You are in: eMedicine Specialties > Urology > Cancer, Prostate Prostate Cancer: Radical Retropubic ProstatectomyArticle Last Updated: Mar 18, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 13
  Author: Reza Ghavamian, MD, Director, Associate Professor, Department of Urology, Section of Urologic Oncology, Montefiore Medical Center, Albert Einstein College of Medicine Reza Ghavamian is a member of the following medical societies: American Urological Association and Society of Urologic Oncology Coauthor(s): Horst Zincke, MD, PhD, Professor, Department of Urology, Mayo Medical School 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: radical retropubic prostatectomy, RRP, robotic-assisted laparoscopic radical prostatectomy, RALP, prostate cancer, prostate-specific antigen, PSA, adenocarcinoma of the prostate, perineal prostatectomy, urinary incontinence, impotence, erectile dysfunction, prostatic adenocarcinoma, prostate adenocarcinoma, radical prostatectomy, minimally invasive radical prostatectomy, robotic prostatectomy, laparoscopic radical prostatectomy INTRODUCTIONSection 2 of 13
  Adenocarcinoma of the prostate is the most commonly diagnosed cancer and the second leading cause of death in American males. The recent surge in the incidence of prostate cancer is most likely due to the use of the serum prostate-specific antigen (PSA) test, which has also changed trends in clinical and pathologic features of prostate cancer. PSA testing offers earlier detection, meaning that patients with known prostate cancer are increasingly younger and have earlier-stage, clinically localized disease. As a result, more patients have potentially curable lesions and can benefit from radical prostatectomy. History of the ProcedureIn 1947, Millin introduced the retropubic approach to prostatectomy. The operation had distinct advantages over perineal prostatectomy in that (1) urologists were more familiar with the retropubic anatomy and that (2) the retropubic approach permits the ability to perform an extraperitoneal pelvic lymph node dissection for staging purposes. During the past decade, modifications in the technique of radical retropubic prostatectomy and the introduction of the anatomic nerve-sparing method have dramatically decreased the frequency of the most concerning associated morbidities—incontinence and impotence. ProblemProstate cancer is the second most common malignancy in males after cutaneous malignancies and is the second most common cause of cancer death among men in the United States. Prostate cancer is predominantly a disease of elderly men, and the absolute number of cases is expected to increase as worldwide life expectancy increases. FrequencyEach day in the The incidence of prostate cancer varies throughout the world but is generally higher in Western developed countries. To illustrate, African American men (in whom the incidence of prostate cancer is highest) are 200 times as likely to develop prostate cancer as are Chinese men living in Migration studies have revealed increased prostate cancer rates among migrants who move from areas with low prevalence to areas of high prevalence. In one study, the incidence of prostate cancer in emigrants from EtiologyMigration studies suggest that environmental factors (eg, diet) play an important role in prostate cancer (see Prostate Cancer: Nutrition). Researchers have found a positive correlation between higher fat consumption, especially animal fat, and a higher prostate-cancer death rate. Higher fat consumption can increase the relative risk by a factor of 1.6-1.9. Experts suggest certain dietary habits to lower the risk of prostate cancer. These include a low-fat, high-fiber diet, which lowers serum androgen levels. Researchers have investigated other dietary factors, including selenium, lycopene, vitamin D, alpha-tocopherol, vitamin E, and large amounts of green tea and have postulated that these factors may prevent prostate cancer. Family history and genetics are important in the etiology of prostate cancer. Having a single first-degree relative with prostate cancer increases the prostate-cancer risk by a factor of 2.1-2.8. Having both a first-degree and a second-degree relative with prostate cancer increases the risk by a factor of 6. Familial predisposition can be due to common environmental exposures; recently, however, researchers mapped a potential major prostate cancer susceptibility locus (1q24-25). This gene, called HPC1, is involved in 33% of hereditary prostate-cancer cases. Men with a family history of female breast cancer are also at an increased risk of prostate cancer. Specific mutations of BRCA1 and BRCA2, 2 genes involved in familial breast cancers, appear to confer an increased risk for prostate cancer. ClinicalBefore the advent of PSA testing, more cases of prostate cancer were detected at a more advanced stage. Today, most prostate cancers are detected with PSA testing, which has resulted in more cases of prostate cancer being detected earlier, at a lower stage, and organ-confined. Over the past 10 years, the number of radical prostatectomies performed for clinically localized prostate cancer has risen. Most of this increase is due to the higher number of surgeries performed for c-T1c disease. The detection of organ-confined prostate cancer has increased through PSA-based screening of asymptomatic men; most tumors detected have clinical and pathologic features of clinically important prostate cancer.INDICATIONSSection 3 of 13
Currently, nerve-sparing radical retropubic prostatectomy remains a reasonable treatment option for men with clinically localized prostate cancer who have at least a 10-year life expectancy and low comorbidities. It is a well-tolerated procedure that is associated with low morbidity. The procedure is not limited to men younger than a certain age, but the authors generally do not consider patients older than 73 years for prostatectomy. The authors believe that cases have to be judged on an individual basis, but, in an elderly patient with prostate cancer who has alternatives to major surgery and in whom a 10-year overall survival is improbable, justifying a major operation is difficult. Although the optimal management of higher-stage disease is controversial, radical prostatectomy remains a viable treatment option in T3 disease for select patients. In patients with poorly differentiated disease, surgery can be supplemented with adjuvant hormonal therapy because monotherapy, in any form, is fraught with failure (see Prostate Cancer: Neoadjuvant Androgen Deprivation). Amling et al (1998) reported the Mayo Clinic experience with radical prostatectomy in clinical T3 disease.4 Some cases of prostate cancer are clinically overstaged and can be cured with surgery alone. The remaining patients with locally advanced disease are identified and can be offered adjuvant therapy (see Outcome and Prognosis). RELEVANT ANATOMYSection 4 of 13
Physicians must have a clear understanding of the anatomy pertinent to radical prostatectomy. The understanding of periprostatic anatomy, achievement of vascular control, and preservation of the neurovascular bundles allow a safe and anatomic approach to the operation, with reduced morbidity.
CONTRAINDICATIONSSection 5 of 13
All patients selected for nerve-sparing radical retropubic prostatectomy should have low comorbidities, at least a 10-year life expectancy, and clinically localized disease. Patients with locally advanced disease cannot undergo the nerve-sparing operation; because of the extent of the local tumor burden (especially posteriorly), the nerve-sparing procedure can compromise the adequacy of the operation. Whether patients with preoperative erectile dysfunction can benefit from nerve-sparing procedures in the sildenafil era has not been extensively studied. Therefore, the authors still do not recommend the nerve-sparing approach in patients with preoperative erectile dysfunction. The nerve-sparing operation should not be attempted to treat locally advanced prostate cancer. In that setting, the radical prostatectomy specimen should include both layers of Denonvilliers fascia, with a wide excision of the lateral pelvic fascia and the neurovascular bundles en bloc with the prostate and ejaculatory organs. WORKUPSection 6 of 13
Lab Studies
Imaging Studies
TREATMENTSection 7 of 13
Preoperative detailsBecause radical prostatectomy is most effective when the cancer is organ- or specimen-confined, accurate preoperative characterization of the cancer is essential for a tailored, safe, and effective operation. Physicians can estimate successful outcomes of radical prostatectomy by using well-established nomograms that provide important prognostic information before therapy. A model combining preoperative PSA, Gleason score, and clinical stage has increased the ability to predict pathologic stage. This model, which was proposed by Partin et al in 1997, involves these 3 clinical variables to predict pathologic stage, using a multinomial log-linear analysis in 3 major institutions, including the John Hopkins Hospital, Baylor College of Medicine, and the University of Michigan.8 The validity of the Partin nomograms were tested independently and vigorously by applying them to a large cohort of patients (2475 patients) treated with radical prostatectomy at the Mayo Clinic.9 The sensitivity and specificity of the Partin tables were similar when tested at this external site. Autologous blood donations are not routinely advocated. Apply a sequential compression device to the patient's lower extremities before the procedure. Intraoperative detailsMake a lower-midline incision. Then, perform an extraperitoneal bilateral pelvic lymphadenectomy. Remove the retropubic fat and isolate and cauterize the superficial branch of the dorsal venous complex. Bluntly incise the endopelvic fascia bilaterally. Sweep all residual muscle fibers (ie, levator ani, pubococcygeus, puborectalis) off the lateral aspect of the prostate laterally to expose the prostatic fascia and the dorsal venous complex (Image 1). Using a suture carrier, pass a 2.0-Vicryl suture just underneath the dorsal venous complex and anterior to the urethra. Control back-bleeders with two 2.0-Vicryl figure-8 sutures (ie, bunching sutures) on the proximal aspect of the dorsal vein complex. Divide the dorsal venous complex using electrocautery, leaving a defect in the prostatic fascia. Make an inverted-V incision in the exposed prostatic fascial edge, carrying the line of the incision distally and proximally, as shown in Image 2. Using a spreading maneuver with Satinsky scissors, carry the incision parallel to the neurovascular bundle toward the urethra and the bladder (Image 3). In this fashion, the lateral prostatic fascia containing the neurovascular bundles is mobilized posteriorly and out of harm's way. Place the index finger of the left hand in the plane between the mobilized prostatic fascia and the prostatic capsule and advance it under the posterior aspect of the prostate. This maneuver separates the anterior Denonvilliers fascia adherent to the posterior aspect of the prostate from the posterior Denonvilliers fascia adherent to the anterior rectum. Move the tip of the left index finger toward the right prostato-apical junction and extend it toward the lateral prostatic fascia on the contralateral side, anterior to and above the right neurovascular bundle. Guided by the tip of the left index finger, pierce the right lateral prostatic fascia above the neurovascular bundle with a right-angle clamp. Spread the clamp and sweep the right neurovascular bundle off the prostate cranially and posteriorly. Divide the membranous urethra at the apex of the prostate using electrocautery. Hold the electrocautery probe at a 45° angle toward the apex. In this fashion, residual delicate fibers of the external urethral rhabdosphincter complex, which cover the anterior aspect of the prostatic apex in a fan-shaped manner, are divided and preserved on the eventual urethral stump (Image 4). After the urethra is divided, mobilize the prostate cephalad and ligate the lateral vascular pedicles close to the prostate with small hemoclips. Divide the anterior layer of Denonvilliers fascia and identify the ampullae of the vas deferens. Dissect the ampullae of the vas deferens off the medial aspect of the seminal vesicles and divide them after mobilizing them distally. Using sharp dissection, mobilize the seminal vesicles to their tips. Careful dissection at this juncture prevents injury to the neurovascular bundles and the pelvic plexus, which lie close to the lateral aspect of the seminal vesicles. Retract the seminal vesicles and the ampullae of the vas deferens cephalad and dissect them free of the bladder base and the posterior aspect of the bladder using electrocautery. Start this dissection at the tip of the visceral bladder fascia, an extension of the posterior Denonvilliers fascia (Image 5). Preserve the circular fibers of the bladder neck and remove the specimen en bloc. With careful bladder neck preservation, extensive bladder neck reconstruction is not necessary. Use a running 3.0-monocryl suture to reconstruct the bladder neck. Start the suture on the right side at the 7-o'clock position and run it, everting the bladder mucosa onto the parietal bladder fascia (Image 6). Lock the suture at the 5-o'clock position and incorporate in the suture the visceral bladder fascia between the 5- and 7-o'clock positions (Image 7). Perform a direct vesicourethral anastomosis using 6 evenly placed absorbable sutures (eg, 2.0-monocryl) utilizing a urethral sound. A critical aspect of the operation is the use of intraoperative frozen-section analysis of the surgical margins. In the event of a positive margin, prostatic induration, or suspected locally advanced prostate cancer, the ipsilateral neurovascular bundle can be excised. Postoperative detailsThe authors routinely use two Jackson-Pratt (JP) drains that are positioned bilaterally in the pelvis with the tip pointed up to avoid slipping and suctioning the vesicourethral anastomosis. Postoperatively, the authors remove the patients' drains when the cumulative output from each is less than or equal to 30 mL over 24 hours. Drain input initially increases in some patients. The drain is left in to prevent lymphocele formation. If drainage is significant, consider the possibility of urine leakage; if the increased drainage continues, the JP drains are taken off bulb suction. This allows the anastomotic leak to seal in most cases. When this does not suffice (extremely rare), a Foley catheter can be hooked up to low wall suction through a Pleurovac to allow for a seal at the anastomotic site. The drainage fluid can be sent for creatinine measurement. A drainage-fluid creatinine level that approximates the serum creatinine level indicates lymphatic drainage rather than urine. Cystography is sometimes helpful to assess the extent of the extravasation. Other potential mechanical problems can occur. Clot retention can be managed with gentle bladder irrigation. Following radical prostatectomy, undue tension and traction should not be applied to the urethral catheter. This is a rare event after radical prostatectomy. The management of a dislodged catheter depends on the timing of the event. At postoperative day 3, with a good anastomosis, a single attempt at reinsertion with a well-lubricated coude-tip catheter is reasonable. However, when in doubt or unsuccessful, flexible cystoscopy at the bedside and passage of a council tip catheter over a wire under direct vision is the safest approach. With a good anastomosis, if the catheter is dislodged after 1 week, the patient should be allowed to void; if he does so with no problems, the authors do not insert a new catheter. Follow-upIn treating prostate cancer, physicians have the luxury of an accurate marker for disease recurrence: the PSA level. Serum PSA is measured every 3 months for the first 2 years. If undetectable, the interval is increased to every 6 months until 5 years postsurgery, when it can be measured yearly. In patients with a detectable PSA level after surgery, the timing of the PSA level rise is important. Abnormal PSA levels need to be confirmed with a repeat measurement. A true PSA level rise less than 1 year after prostatectomy is more indicative of occult distant metastases at the time of surgery. On the other hand, a later PSA level rise is more compatible with local recurrence. Imaging studies, such as bone scan, can be repeated. In patients with a late PSA level rise in whom bone scan results are negative, a Prostascint scan can be considered or performed to rule out distant metastases before local salvage therapy (radiation) is contemplated. In a study by Patel et al (1997), 80% of patients with a PSA level doubling time of 6 months or greater remained clinically disease-free, compared with 64% with PSA level doubling time of less than 6 months.13 Short PSA level doubling time (high log slope), regardless of the time of PSA level recurrence, was strongly associated with clinical recurrence. In a study by Pound et al (1999), PSA level doubling time, along with Gleason score, was also predictive of probability and time to development of metastatic disease.14 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 8 of 13
Radical prostatectomy is a well-tolerated procedure that is associated with low morbidity. The incidence of hemorrhage, the most common intraoperative complication, has decreased with improved surgical technique and increased experience in the large contemporary radical prostatectomy series. Mean estimated blood loss in these series ranges from 300-2000 mL, with most experienced centers reporting less than 1000 mL. In the authors' personal experience, transfusion of any kind is necessary in fewer than 2% of cases. This has made autologous blood donation, with its obvious cost-saving advantages, unnecessary in most cases. The frequencies of intraoperative and late complications have also decreased. A comparison of morbidity from the authors' contemporary radical prostatectomy series to an earlier study revealed no mortalities. The rates of bowel injury, colostomy, total incontinence, pulmonary embolism, and urethral stricture requiring long-term therapy were 0.6%, 0%, 0.8%, 0.6%, and 8.7%, respectively. The contemporary series revealed improved continence and fewer blood transfusions (77% before 1989 vs 22% after 1989). The average patient is discharged from the hospital on the second postoperative day as part of a carefully planned pre- and post–radical prostatectomy patient-care pathway. Urinary incontinence is a troubling complication of radical prostatectomy. The true incidence in different series is difficult to compare because of differences in the definition of incontinence. Most centers with expertise in the surgery report an incontinence rate of less than 10%; this figure includes occasional stress incontinence. The true rate of total incontinence with no urinary control is less than 5% and, for the authors, is less than 1%. In patients who experience this complication, improvement is likely after 1 year. Therefore, defer any invasive treatment until after 1 year. Searching for the cause of incontinence is an important aspect of therapy. Dribbling incontinence can develop with a bladder neck contracture (ie, overflow incontinence). Flexible cystoscopy and dilatation or transurethral resection of the contracture is often necessary. In patients with no anatomic abnormalities, urodynamic testing is warranted. Erectile dysfunction following radical prostatectomy results from numerous factors, including potency before the operation, the age of the patient, the stage of the tumor, and the preservation of the neurovascular bundles. Preservation of the neurovascular bundles allows for better postoperative potency rates. In this regard, surgical techniques are important, and the data on postoperative return of potency differ between centers of excellence and population surveys. The goals of adequate cancer operation and retained potency should be balanced to maintain negative surgical margins. Return of erections is more common in patients who have undergone a bilateral nerve-sparing procedure than in patients who have undergone a unilateral procedure. Generally, potency is retained in 68% of patients who have undergone bilateral nerve-sparing prostatectomy and in 13-47% of men who have undergone a unilateral neurovascular bundle preservation.15 In 2000, Walsh et al administered a validated disease-targeted quality-of-life survey to patients who underwent radical prostatectomy and who were potent before the procedure.16 The study showed that sildenafil improved the quality of erections and that the surveyed patients reported high (86%) overall potency rate at 18 months. Eighty-four percent of respondents reported no or minimal sexual bother. These numbers may also reflect a stage migration in prostate cancer in which more cancers are of lower volume and are organ-confined and in which both (89% in this series) or at least one neurovascular bundle can be saved. Therefore, both neurovascular bundles should be saved when feasible, and saving even one neurovascular bundle is justified. Advanced pathologic stage and patient age also adversely affect the return of potency. Quinlan et al (1991) reported that erectile function at least partially returned in 70% of men with organ-confined disease who had bilateral neurovascular preservation versus 50% in men with seminal vesicle invasion.17 In this series, 90% of men younger than 50 years were potent postsurgery if one or both bundles were preserved. The availability of oral sildenafil, alprostadil suppositories, and intracavernous injection therapy allow adequate postoperative treatment of erectile dysfunction so that quality of life is preserved in most patients. Two studies have addressed the efficacy of sildenafil in patients postprostatectomy. Zippe et al (2000) studied the effects of bilateral, unilateral, and non–nerve-sparing techniques.18 Sildenafil was efficacious in the bilateral nerve-sparing group, with 72% of the patients reporting rigidity that was sufficient for penetration. Only 50% of the patients in the unilateral nerve-sparing group responded to sildenafil. In a study by Marks et al (1999), patients were grouped according to the severity of their impotence based on the International Index of Erectile Function (IIEF).19 All patients undergoing prostatectomy were in the most severe group, with only 40% achieving sufficient tumescence with sildenafil. Sildenafil should be the first agent administered in the treatment of postprostatectomy impotence in the absence of contraindications. However, the response may be poor based on the operation performed and the presence of other comorbidities, such as vascular disease or diabetes. Recently, early combination therapy with intracavernosal injections and sildenafil has been shown to increase sexual activity and to facilitate the return of natural erections after radical prostatectomy. Combination therapy also allows a lower dose of intracavernosal injections, thereby decreasing morbidity and discomfort.20 Some researchers have suggested that pharmacologic treatment begun earlier postprostatectomy increases the likelihood of ultimate spontaneous return of potency. Some carefully conducted studies have disagreed with this finding. Zippe et al (2000) determined that the interval from surgery to the initiation of sildenafil therapy does not significantly influence the positive response rate. However, the dose did influence the positive response rate, with 71% of the patients requiring a 100-mg dose. Zagaja et al (2000) reported that patients who had not yet regained sexual function did not respond to sildenafil before 9 months postsurgery.21 Considering this latency, probably due to prolonged neurapraxia, these authors suggest starting the patient on topical alprostadil or intracavernosal injections to stimulate penile vasculature and to prevent loss of elasticity and, ultimately, cavernosal fibrosis. Recent quality-of-life studies have evaluated the functional outcomes and bother factors after radical prostatectomy and radiation-based therapies. In one study, treatment did not appear to affect health-related quality of life.22 Obstructive and urinary symptoms were more common after brachytherapy. Radiation-based therapies (eg, brachytherapy, external beam radiotherapy) were superior to radical prostatectomy in terms of urinary control and sexual function. However, among men who were potent before treatment, radical prostatectomy and brachytherapy yielded equivalent rates of sexual-function recovery. Bilateral nerve-sparing surgery diminished the differences in functional outcomes between surgery and external beam radiotherapy. In another study, although urinary incontinence was significantly worse after radical prostatectomy than after brachytherapy or high-dose external beam radiotherapy, patients who had undergone brachytherapy reported more irritative symptoms.23 Radical prostatectomy was associated with superior bowel function and fewer irritative functions. All 3 therapies were associated with impaired sexual function, but higher scores were seen in men who selected brachytherapy. Retrospective studies have revealed a definite change in the patients' disease-targeted quality of life. Litwin et al (1999) examined sexual bother and function after radical prostatectomy and radiation using the CaPSURE database.24 Although sexual function declined after surgery, it improved over time in the first year, as it did after radiation. However, during the second year, sexual function declined in patients undergoing radiation therapy. Note that quality of life as a whole after radical prostatectomy is not worse than quality of life after interstitial seed implantation. Krupski et al (2000) directly compared the quality of life and symptoms of patients with localized prostate cancer treated with radical prostatectomy with those treated with brachytherapy alone or in combination with external beam radiotherapy.25 An overall lower quality of life was found in the combination-treatment group than in the radical prostatectomy and brachytherapy groups. Radical prostatectomy was also superior to brachytherapy alone in that patients who underwent surgery had decreased irritative and obstructive voiding symptoms as measured with the American Urological Association (AUA)/International Prostate Symptom Score (IPSS). OUTCOME AND PROGNOSISSection 9 of 13
This section presents outcome analysis with respect to cancer control and survival data after radical prostatectomy and the role of radical prostatectomy in each clinical stage group. The Partin tables are adjuncts for predicting prostate cancer spread and prognosis. The recently devised Kattan nomograms can be used to predict outcomes after different modalities for the treatment of prostate cancer. Using readily available pocket software, the clinician can enter preoperative data and advise the patient concerning the likelihood of organ confinement and outcomes after radical prostatectomy. Chances for recurrence after radical prostatectomy can also be calculated using the pathologic data. This guides the clinician in devising treatment strategy. Clinical stages T1a and T1b This subcategory refers to prostate cancer incidentally detected during transurethral resection of the prostate. Clinical stage T1a refers to low-grade or medium-grade cancer in less than 5% of the resected chips, and T1b refers to high-grade cancer or any grade cancer in more than 5% of the resected chips. In a series from the Mayo Clinic, T1a and T1b tumors constituted 1.5% and 5.6% of all clinically organ-confined tumors, respectively.26 Eighty-eight percent of T1a tumors were pathologically organ-confined at the time of radical prostatectomy, as opposed to 68% of T1b tumors. Significant understaging was evident, especially in the T1b group. Several series reveal that the likelihood of finding significant tumor on examination of the radical prostatectomy specimen for T1a disease ranges from 12-20%. In one series, low-grade tumors (ie, Gleason score ≤3) were not associated with extracapsular extension, but 60% of those with a Gleason score of 7 or above had extracapsular extension. These clinical stages could represent significant prostate cancers. A significant portion of these patients could harbor cancer in the peripheral zone. In one series, two thirds of patients had cancer distal to the verumontanum. Cause-specific survival differences in these 2 subcategories became more significant, especially after 10 years. Currently, the authors recommend radical prostatectomy as a viable treatment option for young healthy patients with a life expectancy of more than 10-15 years and T1a disease. Observation may be a viable treatment option, along with careful follow-up, serial serum PSA testing, digital rectal examination, and ultrasonography with biopsy, when indicated. All cases of significant residual disease (ie, clinical stage T1b, high-grade T1a disease) warrant early treatment with radical prostatectomy. Clinical stages T1c and T2 Since the advent of serum PSA testing, physicians have detected more prostate cancers at an earlier stage. In the authors' contemporary radical prostatectomy series, 45% of patients present with clinical stage T1c disease and 45% present with clinical stage T2 disease. Based on the relationship of tumor volume, grade, DNA ploidy, and likelihood of disease progression, previous studies have shown that 84-92% of c-T1c tumors are clinically significant and warrant definitive treatment. A comparison of PSA-detected nonpalpable prostate cancers (c-T1c) and digitally palpable (c-T2) prostate cancers treated with radical prostatectomy in 4453 patients from 1987-1995 was performed at the Mayo Clinic.27 One thousand and forty-one patients had T1c disease, 1076 patients had T2a disease, and 2336 patients had T2b/c disease. Clinical stage T3 The role of radical prostatectomy in patients with locally advanced disease is controversial. Much of the controversy is based on earlier series, which reported poor 10-year survivals in patients undergoing radical perineal prostatectomy.28, 29 Note that patients in the earlier series were incompletely staged. Because of the high incidence of lymph node metastasis and the potential for incomplete excision, surgeons use monotherapy with androgen deprivation and radiotherapy. Monotherapy with androgen deprivation therapy is associated with a 34% progression to metastatic disease and a 22% mortality rate within 2 years of therapy and should thus be reserved for elderly patients or patients with significant comorbid disease. Radiotherapy alone also yields a poor outcome, especially with regard to local control. Studies show that failure to control the primary tumor results in an increased risk of metastatic disease dissemination. Postirradiation biopsy results following definitive external-beam radiation therapy have been positive in 55-93% of patients. Five- and 10-year survival rates following external-beam radiation range from 60-72% and 41-47% respectively. The authors' approach to radical prostatectomy in locally advanced prostate cancer is based on the principle of wide excision of the neurovascular bundles; en bloc removal of both layers of Denonvilliers fascia, the ampullae of the vas deferens, and the seminal vesicles; precise apical dissection with frozen-section analysis of the apical margins; and wide excision of the circular smooth muscle fibers of the bladder neck, again based on intraoperative frozen-section analysis. Nerve-sparing radical prostatectomy has no role in clinical stage T3 disease. In the event of a cancerous margin, wider excision can be performed. In reviewing the Mayo Clinic experience of radical prostatectomy for clinical stage T3 disease, a prominent feature was inaccurate clinical staging. In 25% of the cases in the authors' recently reported series, prostate cancers were organ-confined pathologically (less than T2c). Only 43% of the patients with clinical T3 disease had pathologic T3 disease. The rate of lymph node metastasis was 31%. In this series of 870 patients, 43% received adjuvant hormonal therapy, 7% received adjuvant external-beam radiation therapy, and 9% received both treatments after radical prostatectomy. Operative and perioperative morbidities were comparable with clinically localized prostate cancers. Crude survival rates at 5, 10, and 15 years were 89%, 70%, and 50%, and the cause-specific survival rates at 5, 10, and 15 years were 93%, 84%, and 74%, respectively. At 10- and 15-year follow-up, 82% and 78% of patients were free of local recurrence, respectively. Review of the authors' contemporary radical prostatectomy series in 1107 patients treated for pathological stage T3a/b disease revealed 9-year progression-free survival rates of 93% with early adjuvant hormonal therapy (within 3 mo of radical prostatectomy), 89% with adjuvant radiation therapy, and 85% with no adjuvant therapy. A more striking advantage was evident when considering local or systemic progression-free and PSA progression-free survival rates in favor of early adjuvant hormonal therapy. The authors' experience with c-T3 disease reveals that excellent long-term survival rates with low treatment-related morbidity can be achieved with radical prostatectomy and adjuvant therapy with pathologically confirmed locally advanced disease that are not achieved by other treatment modalities. Neoadjuvant androgen deprivation does not alter the long-term recurrence rate in men with clinical stage T3 prostate cancer. Review of outcomes after neoadjuvant therapy The value of neoadjuvant hormonal therapy in the treatment of clinical stage T3 prostate cancer has been debated. The benefit is generally better accepted prior to radiation treatment, but the same treatment benefit has been difficult to demonstrate in the prostatectomy series. Gomella et al (1996) demonstrated that pathologic downstaging to T2c or lower was achieved in 48% of patients with 4 months of neoadjuvant hormonal therapy.30 However, the actuarial 3-year biochemical failure rate was 75%. All patients had undergone a laparoscopic lymph node dissection prior to the neoadjuvant hormonal therapy. Question exists regarding the importance of the duration of the neoadjuvant hormonal therapy. Gleave et al (1996) reported that PSA nadir was reached in only 22% of patients when neoadjuvant hormonal therapy was instituted 3 months in advance.31 However, 84% of patients achieved nadir PSA after 8 months of neoadjuvant hormonal therapy. The surgical margin positivity rate was only 4%. In their series of 50 patients, 68% of the cancers were organ confined and 24% were specimen confined. This should be regarded with caution because only 6 of 50 patients had clinical stage T3 tumors and 15 (30%) had well-differentiated disease. Their study, however, indicated that longer duration of neoadjuvant hormonal therapy might produce more favorable results. Consider that, even if the rate of margin positivity is decreased with neoadjuvant hormonal therapy, no evidence exists to suggest that long-term survival will be improved. Amling et al (1997) reviewed the outcome of 72 patients with clinical T3 disease who received at least an 8-week course of neoadjuvant hormonal therapy and compared them to a matched cohort of 144 patients with clinical stage T3 disease who underwent only radical prostatectomy.32 Extracapsular extension was observed in 61% of the patients who received neoadjuvant hormonal therapy versus 81% in the untreated group (P=.002). The 5-year disease-specific survivals were 89% and 97% for the treated and untreated group, respectively, and the 5-year progression-free rate was not significantly different either (48% and 62%, respectively). The role of adjuvant therapy in the setting of a positive margin after radical prostatectomy is controversial. Leibovich et al (2000) studied 76 patients with T2N0 disease with a single site of margin positivity who received radiation treatment.33 The most common site was the apex. These patients were compared to a cohort of 76 matched men without adjuvant radiation therapy. An overall improvement in 5-year biochemical progression-free survival rate occurred in the patients who were radiated compared to the patients who were not radiated (88% vs 59%, P=.005). Interestingly, no patient in this group had local or distant recurrence, while 16% of controls had recurrence. Generally, as the interval to PSA recurrence increases, the likelihood of responding to radiation treatment increases substantially. Valicenti et al (1999) studied the efficacy of early adjuvant radiation treatment for T3N0 prostate cancer after radical prostatectomy.34 This was a matched comparison wherein 72 patients were optimally compared. There was an 88% reduction in the risk of PSA relapse associated with radiation therapy. The 5-year freedom from biochemical failure was 89% for patients who underwent adjuvant radiation versus 55% for those undergoing radical prostatectomy alone. Patients who have multiple gross positive margins, especially at the bladder neck or the prostate base, have a higher likelihood of systemic disease. In a pathologic analysis of anatomic site-specific positive margins, time to PSA recurrence was significantly shorter in patients with seminal vesicle invasion, those who have more than 1 positive margin, or positive margins at the bladder neck or posterolateral surface of the prostate.35 These findings are in agreement with a study performed by Blute et al (1997).36 A positive margin at the bladder neck is usually associated with other adverse pathologic characteristics, such as high Gleason score or preoperative PSA levels and margin positivity at other sites, or it can indicate occult metastatic disease. As a single site, it is responsible for only 5% of the positive margins in the The authors' approach to positive seminal vesicles and lymph nodes postprostatectomy has been to administer early adjuvant hormonal therapy. Early adjuvant hormonal therapy after radical prostatectomy decreases the interval to disease progression. The difference specifically is palpable in patients with positive nodes and diploid tumors. Although the Mayo Clinic has long been a proponent in this setting, others have been skeptical of the use of hormone treatment and the advantages in this setting. The value of immediate hormonal therapy after radical prostatectomy has been demonstrated in a prospective randomized study of 98 men by Messing et al (1999).37 After a median of 7.1 years of follow-up, 7 of 47 men who received immediate hormonal therapy died, as compared to 18 of 51 men in the observation group (P=.02). FUTURE AND CONTROVERSIESSection 10 of 13
With the evolving techniques and improving knowledge of surgical anatomy, physicians can perform radical retropubic prostatectomy with great efficacy and minimal morbidity. The authors believe that surgical treatment of prostate cancer is the best viable option for patients with clinically localized disease. However, its role may be expanded to locally advanced disease when used in combination with early adjuvant androgen ablative therapy in carefully selected patients who have low comorbidities and at least a 10-year life expectancy. In light of the improvement in surgical technique and the advent of nerve-sparing prostatectomies, most patients with prostate cancer have a high quality of life after undergoing radical prostatectomy. Pure laparoscopic radical prostatectomy has a steep learning curve and currently constitutes less than 1% of all prostatectomies in the The primary author has published his experience comparing pure laparoscopic retropubic prostatectomy with radical retropubic prostatectomy performed by a single surgeon. A total of 70 patients who underwent laparoscopic retropubic prostatectomy from 2001-2002, with at least 18 months of follow-up, were compared with a matched cohort of 70 patients who underwent radical retropubic prostatectomy from 1999-2001. The baseline patient characteristics, perioperative and histologic parameters, recovery time, complications, and 18-month functional data were compared. No significant differences were found in the preoperative characteristics. The mean operative time was 181.8 ± 18.7 minutes for radical retropubic prostatectomy and 246.4 ± 46.1 minutes for laparoscopic retropubic prostatectomy (P <.001). The mean estimated blood loss was 563.2 mL for radical retropubic prostatectomy and 275.8 mL for laparoscopic retropubic prostatectomy (P <.001). The positive-margin rates between the radical retropubic prostatectomy and laparoscopic retropubic prostatectomy groups did not significantly differ (20% and 15.7%, respectively). The mean pain score on the postoperative day 1 was 4.5 in the laparoscopic retropubic prostatectomy group and 7.8 in the radical retropubic prostatectomy group on an analog pain score of 0 to 10 (P = .02). Full recovery was achieved at 33 ± 17 days and 45 ± 20 days in the laparoscopic retropubic prostatectomy and radical retropubic prostatectomy groups, respectively (P <.001). The total perioperative complication rates for laparoscopic retropubic prostatectomy and radical retropubic prostatectomy were comparable at 18.5% and 15.7%, respectively. The diurnal continence rate (no pads) for the laparoscopic retropubic prostatectomy and radical retropubic prostatectomy groups was 70.0%, 90.0%, and 92.8% and 71.4%, 87.6%, and 92.0% at 6, 12, and 18 months, respectively. The potency rate after bilateral neurovascular preservation with or without sildenafil for the laparoscopic retropubic prostatectomy and radical retropubic prostatectomy groups was 55.0%, 72.6%, and 79.5% and 43.0%, 58.0%, and 72.4% at 6, 12, and 18 months, respectively, with no significant differences. The authors have concluded that laparoscopic retropubic prostatectomy is well tolerated and provides short-term oncologic and functional results that are comparable with those of radical retropubic prostatectomy. The use of robotic technology offers many advantages over conventional laparoscopic retropubic prostatectomy, including 3-dimensional visualization, magnification, increased degrees of freedom, absence of the fulcrum effect, and robotic-wrist instrumentation. The hypothesis is that robotic-assisted laparoscopic radical prostatectomy (RALP) can successfully reduce the learning curve that even experienced surgeons face while performing laparoscopic retropubic prostatectomy. The steep learning curve for laparoscopic retropubic prostatectomy is often cited as a major impediment for the widespread implementation of laparoscopic retropubic prostatectomy. Any improvement gained by the use of robotic technology would help circumvent this issue and favor the use of a laparoscopic approach over the traditional open technique. The primary author's learning curve for this procedure has been low due to his relatively adequate and prior experience with pure laparoscopic retropubic prostatectomy. The authors believe that the robotic technique has inherent advantages, the greatest of which may lie in the significantly decreased learning curve compared with laparoscopic retropubic prostatectomy. A laparoscopically naive surgeon may require as many as 80-100 cases before reaching the peak in the learning curve for laparoscopic retropubic prostatectomy. The primary author's abbreviated learning curve was in regard only to perioperative parameters such as blood loss, operative time, and anastomosis time. However, the learning curve has different definitions. Just being able to complete the robotic operation quickly does not translate into proficiency and into overcoming the learning curve. Proficiency has to be defined also by the return of functional outcomes after surgery. The learning curve continues to evolve and continues well into one's experience. This has been shown with radical retropubic prostatectomy and is probably also true for RALP. The bar for functional recover (potency and continence) after open radical retropubic prostatectomy is set very high. However, based on the primary author's experience, the robotic approach provides equivalent, if not superior, outcomes. This is in line with recent studies on potency following RALP. Tewari and colleagues reported that 82% of preoperatively potent patients younger than 60 years returned to some sexual activity and that 64% were able to achieve sexual intercourse at 6 months.40 In patients older than 60 years, 75% had some return of sexual activity and 38% reported intercourse at 6 months postoperative. Seventy-six to 95% of patients achieve full continence, defined as no pad use at 12 months following the procedure. Patel and colleagues, who have the longest period of follow-up, have reported that all patients were continent at 18 months after surgery.41 The primary author's experience in radical prostatectomy is unique. After fellowship training in Urologic Oncology, he was proficient in open radical retropubic prostatectomy. He then switched to pure laparoscopic prostatectomy and performed more than 300 procedures. Following the advent of RALP, he adopted the robotic technique and has performed more than 250 operations. RALP follows the same steps as pure laparoscopic prostatectomy. However, the robotic approach provides unique 3-dimensional visualization. The vision magnification, 3-dimensional features, and tremor-free movements provide for a precise operation. At no time in radical prostatectomy history has the anatomy and the intricacies of the slightest surgical maneuvers in the pelvis been so readily visualized and experienced. Presently, RALP is the primary author's preferred method of performing radical prostatectomy. FURTHER READINGSection 11 of 13
For additional information, see Medscape’s Prostate Cancer Resource Center. MULTIMEDIASection 12 of 13
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