eMedicine Specialties > Urology > Cancer, Prostate

Prostate Cancer - Radical Perineal Prostatectomy

Howard J Korman, MD, FACS, Consulting Staff, Department of Urology, William Beaumont Hospital
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

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 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.

Treatment

Preoperative Details

Aspirin and other anticoagulants must be stopped at least 7 days before surgery.

The day before surgery, the patient is given an oral mechanical bowel preparation. While several bowel preparations are available, the authors use Fleet Phospho-Soda (1.5 oz 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.

A prophylactic dose of cefoxitin is administered intravenously on call to the operating room and again twice postoperatively. Given the proximity of the incision to the rectum, antibiotic prophylaxis is indicated.

Intraoperative Details

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

The patient is positioned in the high lithotomy position. Padded Lloyd-Allen or Yellowfin stirrups are used to support the legs. A 6-inch piece of gel-type padding (eg. jelly roll) is placed under the sacrum. Special care should be taken to pad the legs well and to avoid excess torque on the hips (see Image 1). 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 and is generally related to prolonged surgical time and improper positioning.

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.

An O'Connor-Sullivan transurethral resection drape is placed with the finger cot in the rectum to allow palpation of the prostate and rectal wall during the surgery. A curved Lowsley tractor is placed through the urethra and into the bladder, and the wings are opened to allow controlled movement of the prostate into the surgical field.

An inverted-U incision is made, with the apex in the mid perineum and the ends anterior to the midanal line and 1 cm medial to the ischial tuberosities (see Image 2). Allis clamps are used to secure the transurethral resection drape to the skin.

The inverted-U incision is placed in the mid perineum, medial to the ischial tuberosities and anterior to the mid anus.

The authors prefer the Young extrasphincteric approach as opposed to the Belt subsphincteric approach (see Image 3). The ischiorectal fossa is developed on either side of the central tendon, and the central tendon is divided with cautery.

A lateral view illustrates the difference in approaches and the proximity of the rectum to the apex of the prostate. The authors use the Young suprasphincteric approach.

Dissection continues to the fibrous confluence posterior to the raphe of the bulbospongiosum. Once the fibrous confluence is divided, the rectourethralis is seen in the midline and the levator ani muscles are seen laterally.

The rectourethralis is divided, taking care to avoid the rectum. Elevating the fibrous confluence with a forceps displays the rectourethralis and the rectum. The rectum is tented up close to the urethra at the apex of the prostate.

Once the rectum is mobilized posteriorly from the prostatic apex, the scissors are spread against the apex to reveal the pearly white Denonvilliers aponeurosis (fascia). The Lowsley tractor is used to bring the prostate down toward the perineum and to assist with identification of the prostatic apex.

Once the rectourethralis is completely divided, the rectum is swept posteriorly off the Denonvilliers aponeurosis deep into the wound, proximal to the seminal vesicals. A finger is passed along the inside of the levator ani muscles to sweep the periprostatic fatty tissue against the prostate. In wide excision cases, this maneuver ensures a maximal margin of extraprostatic tissue for clean surgical margins. In nerve-sparing cases, a plane is developed immediately medial to the bare levator fibers, lateral to the lateral pelvic fascia. The generous supportive tissue on the posterolateral aspect of the prostate is preserved with the cavernosal nerve bundles. The attachments of this fascia and the thin supportive tissue are separated from the anterolateral aspect of the rectum.

At this point, a Thompson self-retaining perineal retractor or a Bookwalter retractor is used for exposure (see Image 4). A 2-inch malleable retractor blade is placed on the padded rectum, and 2 double-angled blades are placed anterolaterally for further exposure.

The Thompson perineal retractor provides excellent surgical exposure.

Nerve-sparing criteria vary from surgeon to surgeon; however, potent men with low-volume, nonpalpable cancers and Gleason scores of 6 or less are considered for nerve preservation. Unilateral nerve sparing is used when the contralateral bundle is potentially compromised by adjacent cancer.

The Denonvilliers aponeurosis is incised transversely from the medial aspect of one seminal vesical to the medial aspect of the other. Scissors are spread in this space to reveal the ampullae of vas and the seminal vesicals. One vas is grasped and dissected to approximately 5 cm from the prostate, where it is sealed with a LigaSure device and divided. The other vas is similarly managed. A seminal vesical is grasped with Russian forceps and is tracted medially. The Denonvilliers aponeurosis is swept laterally using the tips of the scissors to reveal the lateral aspect. Scissors are spread on the lateral aspect of the seminal vesical, revealing the vessels at its tip. These vessels are sealed with the LigaSure and divided. The posterior bladder neck is pushed off the base of the prostate with a Kuttner dissector.

In nerve-sparing cases, the Denonvilliers aponeurosis is incised from lateral of the midline, over the medial aspect of the ipsilateral seminal vesical to the midline overlying the apex, and back down to the medial aspect of the contralateral seminal vesical (in the shape of an upside-down V). With careful sharp dissection, the fascia and associated cavernosal nerves are mobilized laterally off the lateral aspect of the prostate. A clear plane can be developed between the prostate and the layers of the Denonvilliers aponeurosis investing the cavernosal nerves. This plane is developed around the lateral aspect of the prostate from the apex to the seminal vesicles (see Image 5).

The Denonvilliers aponeurosis (fascia) is carefully incised, and the cavernosal nerve bundles are delicately separated from the prostate.

Branches of the nerves that penetrate the prostate at the apex and base should be divided sharply to avoid injury to the nerve bundles being spared. The cavernosal nerve bundles are mobilized laterally away from the base of the prostate, leaving the vascular pedicle to the prostate base intact. The vascular pedicle at the prostate base is sealed with a LigaSure and divided, with care to avoid a traction injury to the nerve bundles. The prostatovesical junction is identified and separated from the posterior aspect laterally and anteriorly to the puboprostatic ligaments. Care is taken to avoid trauma to the nerve bundles during the rest of the dissection to remove the prostate.

At the apex, the nerve bundles are carefully separated from the urethra. The urethra is then circumferentially dissected from the apical tissues of the prostate by rolling a Kuttner dissector along the urethra into the prostate, up to the verumontanum. This plane is fairly well defined, and manipulation of the urethra is minimized to avoid sphincter dysfunction. The Lowsley tractor is removed, and the urethra is divided just distal to the verumontanum. The procedure continues with the division of puboprostatic ligaments as described below.

In non–nerve-sparing procedures, all periprostatic tissue is swept from the levators medially and left on the prostate to enhance tumor-free margins of resection. The Denonvilliers aponeurosis and the endopelvic fascia are left intact, overlying the posterior and lateral aspects of the prostate, respectively. The prostate pedicles are sealed with the LigaSure and divided. The posterolateral aspect of the prostatovesical junction is developed as above.

Attention is then turned to the prostatic apex (non–nerve-sparing cases). The skeletal muscles near the prostatic apex are separated to expose the urethra distal to the apex. Then, 1-2 mm of pelvic floor muscle is separated from the pelvic floor and left overlying the apex of the prostate to ensure an adequate margin around the apex. Care is taken to avoid violating the prostate anterior to the urethra at the apex.

The urethra is separated from the prostate circumferentially by rolling a Kuttner dissector between the urethra and the apex of the prostate. The apical pedicles are divided with cautery, the Lowsley tractor is removed, and an additional length of urethra is dissected out of the apex up to the verumontanum. The urethra is then divided sharply (see Image 6).

The urethra is dissected out of the apex. Cavernosal nerves are preserved bilaterally as the urethra is dissected out of the apex of the prostate up to the verumontanum.

The puboprostatic ligaments are divided with cautery several millimeters anterior to the anterior aspect of the prostate. A ring clamp is placed on the anterior tissue, with one ring inside the urethra to provide downward traction on the prostate to expose the anterior attachments to the bladder neck. Alternatively, a straight Lowsley tractor can be used. The anterior attachments are divided with cautery. Occasionally, venous bleeding from the dorsal venous complex necessitates ligation with an absorbable suture.

With traction on the prostate, the plane of dissection between the bladder neck and the prostate base is developed, exposing the urethra as it enters the prostate base. The urethra is dissected out of the prostatic base and divided, leaving a 1-cm stump of urethra protruding from an intact bladder neck (see Image 7).

A length of urethra is dissected out of the prostate base, and the bladder neck is left intact.

The operative field is irrigated, and any remaining bleeding points are controlled before starting the anastomosis. The urethral ends are anastomosed with two 3-0 absorbable monofilament (Monocryl) sutures placed near the anterior midline and run posteriorly, where they are tied with minimal tension to avoid reducing the diameter of the anastomosis. Alternatively, interrupted 3-0 absorbable monofilament sutures can be used. The urothelium is not specifically everted; however, each pass of the suture includes urothelium. When the urethral stumps are adequate, urethro-urethrostomy is performed so that the urethra is not anastomosed to the bladder neck (see Image 8).

The urethro-urethrostomy anastomosis is completed with 2 running sutures to ensure an optimally watertight anastomosis. The 2 sutures are nearly ready to be tied together to complete the anastomosis. Note the cavernosal nerve bundles on each side of the urethral anastomosis.

Once the anastomosis is complete, the urethra is injected with sterile saline retrograde from the meatus, and the anastomosis is distended to identify any leaks that may require additional sutures. An 18F catheter is then passed into the bladder, and the bladder is irrigated to free any clots.

In men with a prior transurethral prostate resection, a very large gland, or cancer near the bladder neck, bladder-neck preservation is not necessarily intended. In this situation, the bladder is entered anteriorly after dividing the puboprostatic ligaments. The bladder neck is excised off the prostate, taking care to keep a safe distance from the ureteral orifices. The bladder neck is then tailored to a snug 18F opening without everting the urothelium.

The anastomosis is accomplished in a similar manner, being sure to include urothelium in each anastomotic suture. The "tennis-racquet" closure of the bladder neck is reinforced with another layer of absorbable running sutures.

The retractors are removed, and the rectum is inspected for injury or thin areas, which, if present, are repaired or reinforced. The levator ani muscles are reapproximated in the midline, with a Penrose or Jackson-Pratt drain overlying the rectum. The central tendon is reapproximated, the subcutaneous tissues are closed, and the skin is closed with a subcuticular stitch on both the right and left sides (see Image 9). Optionally, a belladonna and opium suppository can be placed per rectum to reduce postoperative spasms. The catheter is taped without tension to the lower abdomen, and the patient is taken to recovery.

The Penrose drain in the completed incision is removed on the first postoperative day.

Postoperative Details

The patient starts ambulation and begins a regular diet and oral analgesia the day of surgery. Ketorolac (Toradol) can be used for postoperative pain.

The patient and home caregiver (eg, partner, family member) are instructed on incision care, dressing changes, and catheter care.

The Penrose drain is removed the morning after surgery before hospital discharge.

The catheter is removed within approximately 8 days, and the patient is unrestricted in his activities, except for bicycle and horseback riding.

The patient is instructed on pelvic muscle exercises to help reduce incontinence. Some physicians recommend a nightly low-dose phosphodiesterase inhibitor (sildenafil) postoperatively to improve potency outcomes.⁹

Follow-up

A prostate-specific antigen (PSA) blood test is performed every 3 months for the first year, semiannually for the next 2 years, and then annually for life if it remains undetectable and if pathology findings are favorable. For unfavorable pathology, closer monitoring is required. If full continence is not achieved by the first visit, biofeedback associated with pelvic floor exercises can be considered.

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.

Complications

Intraoperative

Bleeding

Intraoperative bleeding rarely results in the need for blood transfusions. Harris transfused 5 (1%) of 508 patients, all in the first 140 patients of his learning curve.¹⁰ Afterward, transfusion was not used in the subsequent 500 cases.

Rectal injury

The prevalence of rectal injury is inversely related to the surgeon's experience and occurs in less than 1-11% of cases. Prompt identification and appropriate repair usually prevent adverse sequelae. If the bowel preparation was adequate, a colostomy is not needed unless the patient has received previous radiation therapy for prostate cancer.

Closure should be performed in a transverse manner using 2 layers (ie, running 3-0 chromic suture followed by an imbricating layer of 3-0 silk). The patient is started on clear liquids on the day of surgery and advanced to an unrestricted diet as tolerated. The authors have not observed an increase in fecal incontinence in their patients.

Neurapraxias

Prolonged procedures with excess positioning tension or pressure points can result in neurapraxias. Most neurapraxias resolve by the morning following surgery, but, rarely, a persistent burning sensation in the soles of the feet may occur after a more severe neurapraxia.

Rhabdomyolysis

Prolonged surgical procedure time and excess flexion can compromise muscle perfusion and result in rhabdomyolysis. The myoglobin liberated from muscle breakdown can lead to tubular obstruction and renal failure. Characteristically, myoglobinuria results in dark-colored urine, which is positive for heme upon dipstick testing but negative for red blood cells upon microscopic urinalysis. Early aggressive hydration and diuresis can lessen the associated renal failure and metabolic acidosis. Alkalinization with sodium bicarbonate should also be instituted.

Cardiovascular

In patients who experienced large fluid shifts or have dilated cardiomyopathy, cardiovascular compromise may result. However, in typical cases with 300 mL of blood loss and 2000 mL of intravenous fluid administration, very little cardiovascular challenge occurs.

Respiratory

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.

Immediate Postoperative

Bleeding

Signs of postoperative bleeding include bloody Penrose drainage, gross hematuria with clots, or an ecchymotic and bulging perineum. If significant bleeding occurs, prompt exploration and evacuation of the hematoma with ligation of bleeding vessels should be considered. Hematoma formation may disrupt the anastomosis; the anastomosis should be inspected at the time of repair. In very rare cases, intraurethral bleeding from the anastomotic sutures requires cystoscopic fulguration for control.

Bladder spasms

Bladder spasms are common but rarely require anticholinergic therapy.

Wound infections

Infections are rare if patients are given preoperative antibiotic coverage. According to a 1999 study of Medicare records by Lu-Yao et al, wound infections occur slightly more frequently with the perineal approach than with the retropubic approach.¹¹ Often, antibiotics and sitz baths are therapeutic. For more severe infections, the wound should be opened, débrided, and packed to allow secondary granulation. Closing the wound in separate halves prevents the need to open the entire wound if only one side is involved.

Anal sphincteric incontinence

While transient fecal urgency is common during the first week after surgery, persistent anal incompetence is rare. A recent publication stated that fecal incontinence can be problematic.

To address this issue, Korman et al performed a retrospective study using a published, validated questionnaire (ie, the bowel function domain of the University of Michigan's validated Expanded Prostate Cancer Index Composite) to assess fecal incontinence rates and bowel function among patients who had undergone radical perineal prostatectomy (RPP) or radical retropubic prostatectomy by the same surgeon.¹² The questionnaire was mailed to 150 consecutive patients who had undergone radical perineal prostatectomy (79) or radical retropubic prostatectomy (71) by the same surgeon from 1998 to 2002.

The age-matched control group consisted of 75 patients who underwent biopsies during the same period as the surgeries. The control group consisted of men undergoing prostate-specific antigen (PSA) screening who would be radical prostatectomy candidates if diagnosed with prostate cancer. No statistical difference was noted in the overall bowel function among the radical perineal prostatectomy group, the radical retropubic prostatectomy group, and the control group (P = .27). After a subgroup analysis, no difference was noted in fecal incontinence rates among groups (5-6% for each group, P = .92).

Dahm et al performed a prospective, longitudinal study on their subjects who were undergoing radical perineal prostatectomy.¹³ They also used the bowel domain of the Expanded Prostate Cancer Index Composite questionnaire. Subjects were evaluated before radical perineal prostatectomy and at 3-month intervals after surgery. Involuntary stool leakage and rectal urgency were present before radical perineal prostatectomy in 11.5% and 19.2% of patients, respectively. Postoperatively, at 9.5 months, 90% of subjects noted a return to baseline fecal urgency symptoms. At 12 months, only 3.9% of subjects considered their fecal incontinence to be worse. Only 2.9% of patients developed de novo fecal incontinence by 12 months after radical perineal prostatectomy.

Persistent wound drainage

Persistent urine leakage from the incision is managed with prolonged urethral catheterization. Fortunately, most cases are self-limited. Retrograde urethrography can be used to assess for continued leakage once the catheter is removed.

Scrotal hyperesthesia

The posterior aspect of the scrotum and the perineum anterior to the incision are sometimes hypersensitive for several weeks but rarely longer. Gabapentin (Neurontin) is occasionally effective in reducing hypersensitivity until the cutaneous nerves recover.

Pulmonary embolism

Because the patient's legs are elevated, gravity drainage, thigh-high thromboembolism-deterrent hose, sequential compression stockings, and early ambulation decrease the risk of deep venous thrombosis.

Cardiovascular

These adverse effects are not a typical concern unless unusual fluid shifts or blood loss occurred during surgery.

Delayed

Prolonged incontinence

Most patients eventually obtain complete urinary control. Prolonged urinary incontinence appears to be more common in patients older than 70 years. Furthermore, reported continence rates are similar for radical perineal prostatectomy and radical retropubic prostatectomy.

Harris and Fischer have reported good success rates using a running anastomosis and bladder neck–sparing techniques. Social continence (0-1 pads/d) was maintained in 45%, 87%, and 98% of patients upon catheter removal, 4 months, and 1 year, respectively (see Image 10).¹⁴ Weldon et al reported that 95% of their patients were dry 10 months after radical perineal prostatectomy, including all patients younger than 69 years.¹⁵

Time until continence in weeks after catheter removal. Socially dry is defined as the use of 0-1 pad daily, and totally dry is defined as the use of no pads. The use of more than 1 pad daily is considered incontinence.

In a 2000 study of 825 patients, Parra reported continence rates of 94% for radical perineal prostatectomy and 93% for radical retropubic prostatectomy.¹⁶ Similarly, continence rates were approximately 92% at 1 year for the retropubic approach from large centers, including Washington University at St. Louis, Johns Hopkins University, Columbia University, and the University of Washington.

Urethral and anastomotic strictures, if present, should be treated with dilation in an office setting or with a precise internal urethrotomy. Detrusor instability often contributes to postprostatectomy incontinence and can be treated with anticholinergics.

Some patients may benefit from an alpha-adrenergic agonist, Kegel exercises, or both. Behavioral modifications, including fluid restriction, double voiding, voiding prior to strenuous activity, and avoiding dietary irritants (eg, caffeine, spicy foods, citrus products), may also be effective. If all of the above measures fail, an artificial sphincter can be placed. In select cases, collagen injections may be effective if the posterior urethra has good compliance above the pelvic floor and distal to the anastomosis.

Impotence

When prostate cancer is juxtaposed near the erectile nerves, adequate cancer resection dictates their wide excision. However, with earlier cancer detection and the availability of effective oral medications to facilitate erections, urologists are being more aggressive with nerve-sparing procedures. A unilateral nerve-sparing procedure performed on the side opposite the tumor is well accepted. Bilateral nerve-sparing procedures are being used in many patients with low-volume disease.

Recent advances in nerve-sparing techniques have been applied to both radical perineal prostatectomy and radical retropubic prostatectomy. In properly selected patients, these techniques can help maintain the ability to achieve spontaneous erections satisfactory for penetration.

Harris reported that, after 12 months, 50% of patients who underwent unilateral nerve-sparing radical perineal prostatectomy and 70% of patients who underwent bilateral nerve-sparing radical perineal prostatectomy were able to achieve an erection adequate for intercourse with or without the use of phosphodiesterase inhibitors (see Image 11).¹⁷ Weldon et al reported potency rates as high as 70%¹⁵ and Parra reported a rate of 34%¹⁶ for selected patients after nerve-sparing radical perineal prostatectomy. These numbers are comparable with reports from Catalona et al of 71%,¹⁸ Parra of 47%,¹⁶ and Stanford et al of 44%¹⁹ after bilateral nerve-sparing procedures using a retropubic approach.

The percentage of men reporting erectile function adequate for vaginal penetration with or without the use of sildenafil (Viagra) in months following unilateral and bilateral cavernosal nerve-sparing radical perineal prostatectomy.

Penile injection therapy, intraurethral pharmacotherapy, vacuum-erection devices, and penile prostheses are generally effective for restoring adequate erections when a wide excision is performed. Sildenafil (Viagra) generally fails in the absence of some erectile-initiating event but may augment erections when nerve-sparing techniques have been performed. Younger patients are reported to have much better outcomes with regard to nerve sparing and erectile function compared with older patients.

Anastomotic stricture

Urethral strictures are less common with radical perineal prostatectomy than with radical retropubic prostatectomy. In recent series, only 1-2% of patients who underwent radical perineal prostatectomy develop anastomotic strictures.¹⁵ Dilation in an office-based setting usually solves the problem; however, direct-vision internal urethrotomy in the operating room may be required. Some patients have recurrences, necessitating periodic intermittent catheterization. Incontinence may be prolonged in these situations.

Urocutaneous fistula

Skin fistulae are exceptionally rare. The fistulous tract may be resected and recurrence prevented with a gracilis interposition flap.¹⁷

Perineal hernia

This rare complication can occur if the pelvic floor muscles are not reapproximated. Vicryl mesh, cadaveric fascia, rectus fascia, or fascia lata may be used to strengthen the pelvic floor repair.

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

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

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.

Multimedia

Media file 1: 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.

Media file 2: The inverted-U incision is placed in the mid perineum, medial to the ischial tuberosities and anterior to the mid anus.

Media file 3: A lateral view illustrates the difference in approaches and the proximity of the rectum to the apex of the prostate. The authors use the Young suprasphincteric approach.

Media file 4: The Thompson perineal retractor provides excellent surgical exposure.

Media file 5: The Denonvilliers aponeurosis (fascia) is carefully incised, and the cavernosal nerve bundles are delicately separated from the prostate.

Media file 6: The urethra is dissected out of the apex. Cavernosal nerves are preserved bilaterally as the urethra is dissected out of the apex of the prostate up to the verumontanum.

Media file 7: A length of urethra is dissected out of the prostate base, and the bladder neck is left intact.

Media file 8: The urethro-urethrostomy anastomosis is completed with 2 running sutures to ensure an optimally watertight anastomosis. The 2 sutures are nearly ready to be tied together to complete the anastomosis. Note the cavernosal nerve bundles on each side of the urethral anastomosis.

Media file 9: The Penrose drain in the completed incision is removed on the first postoperative day.

Media file 10: Time until continence in weeks after catheter removal. Socially dry is defined as the use of 0-1 pad daily, and totally dry is defined as the use of no pads. The use of more than 1 pad daily is considered incontinence.

Media file 11: The percentage of men reporting erectile function adequate for vaginal penetration with or without the use of sildenafil (Viagra) in months following unilateral and bilateral cavernosal nerve-sparing radical perineal prostatectomy.

Media file 12: Nerve-sparing radical perineal prostatectomy.

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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

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

Further Reading