eMedicine Specialties > Urology > Cancer, Prostate
Prostate Cancer - Radical Perineal Prostatectomy: Treatment
Updated: Apr 27, 2009
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.
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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
