You are in: eMedicine Specialties > Urology > Cancer, Prostate Prostate Cancer: Radical Perineal ProstatectomyArticle Last Updated: Dec 27, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Howard J Korman, MD, FACS, Consulting Staff, Department of Urology, William Beaumont Hospital Howard J Korman is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Michigan State Medical Society, Oakland County Medical Society, and Phi Beta Kappa Coauthor(s): Michael Harris, MD, Consulting Staff, Northern Institute of Urology, PC; Consulting Staff, Department of Surgery, Section of Urology, Munson Medical Center Editors: Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dan Theodorescu, MD, PhD, Paul Mellon Professor of Urologic Oncology, Department of Urology, University of Virginia Health Sciences Center; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center Author and Editor Disclosure Synonyms and related keywords: prostate cancer, radical perineal prostatectomy, prostate-specific antigen, PSA, prostate specific antigen, RPP, radical retropubic prostatectomy, RRP, digital rectal exam, digital rectal examination, DRE, radical prostatectomy, prostatectomy, urinary incontinence, fecal incontinence, postprostatectomy incontinence, scrotal hyperesthesia, impotence, erectile function, anastomotic stricture, urethral stricture, transient fecal urgency, Lowsley tractor, Denonvilliers fascia, pelvic lymph node dissection, PLND, da Vinci robotic system, robotic prostatectomy, robotic surgery INTRODUCTIONSection 2 of 11
  Prostate cancer is the most commonly diagnosed cancer in men in the United States and is tied for the second leading cause of cancer-caused death among males (for more information, see Medscape's Prostate Cancer Resource Center). In 2004, an estimated 230,000 new cases were diagnosed and approximately 30,000 prostate cancer deaths occurred. With the widespread use of prostate-specific antigen (PSA) tests and digital rectal examinations for the early detection of prostate cancer, most new cases are being diagnosed at early and potentially curable stages. This is reflected in the decrease in prostate cancer deaths in the While most urologists believe radical prostatectomy is the most effective means of curing clinically localized prostate cancer, surgical morbidity has compromised patients' overall quality of life and acceptance of the procedure. Efforts have been made to decrease surgical morbidity and to improve postoperative quality of life. Walsh defined the periprostatic, vascular, and erectile neural anatomy and developed a nerve-sparing radical prostatectomy. This nerve-sparing technique has enhanced erectile function after surgery while limiting the incidence of iatrogenic positive margins. In addition, preservation of urethral length at the prostatic apex has been advocated to improve postoperative urinary continence. These 2 major advances, along with better delineation of the pelvic and periprostatic anatomy, have significantly decreased the hospital stay and the morbidity associated with both the retropubic and perineal approaches. History of the ProcedureRadical perineal prostatectomy (RPP), the original prostate cancer operation, was first described in 1905 by Young.1 In 1947, Millin first described radical retropubic prostatectomy (RRP).2 He suggested radical retropubic prostatectomy as an alternative to radical perineal prostatectomy because patients often have pelvic lymph node metastasis at diagnosis. Expertise in performing radical retropubic prostatectomy improved, and the importance of pelvic lymph node dissection (PLND) for staging became evident. Over time, radical retropubic prostatectomy became the most common method of radical prostatectomy. Surgeons who performed radical perineal prostatectomy had been performing open PLNDs first. If the PLND findings were negative upon permanent section analysis, they would then proceed with the radical perineal prostatectomy. More recently, many surgeons have performed laparoscopic PLNDs or minilap PLNDs. If the findings from frozen section pathologic analysis are negative for lymph node metastasis, they perform the radical perineal prostatectomy at the same setting. In recent years, with increased PSA screening, stage migration has moved toward more organ-confined disease. Partin and associates found a decrease in seminal vesicle or lymph node involvement from 21% between 1987 and 1992 to 10% between 1993 and 1996.3 Furthermore, they proposed a nomogram whereby patients at risk of lymph node metastasis can be selected using PSA screening, clinical staging based on digital rectal examination findings, and Gleason scoring after diagnostic biopsy. Of the more than 4000 patients in the study who underwent radical prostatectomy for clinically organ-confined disease, only 5% had positive screening results for lymph nodes metastasis. Only 3% of patients with a PSA screening result greater than 10, clinical stage T2a, and a Gleason score of 6 or less had positive screening results for lymph node metastasis. Hence, some authorities have advocated the omission of PLND if these parameters Today, many men diagnosed with prostate cancer have early-stage disease for which PLND is not mandatory. Consequently, the interest in radical perineal prostatectomy has seen a resurgence. Radical perineal prostatectomy can be performed with less blood loss, operative time, hospitalization, and patient convalescence than radical retropubic prostatectomy. INDICATIONSSection 3 of 11
Most surgeons, based on the type of training they have received, favor either a retropubic or perineal approach. Both authors are proficient in both techniques. However, one author now performs the radical perineal prostatectomy exclusively, and the other author uses both surgical approaches. Advantages of radical perineal prostatectomy over radical retropubic prostatectomy include the following:
In cases in which a pelvic lymph node dissection (PLND) is indicated based on clinical parameters, a laparoscopic or minilap PLND can be performed prior to radical perineal prostatectomy or the entire procedure can be performed via a retropubic approach. RELEVANT ANATOMYSection 4 of 11
See Prostate Cancer: Biology, Diagnosis, Pathology, Staging, and Natural History. CONTRAINDICATIONSSection 5 of 11
Radical perineal prostatectomy is performed with the patient in the high lithotomy position (see Image 1). Men with limited hip mobility may have difficulty being positioned; however, only 90° of flexion is necessary, and even men who are morbidly obese can be adequately positioned. Patients with severe hemorrhoid problems may have increased hemorrhoidal discomfort for 1-3 months after surgery. In men with very large prostates (>150 cm3), neoadjuvant hormone therapy is used to reduce the prostate size for easier removal. Massive prostates (>150 cm3) can be effectively reduced with transurethral resection of the prostate at least 3 months before the radical perineal prostatectomy. Alternatively, the surgeon may be more comfortable using the retropubic approach in these patients. TREATMENTSection 6 of 11
Preoperative detailsAspirin and other anticoagulants must stopped at least 7 days before surgery. The day before surgery, the patient is given an oral mechanical bowel preparation. While several bowel preparations are available, the authors use Fleet Phospho-Soda (1.5 oz at 9:00 am and 12:00 pm). The patient is on a clear liquid diet that day. On the morning of surgery, after arrival at the hospital, the patient is given a 1% neomycin enema. Cefotetan or clindamycin is administered intravenously on call to the operating room. Given the proximity of the incision to the rectum, antibiotic prophylaxis is indicated. Intraoperative detailsThe surgery can be safely performed with the patient under spinal or general anesthesia. The patient is positioned in the high lithotomy position. Padded Lloyd-Allen or Yellowfin stirrups are used to support the legs. A 6-inch piece of gel-type padding (eg, jelly roll) is placed under the sacrum. Special care should be taken to pad the legs well and to avoid excess torque on the hips (see Image 1). Excessive tension in positioning may cause sciatic neurapraxia or compromised circulation to the lower extremities and lower abdomen. Rhabdomyolysis has been reported in rare cases and is generally related to prolonged surgical time and improper positioning. An O'Connor-Sullivan transurethral resection drape is placed with the finger cot in the rectum to allow palpation of the prostate and rectal wall during the surgery. A curved Lowsley tractor is placed through the urethra and into the bladder, and the wings are opened to allow controlled movement of the prostate into the surgical field. An inverted-U incision is made, with the apex in the mid perineum and the ends anterior to the midanal line and 1 cm medial to the ischial tuberosities (see Image 2). Allis clamps are used to secure the transurethral resection drape to the skin. The authors prefer the Young extrasphincteric approach as opposed to the Belt subsphincteric approach (see Image 3). The ischiorectal fossa is developed on either side of the central tendon, and the central tendon is divided with cautery. Dissection continues to the fibrous confluence posterior to the raphe of the bulbospongiosum. Once the fibrous confluence is divided, the rectourethralis is seen in the midline and the levator ani muscles are seen laterally. The rectourethralis is divided, taking care to avoid the rectum. Elevating the fibrous confluence with a forceps displays the rectourethralis and the rectum. The rectum is tented up close to the urethra at the apex of the prostate. Once the rectum is mobilized posteriorly from the prostatic apex, the scissors are spread against the apex to reveal the pearly white Denonvilliers aponeurosis (fascia). The Lowsley tractor is used to bring the prostate down toward the perineum and to assist with identification of the prostatic apex. Once the rectourethralis is completely divided, the rectum is swept posteriorly off the Denonvilliers aponeurosis deep into the wound, proximal to the seminal vesicals. A finger is passed along the inside of the levator ani muscles to sweep the periprostatic fatty tissue against the prostate. In wide excision cases, this maneuver ensures a maximal margin of extraprostatic tissue for clean surgical margins. In nerve-sparing cases, a plane is developed immediately medial to the bare levator fibers, lateral to the lateral pelvic fascia. The generous supportive tissue on the posterolateral aspect of the prostate is preserved with the cavernosal nerve bundles. The attachments of this fascia and the thin supportive tissue are separated from the anterolateral aspect of the rectum. At this point, a Thompson self-retaining perineal retractor or a Bookwalter retractor is used for exposure (see Image 4). A 2-inch malleable retractor blade is placed on the padded rectum, and 2 double-angled blades are placed anterolaterally for further exposure. Nerve-sparing criteria vary from surgeon to surgeon; however, potent men with low-volume, nonpalpable cancers and Gleason scores of 6 or less are considered for nerve preservation. Unilateral nerve sparing is used when the contralateral bundle is potentially compromised by adjacent cancer. The Denonvilliers aponeurosis is incised transversely from the medial aspect of one seminal vesical to the medial aspect of the other. Scissors are spread in this space to reveal the ampullae of vas and the seminal vesicals. One vas is grasped and dissected to approximately 5 cm from the prostate, where it is sealed with a LigaSure device and divided. The other vas is similarly managed. A seminal vesical is grasped with Russian forceps and is tracted medially. The Denonvilliers aponeurosis is swept laterally using the tips of the scissors to reveal the lateral aspect. Scissors are spread on the lateral aspect of the seminal vesical, revealing the vessels at its tip. These vessels are sealed with the LigaSure and divided. The posterior bladder neck is pushed off the base of the prostate with a Kuttner dissector. In nerve-sparing cases, the Denonvilliers aponeurosis is incised from lateral of the midline, over the medial aspect of the ipsilateral seminal vesical to the midline overlying the apex, and back down to the medial aspect of the contralateral seminal vesical (in the shape of an upside-down V). With careful sharp dissection, the fascia and associated cavernosal nerves are mobilized laterally off the lateral aspect of the prostate. A clear plane can be developed between the prostate and the layers of the Denonvilliers aponeurosis investing the cavernosal nerves. This plane is developed around the lateral aspect of the prostate from the apex to the seminal vesicles (see Image 5). Branches of the nerves that penetrate the prostate at the apex and base should be divided sharply to avoid injury to the nerve bundles being spared. The cavernosal nerve bundles are mobilized laterally away from the base of the prostate, leaving the vascular pedicle to the prostate base intact. The vascular pedicle at the prostate base is sealed with a LigaSure and divided, with care to avoid a traction injury to the nerve bundles. The prostatovesical junction is identified and separated from the posterior aspect laterally and anteriorly to the puboprostatic ligaments. Care is taken to avoid trauma to the nerve bundles during the rest of the dissection to remove the prostate. At the apex, the nerve bundles are carefully separated from the urethra. The urethra is then circumferentially dissected from the apical tissues of the prostate by rolling a Kuttner dissector along the urethra into the prostate, up to the verumontanum. This plane is fairly well defined, and manipulation of the urethra is minimized to avoid sphincter dysfunction. The Lowsley tractor is removed, and the urethra is divided just distal to the verumontanum. The procedure continues with the division of puboprostatic ligaments as described below. In non–nerve-sparing procedures, all periprostatic tissue is swept from the levators medially and left on the prostate to enhance tumor-free margins of resection. The Denonvilliers aponeurosis and the endopelvic fascia are left intact, overlying the posterior and lateral aspects of the prostate, respectively. The prostate pedicles are sealed with the LigaSure and divided. The posterolateral aspect of the prostatovesical junction is developed as above. Attention is then turned to the prostatic apex (non–nerve-sparing cases). The skeletal muscles near the prostatic apex are separated to expose the urethra distal to the apex. Then, 1-2 mm of pelvic floor muscle is separated from the pelvic floor and left overlying the apex of the prostate to ensure an adequate margin around the apex. Care is taken to avoid violating the prostate anterior to the urethra at the apex. The urethra is separated from the prostate circumferentially by rolling a Kuttner dissector between the urethra and the apex of the prostate. The apical pedicles are divided with cautery, the Lowsley tractor is removed, and an additional length of urethra is dissected out of the apex up to the verumontanum. The urethra is then divided sharply (see Image 6). The puboprostatic ligaments are divided with cautery several millimeters anterior to the anterior aspect of the prostate. A ring clamp is placed on the anterior tissue, with one ring inside the urethra to provide downward traction on the prostate to expose the anterior attachments to the bladder neck. Alternatively, a straight Lowsley tractor can be used. The anterior attachments are divided with cautery. Occasionally, venous bleeding from the dorsal venous complex necessitates ligation with an absorbable suture. With traction on the prostate, the plane of dissection between the bladder neck and the prostate base is developed, exposing the urethra as it enters the prostate base. The urethra is dissected out of the prostatic base and divided, leaving a 1-cm stump of urethra protruding from an intact bladder neck (see Image 7). The operative field is irrigated, and any remaining bleeding points are controlled before starting the anastomosis. The urethral ends are anastomosed with two 3-0 absorbable monofilament (Monocryl) sutures placed near the anterior midline and run posteriorly, where they are tied with minimal tension to avoid reducing the diameter of the anastomosis. Alternatively, interrupted 3-0 absorbable monofilament sutures can be used. The urothelium is not specifically everted; however, each pass of the suture includes urothelium. When the urethral stumps are adequate, urethro-urethrostomy is performed so that the urethra is not anastomosed to the bladder neck (see Image 8). Once the anastomosis is complete, the urethra is injected with sterile saline retrograde from the meatus, and the anastomosis is distended to identify any leaks that may require additional sutures. An 18F catheter is then passed into the bladder, and the bladder is irrigated to free any clots. In men with a prior transurethral prostate resection, a very large gland, or cancer near the bladder neck, bladder-neck preservation is not necessarily intended. In this situation, the bladder is entered anteriorly after dividing the puboprostatic ligaments. The bladder neck is excised off the prostate, taking care to keep a safe distance from the ureteral orifices. The bladder neck is then tailored to a snug 18F opening without everting the urothelium. The anastomosis is accomplished in a similar manner, being sure to include urothelium in each anastomotic suture. The "tennis-racquet" closure of the bladder neck is reinforced with another layer of absorbable running sutures. The retractors are removed, and the rectum is inspected for injury or thin areas, which, if present, are repaired or reinforced. The levator ani muscles are reapproximated in the midline, with a Penrose or Jackson-Pratt drain overlying the rectum. The central tendon is reapproximated, the subcutaneous tissues are closed, and the skin is closed with a subcuticular stitch on both the right and left sides (see Image 9). Optionally, a belladonna and opium suppository can be placed per rectum to reduce postoperative spasms. The catheter is taped without tension to the lower abdomen, and the patient is taken to recovery. Postoperative detailsThe patient starts ambulation and begins a regular diet and oral analgesia the night after surgery. Ketorolac (Toradol) can be used for postoperative pain. The patient and home caregiver (eg, partner, family member) are instructed on incision care, dressing changes, and catheter care. The Penrose drain is removed the morning after surgery before hospital discharge. The catheter is removed in approximately 7-10 days, and the patient is unrestricted in his activities, except for bicycle and horseback riding. The patient is instructed on pelvic muscle exercises to help reduce incontinence. Follow-upA prostate-specific antigen (PSA) blood test is performed every 3 months for the first year, semiannually for the next 2 years, and then annually for life if it remains undetectable and if pathology findings are favorable. For unfavorable pathology findings, closer monitoring is required. If full continence is not achieved by the first visit, biofeedback associated with pelvic floor exercises can be considered. For excellent patient education resources, visit eMedicine's Prostate Health Center, Cancer and Tumors Center, and Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Prostate Cancer and Bladder Control Problems. COMPLICATIONSSection 7 of 11
IntraoperativeBleeding Intraoperative bleeding rarely results in the need for blood transfusions. Harris transfused 5 (1%) of 508 patients, all in the first 140 patients.4 Rectal injury The prevalence of rectal injury is inversely related to the surgeon's experience and occurs in less than 1-11% of cases. Prompt identification and appropriate repair usually prevent adverse sequelae. If the bowel preparation was adequate, a colostomy is not needed unless the patient has received previous radiation therapy for prostate cancer. Closure should be performed in a transverse manner using 2 layers (ie, running 3-0 chromic suture followed by an imbricating layer of 3-0 silk). The patient is started on clear liquids on the day of surgery and advanced to an unrestricted diet as tolerated. The authors have not observed an increase in fecal incontinence in their patients. Neurapraxias Prolonged procedures with excess positioning tension or pressure points can result in neurapraxias. Most neurapraxias resolve by the morning following surgery, but, rarely, a persistent burning sensation in the soles of the feet may occur after a more severe neurapraxia. Rhabdomyolysis Prolonged surgical procedure time and excess flexion can compromise muscle perfusion and result in rhabdomyolysis. The myoglobin liberated from muscle breakdown can lead to tubular obstruction and renal failure. Characteristically, myoglobinuria results in dark-colored urine, which is positive for heme upon dipstick testing but negative for red blood cells upon microscopic urinalysis. Early aggressive hydration and diuresis can lessen the associated renal failure and metabolic acidosis. Alkalinization with sodium bicarbonate should also be instituted. Cardiovascular In patients who experienced large fluid shifts or have dilated cardiomyopathy, cardiovascular compromise may result. However, in typical cases with 300 mL of blood loss and 2000 mL of intravenous fluid administration, very little cardiovascular challenge occurs. Respiratory Obese men who are in an exaggerated lithotomy position generally have shallower respirations. General anesthesia may be preferable to spinal anesthesia in order to control ventilation. Immediate PostoperativeBleeding Signs of postoperative bleeding include bloody Penrose drainage, gross hematuria with clots, or an ecchymotic and bulging perineum. If significant bleeding occurs, prompt exploration and evacuation of the hematoma with ligation of bleeding vessels should be considered. Hematoma formation may disrupt the anastomosis; the anastomosis should be inspected at the time of repair. Bladder spasms Bladder spasms are common, occasionally requiring anticholinergic therapy. Wound infections Infections are rare if patients are given preoperative antibiotic coverage. According to a 1999 study of Medicare records by Lu-Yao et al, wound infections occur slightly more frequently with the perineal approach than with the retropubic approach.5 Often, antibiotics and sitz baths are therapeutic. For more severe infections, the wound should be opened, débrided, and packed to allow secondary granulation. Closing the wound in separate halves prevents the need to open the entire wound if only one side is involved. Anal sphincteric incontinence While transient fecal urgency is common during the first week after surgery, persistent anal incompetence is rare. A recent publication stated that fecal incontinence can be problematic. To address this issue, Korman et al performed a retrospective study using a published, validated questionnaire (ie, the bowel function domain of the University of Michigan's validated Expanded Prostate Cancer Index Composite) to assess fecal incontinence rates and bowel function among patients who had undergone radical perineal prostatectomy or radical retropubic prostatectomy by the same surgeon.6 The questionnaire was mailed to 150 consecutive patients who had undergone radical perineal prostatectomy (79) or radical retropubic prostatectomy (71) by the same surgeon from 1998 to 2002. The age-matched control group consisted of 75 patients who underwent biopsies during the same period as the surgeries. The control group consisted of men undergoing prostate-specific antigen (PSA) screening who would be radical prostatectomy candidates if diagnosed with prostate cancer. No statistical difference was noted in the overall bowel function among the radical perineal prostatectomy group, the radical retropubic prostatectomy group, and the control group (P = .27). After a subgroup analysis, no difference was noted in fecal incontinence rates among groups (5-6% for each group, P = .92). Dahm et al performed a prospective, longitudinal study on their subjects who were undergoing radical perineal prostatectomy.7 They also used the bowel domain of the Expanded Prostate Cancer Index Composite questionnaire. Subjects were evaluated before radical perineal prostatectomy and at 3-month intervals after surgery. Involuntary stool leakage and rectal urgency were present before radical perineal prostatectomy in 11.5% and 19.2% of patients, respectively. Postoperatively, at 9.5 months, 90% of subjects noted a return to baseline fecal urgency symptoms. At 12 months, only 3.9% of subjects considered their fecal incontinence to be worse. Only 2.9% of patients developed de novo fecal incontinence by 12 months after radical perineal prostatectomy. Persistent wound drainage Persistent urine leakage from the incision is managed with prolonged urethral catheterization. In rare instances, fistula tract excision and placement of a gracilis muscle interposition flap are necessary. Scrotal hyperesthesia The posterior aspect of the scrotum and the perineum anterior to the incision are sometimes hypersensitive for several weeks but rarely longer. Gabapentin (Neurontin) is occasionally effective in reducing hypersensitivity until the cutaneous nerves recover. Pulmonary embolism Because the patient's legs are elevated, gravity drainage, thigh-high thromboembolism-deterrent hose, sequential compression stockings, and early ambulation decrease the risk of deep venous thrombosis. Cardiovascular These adverse effects are not a typical concern unless unusual fluid shifts or blood loss occurred during surgery. DelayedProlonged incontinence Most patients eventually obtain complete urinary control. Prolonged urinary incontinence appears to be more common in patients older than 70 years. Furthermore, reported continence rates are similar for radical perineal prostatectomy and radical retropubic prostatectomy. Harris and associates reported that 2.5% of patients were incontinent at 1 year after radical perineal prostatectomy when an interrupted suture technique had been used. On the other hand, when running anastomosis is used, full continence upon catheter removal is reported in 50% of patients and in 93% and 99% at 4 months and 1 year, respectively. Weldon reported that 95% of his patients were dry 10 months after radical perineal prostatectomy, including all patients younger than 69 years.8 In a 2000 study of 825 patients, Parra reported continence rates of 94% for radical perineal prostatectomy and 93% for radical retropubic prostatectomy.9 Similarly, continence rates were approximately 92% at 1 year for the retropubic approach from large centers, including Washington University at St. Louis, Johns Hopkins University, Columbia University, and the University of Washington. Increased interest in robotic prostatectomy has led to a need to compare outcomes with those of perineal surgery. Springhart et al showed no statistical difference in urinary incontinence and satisfaction between the two approaches.10 Continence rates defined as 0-1 pads per day were approximately 80% for both robotic and perineal prostatectomy 6 months after surgery. Urethral and anastomotic strictures, if present, should be treated with dilation in an office setting or with a precise internal urethrotomy. Detrusor instability often contributes to postprostatectomy incontinence and can be treated with anticholinergics. Some patients may benefit from an alpha-adrenergic agonist, Kegel exercises, or both. Behavioral modifications, including fluid restriction, double voiding, voiding prior to strenuous activity, and avoiding dietary irritants (eg, caffeine, spicy foods, citrus products), may also be effective. If all of the above measures fail, an artificial sphincter can be placed. In select cases, collagen injections may be effective if the posterior urethra has good compliance above the pelvic floor and distal to the anastomosis. Impotence When prostate cancer is juxtaposed near the erectile nerves, adequate cancer resection dictates their wide excision. However, with earlier cancer detection and the availability of effective oral medications to facilitate erections, urologists are being more aggressive with nerve-sparing procedures. A unilateral nerve-sparing procedure performed on the side opposite the tumor is well accepted. Bilateral nerve-sparing procedures are being used in many patients with low-volume disease. Recent advances in nerve-sparing techniques have been applied to both radical perineal prostatectomy and radical retropubic prostatectomy. In properly selected patients, these techniques can help maintain the ability to achieve spontaneous erections satisfactory for penetration. Harris reports that, after 12 months, 56% of unilaterally nerve-spared and 74% of bilaterally nerve-spared radical perineal prostatectomy patients were able to have intercourse without assistance, with or without the use of phosphodiesterase inhibitors, respectively. Weldon et al reported potency rates as high as 70%8 and Parra reported a rate of 34%9 for selected patients after nerve-sparing radical perineal prostatectomy. These numbers are comparable with reports from Catalona et al of 71%,11 Parra of 47%,9 and Stanford et al of 44%12 after bilateral nerve-sparing procedures using a retropubic approach. Penile injection therapy, intraurethral pharmacotherapy, vacuum-erection devices, and penile prostheses are generally effective for restoring adequate erections when a wide excision is performed. Sildenafil (Viagra) generally fails in the absence of some erectile-initiating event but may augment erections when nerve-sparing techniques have been performed. Younger patients are reported to have much better outcomes with regard to nerve sparing and erectile function compared with older patients. Anastomotic stricture Urethral strictures are less common with radical perineal prostatectomy than with radical retropubic prostatectomy. In recent series, only 1-2% of patients who underwent radical perineal prostatectomy develop anastomotic strictures. Dilation in an office-based setting usually solves the problem; however, direct-vision internal urethrotomy in the operating room may be required. Some patients have recurrences, necessitating periodic intermittent catheterization. Incontinence may be prolonged in these situations. Urocutaneous fistula Skin fistulae are exceptionally rare. The fistulous tract may be resected and recurrence prevented with a gracilis interposition flap. Perineal hernia This rare complication can occur if the pelvic floor muscles are not reapproximated. Vicryl mesh, cadaveric fascia, rectus fascia, or fascia lata may be used to strengthen the pelvic floor repair. OUTCOME AND PROGNOSISSection 8 of 11
The Partin tables are the best nomogram for predicting prostate cancer spread and prognosis. Cancer control The 2003 series by Harris included 508 patients and had follow-up of 3 months to 8.5 years with an average of 4 years.4 In this series, 96.3% of patients with organ-confined disease had no evidence of prostate-specific antigen (PSA) recurrence. Moreover, 79.4% of patients with extracapsular extension but negative margins were free of biochemical recurrence. While 36% of patients had extracapsular disease, positive margins were observed in only 15.8% without seminal vesicle invasion. Margins were focally positive (<1 mm) in 8.9%, isolated and nonfocal in 4.3%, and multifocal in 3.1%. As expected, biochemical failure was more common with increasing pathological stage. Four men who underwent radical perineal prostatectomy were found to have lymph node metastasis upon permanent section analysis. A 2006 prospective study of 1400 consecutive radical perineal prostatectomies reported by Goetz et al reported 13.8% biochemical recurrence rates with a mean follow-up of 90 months among patients with T2 disease.13 Outcome Data From 508 Consecutive Radical Perineal Prostatectomies by a Single Surgeon4
Korman et al reported a blinded comparison of pathologic specimens from radical perineal and retropubic prostatectomy performed by a single surgeon.14 Specimens were centrally reviewed and matched for clinical stage, PSA value, Gleason scores, and prostate size. Radical perineal prostatectomy had a statistical advantage for obtaining a wider apical margin in select patients. Otherwise, no statistical difference was noted for the amount of extracapsular tissue that could be excised, the distance of surgical margins around tumors, the rate of capsular incision, or the rate of overall margin positivity based on surgical approach. Similarly, Parra reported positive margin rates of 16% and 18% for radical perineal prostatectomy and radical retropubic prostatectomy, respectively, in his large prostatectomy series.9 Urinary continence In the 2003 Harris series, since incorporating a running anastomosis, 50% of patients were free of pad use within the first week after catheter removal.4 By 1 month, 2 months, 4 months, and 12 months, 62%, 77%, 93%, and 99% of patients, respectively, were not using pads. Most of the remaining men used one pad daily for minimal stress incontinence (see Image 10). Return of erectile function In the 2003 Harris series, criteria for cavernosal nerve preservation were based on staging by sextant biopsies.4 Until July 2001, fully potent men with unilateral nonapical tumors were offered preservation of the contralateral nerve bundle. Since July 2001, patients with low-volume, nonpalpable tumors with Gleason scores of less than 7 and reliable erections with or without phosphodiesterase inhibitor therapy are considered for bilateral or unilateral nerve-sparing procedures. The nerve-sparing technique has been modified substantially to the description noted in Intraoperative details, resulting in improved unilateral nerve-sparing results over earlier reports (1996) by Harris.15 Men who have undergone a bilateral nerve-sparing procedure regain adequate erections sooner than men who have undergone a unilateral nerve-sparing procedure. More than half of men who underwent unilateral nerve-sparing procedures and more than 90% of men who underwent bilateral nerve-sparing procedures regained erections sufficient for penetration. Image 11 shows the percent of men capable of vaginal penetration with or without phosphodiesterase inhibitor therapy in the months following unilateral and bilateral nerve-sparing radical perineal prostatectomy. Cost analysis With the surge of interest in robotic prostatectomy, cost analysis has become an important issue. Joseph et al evaluated the da Vinci robotic system and showed that high fixed costs drove the expense of the procedure. In other words, improved surgical efficiency and experience do not contribute substantially to cost reduction. A community-hospital study by Bernstein et al from William Beaumont Hospital in Royal Oak, Mich, showed that the actual profit for hospitals per case was $1560 for perineal, $1060 for open retropubic, and $92 for robotic prostatectomy.16 Similarly, Burgess et al reported that perineal prostatectomy was significantly more cost-effective than robotic prostatectomy, even after the robotic learning curve has been overcome.17 Thus, with the current concerns about health care cost and delivery, radical perineal prostatectomy appears to be the most cost-effective approach available. Unless superior outcomes from robotic surgery can be clearly demonstrated, the intrinsic increase in expenses associated with the robotic approach is difficult to justify. FUTURE AND CONTROVERSIESSection 9 of 11
Radical perineal prostatectomy is a well-tolerated and effective treatment for clinically organ-confined prostate cancer. It is associated with less perioperative morbidity, less hospital time and expense, and quicker recovery than radical retropubic prostatectomy. Its favorable profile as a minimally invasive treatment for prostate cancer endures, even as interest in robotic and laparoscopic radical prostatectomy and other minimally invasive procedures continues to increase. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Prostate Cancer: Radical Perineal Prostatectomy excerpt Article Last Updated: Dec 27, 2007 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
