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Perineal Bookwalter — Jordan and Brooke Modifications

The perineal Bookwalter is a table-fixed ring configured with blades for perineal exposure. Two names appear in the urologic literature:

  • Bookwalter-Jordan configuration. Described in posterior-urethroplasty teaching as one option for static ring exposure.[6]
  • 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 use a table-fixed ring with blade selection tailored to the target. Both are exposure aids; no comparative data show superiority over other perineal retractors.

The Two Modifications​

Jordan perineal modification — posterior urethroplasty​

  • Bookwalter-style circumferential ring mounted to a table-fixed post between the patient's legs.
  • Perineal blades. Selected and positioned for skin, bulbospongiosus and deeper corporal or urethral exposure. A 2025 technique article depicts rake and Richardson blades on a perineal Bookwalter; an assistant holds a separate Deaver retractor against the corpus cavernosum.[7]
  • Patient positioning and the ring are separate decisions. Posterior urethroplasty may use lithotomy and a static ring, but blades should not be used to pull the legs or substitute for safe positioning.

Posterior urethroplasty can require sustained exposure through a narrow perineal corridor. The 2018 open review states that a static ring such as Denis-Browne, Lone Star/Scott or Bookwalter-Jordan can facilitate the operation.[6]

RU uses for the Jordan modification:

  • Posterior urethroplasty for pelvic-fracture urethral injuries (PFUI) is the signature application.
  • Re-do bulbar / membranous urethroplasty through hostile re-operative perineal tissue.
  • Transperineal RUF repair with gracilis interposition.
  • Complex perineal reconstruction when a table-fixed ring and available blade set fit the required exposure.

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 or superior retraction that exposes the prostatic apex, prostatic pedicles, seminal vesicles, and vasa deferentia through the perineal approach.
  • The 1997 technical report states that the blade permits mobilization of the seminal vesicles and vasa before apical dissection and facilitates bladder-neck-sparing prostatectomy.[1]
  • Allows a single surgeon to perform the entire perineal prostatectomy without an assistant dedicated to retraction.[1]
  • A review of the perineal approach notes that it avoids the dorsal venous complex and can ease the vesicourethral anastomosis; the surgeon uses a modified Belt approach.[5]

Radical prostatectomy is primarily cancer surgery.

  • Simple perineal prostatectomy is described in a 22-patient retrospective open-prostatectomy series, including six perineal cases. The report does not specify use of the Brooke blade.[3]
  • Selected reconstructive or salvage perineal exposure may use a table-fixed ring with deep blades. No source establishes that irradiated or post-prostatectomy cases require the Brooke blade specifically.

Setup for the Perineal Case​

The perineal Bookwalter configuration differs from the abdominal Bookwalter setup:

  1. Position: use procedure-appropriate lithotomy with the perineum exposed and all pressure points protected. Exact hip and knee angles depend on the patient, table and operation.
  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. Begin with superficial blades and exchange or add deeper blades only as the dissection requires. The Brooke report supports its prostatic/seminal-vesicle exposure; a modern posterior-stenosis technique shows rake-to-Richardson exchange and selective handheld Deaver use.[1][7]
  5. Reassess frequently: keep blade tips and protected structures visible when possible, minimize force and duration, and coordinate retractor pressure with lithotomy-position checks. No universal reassessment interval has been established.

Safety in the Perineal Corridor​

The standard Bookwalter safety profile applies. The Noldus retrospective series found four large-bowel injuries and one femoral neuropathy in more than 4,000 uses over 10 years, mostly transperitoneal or retroperitoneal; it gives no perineal-Bookwalter event rate.[4]

  • Rectum, urethra and adjacent soft tissue: deep blades can injure structures outside the immediate view; insert and tension them under direct control and reassess after every change.
  • Position-related neuropathy. Exaggerated lithotomy is associated with lower-extremity neuropraxia, rhabdomyolysis and acute renal failure. Inadequate gel padding with a beanbag and operations lasting more than 5 hours increase these risks.[6] Padding, symmetric positioning and repeated checks are needed.
  • Blade pressure. Kaldany and colleagues use Bookwalter rake blades for initial exposure, exchange them for a ratcheted Richardson blade to retract the split bulbospongiosus atraumatically when circumferential exposure is needed, and use a separately held Deaver on the corpus cavernosum during unilateral dissection.[7]

Comparison Within the Perineal-Retractor Family​

RetractorMountingFrame / bladesReported or typical use
Perineal Bookwalter — JordanTable-fixed postRing + selected perineal bladesPosterior urethroplasty, PFUI repair
Perineal Bookwalter — Brooke bladeTable-fixed postStandard ring + deep posterior prostatic bladeRadical perineal prostatectomy
Turner-WarwickRing configuration varies by systemInterchangeable bladesAlternative perineal exposure platform
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​

The shared architectural point is modularity: a table-fixed ring supports different blades for different perineal targets. The Brooke blade has a discrete technical publication; “Bookwalter-Jordan” is used in posterior-urethroplasty teaching.[8] CS Surgical's 2013 catalog lists a Jordan-Simpson perineal set (CS1000-60) with a segmented ring and named blades compatible with Bookwalter and Simpson systems.[8] No head-to-head comparison with other perineal rings is cited here.

Historical Context​

  • Bookwalter-Jordan. The eponym appears in a posterior-urethroplasty review.[6] No single inventor or original commercial specification is documented.
  • Thompson and colleagues (1997) described the Brooke blade for radical perineal prostatectomy; Harris and Thompson's 1996 article describes the broader anatomic technique.[1][2] Check current availability with the tray or manufacturer.

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

6. Gomez RG, Scarberry K. Anatomy and techniques in posterior urethroplasty. Transl Androl Urol. 2018;7(4):567–579. doi:10.21037/tau.2018.03.05

7. Kaldany A, Cedars B, Nikolavsky D. Substitution urethroplasty for posterior urethral stenosis. Transl Androl Urol. 2025;14(12):3962–3974. doi:10.21037/tau-2025-566

8. CS Surgical, Inc. Specialty Instruments for the Urologist. Manufacturer catalog, rev. 02-13 URO CAT; 2013:2. PDF.