contributed useful insights. Both authors have read and approved the 鍖nal manuscript. Guarantor William Aiken. References [1] C. Von Bodman, M.P. Matikainen, L.H. Yunis, et al., Ethnic variation in pelvimetric measures and its impact on positive surgical margins at radical prostatectomy, Urology 76 (5) (2010) 10921096, http://dx.doi.org/10.1016/j. urology.2010.02.020 [2] F.F. Marshall, S.C. Hortopan, Y. Lakshmanan, Partial resection of symphysis: an aid in radical prostatectomy, J. Urol. 157 (2) (1997) 578579 (accessed 28.11.14) http://www.ncbi.nlm.nih.gov/pubmed/8996362 [3] S.C. Kim, A.C. Weiser, R.B. Nadler, Resection of a posterior pubic symphyseal protuberance using the electrocautery device, Urology 55 (4) (2000) 586587 (accessed 28.11.14) http://www.ncbi.nlm.nih.gov/pubmed/10736509 [4] K. Robertson, M. Verghese, S.R. Ghasemian, A.M. Kwart, A novel technique of exposure during radical retropubic prostatectomy, J. Urol. 167 (5) (2002) 21232124 (accessed 28.11.14) http://www.ncbi.nlm.nih.gov/pubmed/ 11956455 Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.