Practice Essentials
Radical perineal prostatectomy (RPP) was described in 1905 by Young. [1] It was the first method used to remove the prostate as part of cancer therapy.
In 1947, Millin first described radical retropubic prostatectomy (RRP). [2] He suggested the procedure as an alternative to RPP, on the grounds that patients often had pelvic lymph node metastases at diagnosis. As expertise in performing RRP improved, the importance of pelvic lymph node dissection (PLND) for staging became evident. Over time, RRP became the most common method of radical prostatectomy. However, Keller et al have experimented with a perineal approach for PLND and have published encouraging results. [3]
Advantages of RPP over RRP include the following:
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A small, hidden incision for better cosmesis
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Avoidance of major muscle groups
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Less pain and patient convalescence
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Faster return to work and strenuous activities
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Fewer adverse cardiovascular effects because fluid shifts are reduced
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Less blood loss
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Shorter operating time and duration of hospitalization
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Excellent posterior exposure to limit positive margins posteriorly, laterally, and apically
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Precise watertight anastomosis performed under direct vision
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Easier for patients who are obese
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Avoidance of scar tissue from previous abdominal surgery
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Better visualization of the prostatic apex – The improved visualization of the apex facilitates avoidance of positive apical margins, sparing of neurovascular bundles, and visualization of the membranous urethra
Although most urologists believe that radical prostatectomy is the most effective means of curing clinically localized prostate cancer, the associated surgical morbidity has compromised patients’ overall quality of life and hindered their acceptance of the procedure. Accordingly, efforts have been made to reduce surgical morbidity and improve postoperative quality of life by developing different surgical options for prostatectomy. [4]
Trends in prostate cancer management
In the United States, prostate cancer is the most commonly diagnosed nonskin cancer in men and is the second leading cause of cancer-caused death among males. The American Cancer Society estimated that in 2020, there would be 191,930 new cases of prostate cancer in the United States and that 33,330 prostate cancer deaths would occur. [5]
With the widespread use of prostate-specific antigen (PSA) testing and digital rectal examination (DRE) for the early detection of prostate cancer, most new cases of the disease are now being diagnosed at early, potentially curable stages. This change is reflected in the decrease in prostate cancer deaths in the United States and Canada between 1990 and 2000, as compared with the period between 1973 and 1990. With increased PSA screening, stage migration has moved toward more organ-confined disease. [6]
Partin et al found a decrease in seminal vesicle or lymph node involvement in prostate cancer from 21% between 1987 and 1992 to 10% between 1993 and 1996. [7] Furthermore, they proposed a nomogram whereby patients at risk for lymph node metastasis could be selected by means of PSA screening, clinical staging based on DRE 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 node metastasis. [7] Only 3% of patients with a PSA level lower than 10 ng/mL, clinical stage T2a disease, and a Gleason score of 6 or less had positive screening results for lymph node metastasis. (The Partin tables are the best nomogram for predicting prostate cancer spread and prognosis.)
Hence, some authorities have advocated the omission of PLND if these parameters suggest an exceptionally low risk of lymph node metastasis.
Today, many men diagnosed with prostate cancer have early-stage disease for which PLND is not mandatory. Consequently, interest in RPP has seen a resurgence. Compared with RRP, RPP can offer reductions in blood loss, operating time, duration of hospitalization, and duration of convalescence. [8]
In 1982, Walsh defined the periprostatic, vascular, and erectile neural anatomy and developed the nerve-sparing radical prostatectomy. This nerve-sparing technique has enhanced erectile function after surgery while limiting the incidence of 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 RRP and RPP.
Fueled partially by competition among hospitals, robotic-assisted laparoscopic prostatectomy (RALP) has rapidly become a popularly utilized technique. [9] In general, however, patients with pulmonary disease or congestive heart failure may not tolerate the abdominal insufflation that laparoscopic surgery requires. Patients who have previously undergone multiple peritoneal operations and those with very large prostates may be better served by an open approach than by laparoscopy.
Technical Considerations
Procedural planning
The prostate gland is located posterior to the pubic symphysis, superior to the perineal membrane, inferior to the bladder, and anterior to the rectum. The base of the prostate is in continuity with the bladder and the prostate ends at the apex before becoming the striated external urethral sphincter. The sphincter is a vertically oriented tubular sheath that surrounds the membranous urethra and prostate.
For more information about the relevant anatomy, see Prostate Anatomy, Seminal Vesicle Anatomy, and Male Reproductive Organ Anatomy.
A normal prostate gland is approximately 20 g in volume, 3 cm in length, 4 cm in width, and 2 cm in depth. As men get older, the prostate gland may vary in size secondary to benign prostatic hyperplasia (BPH).
While selecting patients for RPP, those with smaller glands (20-60cc) located deeper within the pelvis may yield less challenging procedures. [10] In men with very large prostates (>150 cm3), neoadjuvant hormone therapy or 5-alpha-reductase inhibitors are used to reduce the prostate size for easier removal. Massive prostates can be effectively reduced with transurethral resection of the prostate (TURP) at least 3 months before RPP. Alternatively, the surgeon may be more comfortable performing RRP in these patients.
Complication prevention
Aspirin and other anticoagulants must be stopped at least 7 days before the operation.
The day before the procedure, the patient is given an oral mechanical bowel preparation (eg, Fleet Phospho-soda, a 1.5-oz. dose of which is taken 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.
Because of the proximity of the incision to the rectum, antibiotic prophylaxis is indicated. A prophylactic dose of cefoxitin is administered intravenously on call to the operating room and twice postoperatively.
Outcomes
The increased interest in RALP has led to a comparison of outcomes among various surgical approaches.
Although the average blood loss associated with robotic procedures is lower, in part because of the hemostatic effects of abdominal insufflation, the difference amounts to only a few hundred milliliters and is generally not associated with higher transfusion rates. [11]
Perineal, retropubic, and robotic approaches to radical prostatectomy procedures yield similar rates in terms of cancer control. Some studies have suggested that the robotic technique may yield a lower incidence of positive margins than RRP does (9.4% vs 24.1% in T2 disease, respectively), but it has not yet been compared with RPP in this regard. [12] Most comparison studies have shown that robotic and retropubic approaches yield similar PSA recurrence rates as well as biochemical recurrence free survival. [13, 14]
Boris et al found no statistical differences in urinary incontinence among the perineal, retropubic, and robotic approaches. [15] Continence was defined as 0-1 pads per day, and rates were found to be approximately 96% for robotic and perineal prostatectomy at 12 months after surgery. Potency rates vary according to definition and institution; nonetheless, perineal and retropubic procedures yield similar rates.
Cancer control
In a study of 703 patients who underwent RPP, with an average follow-up period of 4.2 years, [16] Harris found that 94.5% of patients with organ-confined disease had no evidence of PSA recurrence at 5 years. Moreover, 80% of patients with extracapsular extension but negative margins were free of biochemical recurrence at 5 years (see Table 1 below).
Table 1. Outcome Data From 703 Consecutive Radical Perineal Prostatectomies Performed by 1 Surgeon [16] (Open Table in a new window)
Pathologic Stage |
No. of Patients |
PSA < 0.2 ng/mL, % |
T2 |
521 |
95.6 |
T3 with negative margins |
79 |
79.7 |
T3 with positive margins |
70 |
67.1 |
T3 with positive seminal vesicle |
29 |
34.5 |
Positive nodes |
4 |
0 |
Total |
703 |
87.8 |
PSA = Prostate-specific antigen. |
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Whereas 33% of patients in the Harris study had extracapsular disease, positive margins were observed in only 17.6% without seminal vesicle invasion. [16] Margins were focally positive (< 1 mm) in 8.8% and were nonfocal or multifocal in 7.9%. As expected, biochemical failure was more common with higher pathologic stages. Four men who underwent RPP were found to have lymph node metastasis upon permanent section analysis.
In a prospective study of 1400 consecutive RPPs, Goetz et al reported biochemical recurrence rates of 13.8%, with a mean follow-up of 90 months among patients with T2 disease. [17]
According to a study by Korman et al, RPP had a statistical advantage over RRP for obtaining a wider apical margin in select patients, though no statistical difference based on surgical approach 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. [18]
Similarly, Parra reported positive margin rates of 16% for RPP and 18% for RRP in his large prostatectomy series. [19]
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In high lithotomy position, legs are supported with Allen or Yellowfin stirrups, and gel-type padding (eg, jelly roll) is placed under sacrum. Pneumatic stirrups facilitate leg repositioning during surgery and are helpful adjuncts.
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Inverted-U incision is placed in midperineum, medial to ischial tuberosities and anterior to midanus.
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Lateral view illustrates difference in surgical approaches and proximity of rectum to apex of prostate. Authors use Young suprasphincteric approach.
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Thompson perineal retractor provides excellent surgical exposure.
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Denonvilliers aponeurosis (fascia) is carefully incised, and cavernosal nerve bundles are delicately separated from prostate.
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Urethra is dissected out of apex. Cavernosal nerves are preserved bilaterally as urethra is dissected out of apex of prostate up to verumontanum.
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Length of urethra is dissected out of prostate base, and bladder neck is left intact.
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Urethrourethrostomy is completed with 2 continuous sutures to ensure optimally watertight anastomosis. Sutures are nearly ready to be tied together to complete anastomosis. Note cavernosal nerve bundles on each side of urethral anastomosis.
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Penrose drain in completed incision is removed on postoperative day 1.
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Time until continence in weeks after catheter removal. Socially dry is defined as use of 0-1 pad daily; totally dry is defined as use of no pads. Use of more than 1 pad daily is considered incontinence.
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Percentage of men reporting erectile function adequate for vaginal penetration with or without use of sildenafil in months following unilateral and bilateral cavernosal nerve-sparing radical perineal prostatectomy.
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Nerve-sparing radical perineal prostatectomy.
Tables
Pathologic Stage |
No. of Patients |
PSA < 0.2 ng/mL, % |
T2 |
521 |
95.6 |
T3 with negative margins |
79 |
79.7 |
T3 with positive margins |
70 |
67.1 |
T3 with positive seminal vesicle |
29 |
34.5 |
Positive nodes |
4 |
0 |
Total |
703 |
87.8 |
PSA = Prostate-specific antigen. |
||
Institution |
Procedure |
1 year |
2 years |
3 years |
4 years |
Memorial Sloan-Kettering Cancer Center [21] |
Radical retropubic prostatectomy |
30% |
42% |
47% |
53% |
Northern Institute of Urology |
Radical perineal prostatectomy |
53.6% |
71.7% |
78.9% |
81% |
