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Radical Perineal Prostatectomy for Prostate Cancer Periprocedural Care

  • Author: Howard J Korman, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Dec 02, 2014
 

Patient Education and Consent

Patient instructions

The patient and the home caregiver (eg, partner, family member) are given instructions on incision care, dressing changes, and catheter care. The patient is instructed on pelvic muscle exercises to help reduce incontinence.[20]

For patient education information, see Prostate Cancer and Bladder Control Problems.

Patient expectations

Dr Peter Scardino of 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, Scardino evaluated the likelihood that a potent, continent man undergoing nerve-sparing radical retropubic prostatectomy (RRP) at MSKCC will be (1) cancer-free, (2) continent (no pads), and (3) potent (ie, capable of erections firm enough for intercourse, with or without the use of phosphodiesterase medications) after the procedure.[21]

Using the same criteria for evaluation of patients undergoing nerve-sparing radical perineal prostatectomy (RPP), Harris et al calculated “trifecta” results for RPP at the Northern Institute of Urology. The results of the 2 studies are compared in Table 2 below.

Table 2. Percentage of Patients Who Were Cancer-Free, Continent, and Potent After Radical Prostatectomy at 2 Separate Institutions (Open Table in a new window)

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%
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Patient Preparation

Anesthesia

The operation can be performed with the patient under spinal or general anesthesia. 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.

Positioning

RPP is performed with the patient in the high lithotomy position (see the image below). This positioning may prove difficult with patients who have limited hip mobility; however, only 90° of flexion is necessary, and even men who are morbidly obese can usually be positioned adequately.[22] Padded Lloyd-Allen or Yellowfin stirrups are used to support the legs. A 6-in. piece of gel-type padding (eg, jelly roll) is placed under the sacrum.

In high lithotomy position, legs are supported wit 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.

Special care should be taken to pad the legs well and to avoid excessive torque on the hips. 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; it is usually related to prolonged operating time and improper positioning.

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Monitoring and Follow-up

Serum prostate-specific antigen (PSA) testing is performed every 3 months for the first year, semiannually for the next 2 years, and then annually for life if serum PSA remains undetectable and if pathologic findings are favorable. If pathologic findings are unfavorable, closer monitoring is required. If full continence is not achieved by the first visit, biofeedback in conjunction with pelvic floor exercises may be considered.

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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, 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: Association of American Physicians and Surgeons, SWOG, Societe Internationale d'Urologie (International Society of Urology), American Association of Clinical Urologists, American Urological Association

Disclosure: Nothing to disclose.

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, American Urological Association

Disclosure: Nothing to disclose.

Emily Blum, MD Resident Physician, Department of Urology, William Beaumont Hospital

Disclosure: Nothing to disclose.

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, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Acknowledgements

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Dan Theodorescu, MD, PhD Paul A Bunn Professor of Cancer Research, Professor of Surgery and Pharmacology, Director, University of Colorado Comprehensive Cancer 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: Key Genomics Ownership interest Co-Founder-50% Stock Ownership; KromaTiD, Inc Stock Options Board membership

References
  1. Young HH. The Early Diagnosis and Radical Cure of Carcinoma of the Prostate. Bulletin of the Johns Hopkins Hospital. 1905. VXVI:315-21.

  2. Millin T. Retropubic Urinary Surgery. Carcinoma of the Prostate: Radical Retropubic Prostatectomy. Baltimore, Md: Williams & Wilkins; 1947. 15-7.

  3. Keller H, Lehmann J, Beier J. Radical perineal prostatectomy and simultaneous extended pelvic lymph node dissection via the same incision. Eur Urol. 2007 Aug. 52(2):384-8. [Medline].

  4. Fu Q, Moul JW, Sun L. Contemporary radical prostatectomy. Prostate Cancer. 2011. 2011:645030. [Medline]. [Full Text].

  5. Cancer Facts and Figures 2007. 2007;

  6. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008 Aug 5. 149(3):185-91. [Medline].

  7. Partin AW, Kattan MW, Subong EN, Walsh PC, Wojno KJ, Oesterling JE, et al. Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update. JAMA. 1997 May 14. 277(18):1445-51. [Medline].

  8. Harris MJ, Thompson IM Jr. The anatomic radical perineal prostatectomy: a contemporary and anatomic approach. Urology. 1996 Nov. 48(5):762-8. [Medline].

  9. Barbash GI, Friedman B, Glied SA, Steiner CA. Factors associated with adoption of robotic surgical technology in US hospitals and relationship to radical prostatectomy procedure volume. Ann Surg. 2014 Jan. 259(1):1-6. [Medline].

  10. Horuz R, Göktas C, Çetinel CA, Akça O, Cangüven Ö, Sahin C. Simple preoperative parameters to assess technical difficulty during a radical perineal prostatectomy. Int Urol Nephrol. 2013 Feb. 45(1):129-33. [Medline].

  11. Berryhill R Jr, Jhaveri J, Yadav R, Leung R, Rao S, El-Hakim A, et al. Robotic prostatectomy: a review of outcomes compared with laparoscopic and open approaches. Urology. 2008 Jul. 72(1):15-23. [Medline].

  12. Smith JA Jr, Chan RC, Chang SS, Herrell SD, Clark PE, Baumgartner R, et al. A comparison of the incidence and location of positive surgical margins in robotic assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy. J Urol. 2007 Dec. 178(6):2385-9; discussion 2389-90. [Medline].

  13. Schroeck FR, Sun L, Freedland SJ, Albala DM, Mouraviev V, Polascik TJ, et al. Comparison of prostate-specific antigen recurrence-free survival in a contemporary cohort of patients undergoing either radical retropubic or robot-assisted laparoscopic radical prostatectomy. BJU Int. 2008 Jul. 102(1):28-32. [Medline].

  14. Ritch CR, You C, May AT, Herrell SD, Clark PE, Penson DF, et al. Biochemical recurrence-free survival after robotic-assisted laparoscopic vs open radical prostatectomy for intermediate- and high-risk prostate cancer. Urology. 2014 Jun. 83(6):1309-15. [Medline].

  15. Boris RS, Kaul SA, Sarle RC, Stricker HJ. Radical prostatectomy: a single surgeon comparison of retropubic, perineal, and robotic approaches. Can J Urol. 2007 Jun. 14(3):3566-70. [Medline].

  16. Harris MJ. The anatomic radical perineal prostatectomy: an outcomes-based evolution. Eur Urol. 2007 Jul. 52(1):81-8. [Medline].

  17. Goetz T, Neugart F, Groh R. Radical perineal prostatectomy--A single institution study on prospectively controlled results in a consecutive series of 1400 cases. J Urol. 2006. 175:208-9A.

  18. Korman HJ, Leu PB, Huang RR, Goldstein NS. A centralized comparison of radical perineal and retropubic prostatectomy specimens: is there a difference according to the surgical approach?. J Urol. 2002 Sep. 168(3):991-4. [Medline].

  19. Parra RO. Analysis of an experience with 500 radical perineal prostatectomies in localized prostate cancer [abstract]. J Urol. 2000. 1265.

  20. Bannowsky A, Schulze H, van der Horst C, Hautmann S, Jünemann KP. Recovery of erectile function after nerve-sparing radical prostatectomy: improvement with nightly low-dose sildenafil. BJU Int. 2008 May. 101(10):1279-83. [Medline].

  21. Saranchuk JW, Kattan MW, Elkin E, Touijer AK, Scardino PT, Eastham JA. Achieving optimal outcomes after radical prostatectomy. J Clin Oncol. 2005 Jun 20. 23(18):4146-51. [Medline].

  22. Fitzsimons NJ, Sun LL, Dahm P, Moul JW, Madden J, Gan TJ, et al. A single-institution comparison between radical perineal and radical retropubic prostatectomy on perioperative and pathological outcomes for obese men: an analysis of the Duke Prostate Center database. Urology. 2007 Dec. 70(6):1146-51. [Medline].

  23. Gianino MM, Galzerano M, Martin B, Chiadò Piat S, Gontero P. Costs in surgical techniques for radical prostatectomy: a review of the current state. Urol Int. 2012. 88(1):1-5. [Medline].

  24. Harris MJ. Radical perineal prostatectomy: cost efficient, outcome effective, minimally invasive prostate cancer management. Eur Urol. 2003 Sep. 44(3):303-8; discussion 308. [Medline].

  25. Lu-Yao GL, Albertsen P, Warren J, Yao SL. Effect of age and surgical approach on complications and short-term mortality after radical prostatectomy--a population-based study. Urology. 1999 Aug. 54(2):301-7. [Medline].

  26. Harris MJ, Fischer MC. Urinary Continence After Perineal Prostatectomy with a Running Anastomosis and Four-Day Catheterization. September 2000.

  27. Weldon VE, Tavel FR, Neuwirth H. Continence, potency and morbidity after radical perineal prostatectomy. J Urol. 1997 Oct. 158(4):1470-5. [Medline].

  28. Korman HJ, Mulholland TL, Huang R. Preservation of fecal continence and bowel function after radical perineal and retropubic prostatectomy: a questionnaire-based outcomes study. Prostate Cancer Prostatic Dis. 2004. 7(3):249-52. [Medline].

  29. Dahm P, Silverstein AD, Weizer AZ, Young MD, Vieweg J, Albala DM, et al. A longitudinal assessment of bowel related symptoms and fecal incontinence following radical perineal prostatectomy. J Urol. 2003 Jun. 169(6):2220-4. [Medline].

  30. Catalona WJ, Carvalhal GF, Mager DE, Smith DS. Potency, continence and complication rates in 1,870 consecutive radical retropubic prostatectomies. J Urol. 1999 Aug. 162(2):433-8. [Medline].

  31. Stanford JL, Feng Z, Hamilton AS, Gilliland FD, Stephenson RA, Eley JW, et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA. 2000 Jan 19. 283(3):354-60. [Medline].

 
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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.
Inverted-U incision is placed in midperineum, medial to ischial tuberosities and anterior to midanus.
Lateral view illustrates difference in surgical approaches and proximity of rectum to apex of prostate. Authors use Young suprasphincteric approach.
Thompson perineal retractor provides excellent surgical exposure.
Denonvilliers aponeurosis (fascia) is carefully incised, and cavernosal nerve bundles are delicately separated from prostate.
Urethra is dissected out of apex. Cavernosal nerves are preserved bilaterally as urethra is dissected out of apex of prostate up to verumontanum.
Length of urethra is dissected out of prostate base, and bladder neck is left intact.
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.
Penrose drain in completed incision is removed on postoperative day 1.
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.
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.
Nerve-sparing radical perineal prostatectomy.
Table 1. Outcome Data From 703 Consecutive Radical Perineal Prostatectomies Performed by 1 Surgeon [16]
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.
Table 2. Percentage of Patients Who Were Cancer-Free, Continent, and Potent After Radical Prostatectomy at 2 Separate Institutions
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%
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