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OPERATIVE REPORT Patient Name: Richard Cates Patient ID: 002876DOB: 02/02 Age: 53 Sex: M Date of Admission: 01/25/2012 Date of Procedure: 01/26/2012 Admitting Physician: Bernard Kester, MD Surgeon: Bernard Kester, MD Assistant: Jimmy Dale Jett, RN, Circulating Nurse Preoperative Diagnosis: Prostate Cancer.

Postoperative Diagnosis: Prostate Cancer. Operative Procedure: Laparoscopic radical prostatectomy. Anesthesia: General endotracheal by Dr. Carl Erickson Avalon. Specimen Removed: Prostate. IV Fluids: See Nurses Notes.

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Estimated Blood Loss: 600mL. Blood Transfusions: None. Urine Output: See Nurses Notes.Complications: None. INDICATIONS: This is a 53 year old Caucasian male with recently diagnosed localized prostate cancer.

He presents now a laparoscopic prostatectomy. DESCRIPTION OF OPERATION: The patient was placed on the operating room table in supine position. He was prepped and draped in the usual sterile fashion. A rectal catheter was placed prior to draping the patient and a Foley catheter was placed on the field using a septic technique. A midline infraumbilical incision approximately 2cm in length was made.

The section was carried down to level of the fascia, which was incised in the midline.The space of Retzius was developed bluntly with the index finger and then the peritoneum was swept cephalad to allow pararectal 12mm trocar placement bilaterally. These were placed and the balloon trocar was placed in the midline incision. Subsequently under lapascropic vision, the space was developed such that the pubis was identified. The peritoneum OPERATIVE REPORT Patient Name: Richard Cates Patient ID: 002876 Date of Procedure: 01/26/2012 Page 2 was again swept cephalad laterally, such that the 5ml trocars could be placed at the anterior superior iliac spine bilaterally.

The endopelvic fascia was incised and the puboprostatic ligaments were incised and stints were placed around the dorsal venous complex. Next the anterior bladder neck was incised and the ureteral orifices were identified with the assistance of indigo carmine. With the orifices under direct vision the posterior bladder neck was divided and the retrovesical space entered. The vasa deferentia were identified and divided along with the seminal vesicles which were dissected out. Care was taken to cauterize feeding vessels to the seminal vesicles.

Next Denonvilliers fascia was identified and was incised. The plane between the rectum and the prostate was developed. Pedicles were cauterized and taken down off the prostate. This allowed for neurovascular bundle dissection with cold scissors. Next staying right on the capsule of the prostate we pushed the neurovascular bundles laterally.

Next the dorsal venous complex was divided with cautery and the urethra was identified and incised with cold scissors. With the urethra divided the prostate was amputated and it was removed via Endo Catch bag through the midline incision.The balloon trocar was replaced after the prostate had been removed and the rectum was checked for injury by flooding the pelvis with irrigation fluid and injecting air through the rectal Foley. No sign of rectal injury was seen therefore attention was turned toward reconstruction. The bladder neck was reconstructed in a tennis racket fashion using a 2-0 Vicryl stitch posteriorly. The orifices were under direct vision during this reconstruction.

With the newly reconstructed bladder neck approximately 24 French in size, the anastomosis was started using a double armed 2-0 Monocryl stitch.The posterior line was completed and the final Foley catheter was then positioned. This was the number 22 French Foley catheter. Finally the anterior row of the anastomosis was completed in running fashion. Lapra-Ty sutures were used to secure the stitches. The Foley balloon was inflated with 15mL of sterile water and the catheter in bladder were irrigated well with no leak identified.

A drain was placed exiting from the right lateral 5mm trocar site. It was stitched and placed at the level of the skin. All trocars were removed under direct vision. No bleeding was seen from the trocar sites.Midline incision was closed with a Vicryl stitch at the level of the fascia.

The skin was approximated for all trocar sites with the skin staples. Sterile dressings were applied. OPERATIVE REPORT Patient Name: Richard Cates Patient ID: 002876 Date of Procedure: 01/26/2012 Page 3 The Foley catheter was secured to the thigh. Good clear urine output was seen at the conclusion of the case. The patient tolerated the procedure well.

No complications. The patient was escorted to the recovery room in stable condition. Once he meets all his criteria he will be discharged to home. ______________________________________________ Bernard Kester, MD