eMedicine Specialties > Urology > Cancer, Prostate

Prostate Cancer - Radical Perineal Prostatectomy

Author: Howard J Korman, MD, FACS, Consulting Staff, Department of Urology, William Beaumont Hospital
Coauthor(s): Michael J Harris, MD, Consulting Staff, Northern Institute of Urology, PC; Consulting Staff, Department of Surgery, Section of Urology, Munson Medical Center; Damon James Dyche, MD, Resident Physician, Department of Urology, William Beaumont Hospital
Contributor Information and Disclosures

Updated: Apr 27, 2009

Introduction

Prostate cancer is the most commonly diagnosed nonskin cancer in men in the United States and is the second leading cause of cancer-caused death among males. In 2007, an estimated 218,890 new cases were diagnosed and approximately 27,050 prostate cancer deaths occurred.1 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 United States and Canada between 1990 and 2000 compared with the period between 1973 and 1990.

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.

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 the retropubic and perineal approaches.

For additional information on prostate cancer, see Medscape’s Prostate Cancer Resource Center.

History of the Procedure

Radical perineal prostatectomy (RPP) was described in 1905 by Young.2 It was the first method used to remove the prostate as part of cancer therapy.

In 1947, Millin first described radical retropubic prostatectomy (RRP).3 He suggested radical retropubic prostatectomy as an alternative to radical perineal prostatectomy because patients often had pelvic lymph node metastasis at diagnosis. As expertise in performing radical retropubic prostatectomy improved, 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.

In the past, surgeons would begin with the PLND; if the permanent section analysis findings were negative, they would then continue 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 1996.4 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 level of less 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 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, the interest in radical perineal prostatectomy has seen a resurgence. Radical perineal prostatectomy can offer less blood loss, shorter operative time, shorter hospitalization, and shorter patient convalescence than radical retropubic prostatectomy.5

Despite the apparent survival advantage of early diagnosis conferred by PSA screening, a recent U.S. Preventive Services Task Force statement recommends against screening for prostate cancer in men aged 75 years or older. The statement also concludes that, currently, the balance of benefits versus drawbacks of prostate cancer screening in men younger than age 75 years cannot be assessed because of insufficient evidence.6

Indications

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 (RPP) exclusively, and the other author uses both surgical approaches.

Advantages of radical perineal prostatectomy over radical retropubic prostatectomy include the following:

  • A small, hidden incision for better cosmesis
  • Avoidance of major muscle groups
  • Less pain and patient convalescence
  • Faster return to work and strenuous activities
  • Fewer adverse cardiovascular effects because fluid shifts are reduced
  • Less blood loss
  • Less operative time and length of hospitalization
  • Excellent posterior exposure to limit positive margins posteriorly, laterally, and apically
  • Precise watertight anastomosis performed under direct vision
  • Easier for patients who are obese
  • Avoidance of scar tissue from previous abdominal surgery
  • Better visualization of the prostatic apex than with radical retropubic prostatectomy, facilitating avoidance of positive apical margins, easing the sparing of neurovascular bundles, and improving visualization of the membranous urethra

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. Recently, a German group (Keller et al) has be experimenting with a perineal approach for PLND and have published encouraging results.7

Robotic-assisted laparoscopic prostatectomy (RALP) is a third surgical technique that has become increasingly popular. RALP allows the surgeon to access tight areas of the pelvis with the benefit of optical magnification and fine grasping tools. A single large incision, as performed with an open operation, is traded for 4-5 one-cm incisions that patients find less painful and cause less scarring. PLND is possible using the standard robotic approach without the need for a secondary operation. In general, patients with pulmonary disease or congestive heart failure may not tolerate the abdominal insufflation necessary to perform laparoscopic surgery. Patients who have undergone multiple prior peritoneal operations and those with very large prostates may be better served with an open approach rather than laparoscopic surgery.

Relevant Anatomy

See Prostate Cancer: Biology, Diagnosis, Pathology, Staging, and Natural History.

Contraindications

Radical perineal prostatectomy (RPP) 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.8

In the high lithotomy position, the legs are supp...

In the high lithotomy position, the legs are supported with Allen or Yellowfin stirrups, and gel-type padding (eg, jelly roll) is placed under the sacrum. Pneumatic stirrups facilitate leg repositioning during surgery and are a helpful adjunct.

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In the high lithotomy position, the legs are supp...

In the high lithotomy position, the legs are supported with Allen or Yellowfin stirrups, and gel-type padding (eg, jelly roll) is placed under the sacrum. Pneumatic stirrups facilitate leg repositioning during surgery and are a helpful adjunct.


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 or 5-alpha-reductase inhibitors are 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.

More on Prostate Cancer - Radical Perineal Prostatectomy

Overview: Prostate Cancer - Radical Perineal Prostatectomy
Treatment: Prostate Cancer - Radical Perineal Prostatectomy
Follow-up: Prostate Cancer - Radical Perineal Prostatectomy
Multimedia: Prostate Cancer - Radical Perineal Prostatectomy
References
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References

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Further Reading

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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

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Contributor Information and Disclosures

Author

Howard J Korman, MD, FACS, Consulting Staff, Department of Urology, William Beaumont Hospital
Howard J Korman, MD, FACS 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
Disclosure: Nothing to disclose.

Coauthor(s)

Michael J Harris, MD, Consulting Staff, Northern Institute of Urology, PC; Consulting Staff, Department of Surgery, Section of Urology, Munson Medical Center
Michael J Harris, MD is a member of the following medical societies: American Association of Clinical Urologists, American Urological Association, Association of American Physicians and Surgeons, Société Internationale d'Urologie (International Society of Urology), and Southwest Oncology Group
Disclosure: Lilly  Honoraria Speaking and teaching

Damon James Dyche, MD, Resident Physician, Department of Urology, William Beaumont Hospital
Damon James Dyche, MD is a member of the following medical societies: Alpha Omega Alpha and American Urological Association
Disclosure: Nothing to disclose.

Medical Editor

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
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Dan Theodorescu, MD, PhD, Paul Mellon Professor of Urologic Oncology, Department of Urology, University of Virginia Health Sciences Center
Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

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
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
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