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Prostate Cancer - Radical Perineal Prostatectomy: Follow-up
Updated: Apr 27, 2009
Outcome and Prognosis
The Partin tables are the best nomogram for predicting prostate cancer spread and prognosis.
Cancer control
Harris (2007) studied 703 patients who underwent radical perineal prostatectomy (RPP), with an average follow-up period of 4.2 years.17 In this series, 94.5% of patients with organ-confined disease had no evidence of prostate-specific antigen (PSA) recurrence at 5 years. Moreover, 80% of patients with extracapsular extension but negative margins were free of biochemical recurrence at 5 years.
While 33% of patients had extracapsular disease, positive margins were observed in only 17.6% without seminal vesicle invasion. Margins were focally positive (<1 mm) in 8.8% and nonfocal or multifocal in 7.9%.
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.20
Table 1. Outcome Data From 703 Consecutive Radical Perineal Prostatectomies by a Single Surgeon17
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Table
| Pathological Stage | Number of Patients | PSA <0.2, % |
| 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 |
| Pathological Stage | Number of Patients | PSA <0.2, % |
| 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 |
Korman et al reported a blinded comparison of pathologic specimens from radical perineal and retropubic prostatectomy performed by a single surgeon.21 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.16
Patient Expectations
Dr. Scardino at the Memorial Sloan Kettering Cancer Center (MSKCC) in New York coined the term "trifecta" to summarize the 3 primary objectives facing patients undergoing prostate cancer treatment. Because radical prostatectomy is the best treatment for curing prostate cancer, he evaluated the likelihood that a potent continent man undergoing nerve-sparing radical retropubic prostatectomy at MSKCC will be cancer-free, continent (no pads), and potent (erections firm enough for intercourse with or without the use of phosphodiesterase medications) after the procedure.22 Using the same criteria for evaluation of patients undergoing nerve-sparing radical perineal prostatectomy, Harris et al calculated his "trifecta" results for radical perineal prostatectomy at the Northern Institute of Urology (NIU). The following table compares the results of the two studies.
Table 2. Percentage of Patients Who Were Cancer-Free, Continent, and Potent Following Radical Prostatectomy at Two Separate Institutions
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Table
Institution | Procedure | 1 year | 2 years | 3 years | 4 years |
MSKCC | Radical retropubic prostatectomy | 30% | 42% | 47% | 53% |
NIU | Radical perineal prostatectomy | 53.6% | 71.7% | 78.9% | 81% |
Institution | Procedure | 1 year | 2 years | 3 years | 4 years |
MSKCC | Radical retropubic prostatectomy | 30% | 42% | 47% | 53% |
NIU | Radical perineal prostatectomy | 53.6% | 71.7% | 78.9% | 81% |
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.23 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.24 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.25
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 Controversies
An increased interest in robotic prostatectomy has led to a comparison of outcomes among various surgical approaches. Because of the time required to set up and dock the robotic equipment, the average surgical times associated with this procedure are generally longer than with perineal and retropubic prostatectomy. While the average blood loss associated with robotic procedures is lower, in part because of the hemostatic effects of abdominal insufflation, the difference is only a few hundred milliliters and generally not associated with higher transfusion rates.26
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 retropubic prostatectomy (9.4% vs 24.1% in T2 disease), but a comparison with perineal prostatectomy is lacking.27 Most comparison studies have shown that robotic and retropubic approaches yield similar PSA recurrence rates.28
Long-term outcome data from robotic procedures is now maturing, and initial results appear similar to perineal and retropubic approaches. Boris et al showed no statistical difference in urinary incontinence among the perineal, retropubic, and robotic approaches.29 Continence was defined as 0-1 pads per day, and rates were approximately 96% for both 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.
Radical perineal prostatectomy (RPP) is a well-tolerated and effective treatment for clinically organ-confined prostate cancer. It is associated with less perioperative morbidity, less hospital time, less 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-assisted radical prostatectomy and other minimally invasive procedures continues to grow.
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References
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Further Reading
Keywords
prostate cancer, radical perineal prostatectomy, prostate-specific antigen, PSA, 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
