Skip to main content

Perineal Bookwalter — Jordan and Brooke Modifications

The perineal Bookwalter is a family of specialty-blade adaptations of the standard Bookwalter ring system for deep perineal exposure. Two named modifications anchor the family in reconstructive urology:

  • Jordan perineal modification — developed by Gerald H. Jordan (Eastern Virginia Medical School) for deep posterior urethroplasty and the operative cone it requires.
  • Brooke Bookwalter blade — described by Thompson, Harris and colleagues in the late 1990s for radical perineal prostatectomy during the perineal-RP resurgence.[1][2]

Both modifications share the Bookwalter's defining table-fixed ring architecture; what differs is the blade geometry matched to the specific perineal target — bulbar / membranous urethra and posterior pubic stump for the Jordan, deep prostatic apex and seminal-vesicle plane for the Brooke.

The Two Modifications​

Jordan perineal modification — posterior urethroplasty​

  • Bookwalter-style circumferential ring mounted to a table-fixed post between the patient's legs.
  • Perineal-specific blades that hook under the ischial tuberosities and provide deep stable retraction of the perineal corridor.
  • Thigh retractors that pull the legs outward, creating the exaggerated-lithotomy operative cone required for posterior urethroplasty.

Why it matters: posterior urethroplasty requires deep, stable exposure maintained for hours through a narrow perineal corridor. Lighter wound-edge systems (Lone Star, Adson-Beckman) cannot achieve the depth needed to reach the membranous urethra in exaggerated lithotomy. The Jordan-modified perineal Bookwalter creates the cone, anchors it to the table, and holds the exposure rock-steady through the multi-hour case.

RU uses for the Jordan modification:

  • Posterior urethroplasty for pelvic-fracture urethral injuries (PFUI) — the signature application.
  • Re-do bulbar / membranous urethroplasty through hostile re-operative perineal tissue.
  • Transperineal RUF repair with gracilis interposition.
  • Complex perineal reconstruction that needs sustained deep exposure beyond what the Turner-Warwick perineal retractor can deliver.

Brooke blade — radical / simple perineal prostatectomy​

  • Specialized deep-retraction blade that attaches to the standard Bookwalter ring at the perineal posterior position.
  • Provides deep posterior / superior retraction that exposes the prostatic apex, prostatic pedicles, seminal vesicles, and vasa deferentia through the perineal approach.
  • Enables full mobilization of the seminal vesicles before apical prostatic dissection — a notoriously difficult step in perineal-RP — and supports the bladder-neck-sparing technique associated with improved continence.[1]
  • Allows a single surgeon to perform the entire perineal prostatectomy without an assistant dedicated to retraction.[1]

Use cases relevant to the WARWIKI scope (radical prostatectomy is primarily cancer surgery and out of scope as a primary topic; the Brooke blade enters reconstructive practice through):

  • Simple perineal prostatectomy for selected BPH patients — Bernie & Schmidt 2003 modern series.[3]
  • Reconstructive consequences of radical perineal prostatectomy — perineal-prostatectomy patients later need BNR for BNC, AUS or sling for SUI, RUF repair, and salvage perineal exposures, all of which inherit the Bookwalter / Brooke perineal-exposure paradigm.
  • Salvage perineal exposure after pelvic radiation when the rectum and prostatic bed are scarred and the surgeon needs maximal deep retraction.

Setup for the Perineal Case​

The perineal Bookwalter configuration differs from the abdominal Bookwalter setup:

  1. Position: exaggerated lithotomy on a perineal-prostatectomy / urethroplasty table, hips and knees flexed beyond 90°, scrotum and perineum exposed.
  2. Post placement: post and clamp attached to the side rail between the patient's legs.
  3. Ring orientation: ring positioned over the perineal wound, parallel to the perineal skin, oriented for 360° circumferential retraction of perineum, scrotum, and surrounding soft tissues.
  4. Blade sequence: anterior and lateral perineal blades first, retracting ischiorectal fat, bulbospongiosus, and perineal skin; then the Jordan thigh / ischial-tuberosity blades for the deep cone (urethroplasty) or the Brooke deep posterior blade for the prostatic / seminal-vesicle plane.[1]
  5. Reassess every 30–60 minutes — the same blade-pressure principles that govern abdominal Bookwalter use apply with greater consequence in the perineal corridor because the femoral nerve, peroneal nerve, and rectum are all close to the blade footprint.

Safety in the Perineal Corridor​

The standard Bookwalter safety profile applies, with perineal-specific risks that warrant additional attention:[4][5]

  • Rectal injury — the rectum lies directly posterior to the prostate and membranous urethra; an over-tensioned deep posterior Brooke blade or Jordan posterior blade is the canonical mechanism. Periodic rectal exam during long perineal cases is a low-cost safety check.
  • Femoral / peroneal neuropraxia — lithotomy plus prolonged retractor tension is the worst-case combination for lower-extremity nerve injury. Limit combined lithotomy + retractor time and check leg position periodically.
  • Pudendal-nerve neuropraxia — blade compression of the pudendal nerve in Alcock's canal during prolonged perineal exposure.
  • Posterior-urethral injury from inadvertent deep-blade engagement during posterior urethroplasty dissection.

Comparison Within the Perineal-Retractor Family​

RetractorMountingFrame / bladesBest fit
Perineal Bookwalter — JordanTable-fixed postStandard ring + perineal / thigh / ischial bladesPosterior urethroplasty, PFUI repair
Perineal Bookwalter — Brooke bladeTable-fixed postStandard ring + deep posterior prostatic bladePerineal prostatectomy (simple / radical), perineal reconstructive salvage
Turner-WarwickPatient-supported ringRing + 360° interchangeable bladesBulbar / membranous urethroplasty when table-fixed setup is unnecessary
Lone StarDisposable plastic ringElastic stays with hooksSoft-tissue perineal traction (urethroplasty, hypospadias, vaginal, anorectal)
Young perineal retractorHandheldFixed perineal bladeHistorical perineal prostatectomy; not self-retaining
Adson-BeckmanSelf-retaining wedgeTwo-blade frameSuperficial perineal exposure only

Why Two Modifications Belong Together​

Both the Jordan and Brooke perineal Bookwalter share the same architectural insight: for the deep perineal case, the table-fixed Bookwalter ring delivers more stable, sustainable exposure than any wound-edge or patient-supported alternative, but only when the blade geometry matches the target. Jordan's blade family was engineered for the urethral cone; Brooke's deep posterior blade was engineered for the prostatic-apical / seminal-vesicle plane. Both demonstrate that the Bookwalter system's modularity is its real value — the ring is a platform, and the specialty blade designs are the operative levers.

Historical Context​

  • Gerald H. Jordan — one of the founders of the modern US reconstructive tradition through the Devine-Jordan school at EVMS. The Jordan perineal modification was developed to operationalize the exposure required for the posterior-urethroplasty techniques he championed. Remains the gold-standard exposure for deep perineal reconstruction.
  • Thompson and Harris (1997) — described the Brooke Bookwalter blade as part of the late-1990s renewed interest in anatomic radical perineal prostatectomy.[1][2] Although robotic-assisted prostatectomy has since become the dominant approach, the Brooke blade persists as a useful deep-perineal-exposure tool whenever the perineal route is selected (simple perineal prostatectomy, perineal salvage exposure, perineal reconstructive cases in the post-prostatectomy patient).

See also: Bookwalter Retractor, Turner-Warwick Retractor, Lone Star, Turner-Warwick Ryder, Gerald H. Jordan profile.

References​

1. Thompson IM, Rozanski TA, Foley JP, Harris M. "Facilitated radical perineal prostatectomy with the Brooke Bookwalter retractor blade." Urology. 1997;49(5):766–7. doi:10.1016/S0090-4295(97)00061-7

2. Harris MJ, Thompson IM. "The anatomic radical perineal prostatectomy: a contemporary and anatomic approach." Urology. 1996;48(5):762–8. doi:10.1016/S0090-4295(96)00252-X

3. Bernie JE, Schmidt JD. "Simple perineal prostatectomy: lessons learned from a modern series." J Urol. 2003;170(1):115–8. doi:10.1097/01.ju.0000071681.03755.b3

4. Noldus J, Graefen M, Huland H. "Major postoperative complications secondary to use of the Bookwalter self-retaining retractor." Urology. 2002;60(6):964–7. doi:10.1016/s0090-4295(02)01946-5

5. Melman A, Boczko J, Figueroa J, Leung AC. "Critical surgical techniques for radical perineal prostatectomy." J Urol. 2004;171(2 Pt 1):786–90. doi:10.1097/01.ju.0000107834.23316.59