PMC4529652_01
Intraoperative photograph showing a prominent posterior pubic symphyseal protuberance viewed from above, limiting access to the prostate.
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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).
View of the retropubic space after resection of the posterior pubic symphyseal protuberance and with a sponge stick depressing the prostate showing improved access.
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The posterior pubic symphyseal protuberance was resected with the cutting electrocautery as recommended and described by Kim et al. and following this the prostate was more readily visualized (Fig. 2) but the region of the apical prostate was still difficult to access due to the configuration of the pelvis.
Male model lying supine on flexed operating table demonstrating waist extension used to improve visualization of prostatic apex.
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To facilitate visualization of the apical prostate the patient's position was modified by further flexion 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.