eMedicine Specialties > Urology > Cancer, Prostate
Prostate Cancer - Radical Retropubic Prostatectomy: Treatment
Updated: Apr 27, 2009
Treatment
Preoperative Details
Because radical prostatectomy is most effective when the cancer is organ- or specimen-confined, accurate preoperative characterization of the cancer is essential for a tailored, safe, and effective operation. Physicians can estimate successful outcomes of radical prostatectomy by using well-established nomograms that provide important prognostic information before therapy.
A model combining preoperative PSA, Gleason score, and clinical stage has increased the ability to predict pathologic stage. This model, which was proposed by Partin et al in 1997, involves these 3 clinical variables to predict pathologic stage, using a multinomial log-linear analysis in 3 major institutions, including the John Hopkins Hospital, Baylor College of Medicine, and the University of Michigan.9 The validity of the Partin nomograms were tested independently and vigorously by applying them to a large cohort of patients (2475 patients) treated with radical prostatectomy at the Mayo Clinic.10 The sensitivity and specificity of the Partin tables were similar when tested at this external site.
In recent years, efforts have been made to predict the likelihood of disease recurrence after radical prostatectomy. One of the most useful models has been the Kattan nomogram, which was originally validated in one institution and subsequently underwent external validation.11,12 Combining clinical prognostic factors, it allows the preoperative prediction of freedom from recurrence after radical prostatectomy using PSA levels as an endpoint. This was recently validated in a large community-based cohort from the CaPSURE database with surgeons of differing clinical experience with radical prostatectomy.13
Discuss the risks of the procedure, including erectile dysfunction, incontinence, risk of transfusion, and other acute surgical morbidities with the patient before the operation.
Autologous blood donations are not routinely advocated.
Apply a sequential compression device to the patient's lower extremities before the procedure.
Intraoperative Details
Make a lower-midline incision. Then, perform an extraperitoneal bilateral pelvic lymphadenectomy. Remove the retropubic fat and isolate and cauterize the superficial branch of the dorsal venous complex. Bluntly incise the endopelvic fascia bilaterally. Sweep all residual muscle fibers (ie, levator ani, pubococcygeus, puborectalis) off the lateral aspect of the prostate laterally to expose the prostatic fascia and the dorsal venous complex (Image 1).
Fascial anatomy after division of the endopelvic fascia (EPF). Reprinted with permission from Ghavamian R, Zincke H. An updated simplified approach to nerve-sparing radical retropubic prostatectomy. BJU Int. Jul 1999;84(1):160-3. Note the abbreviations: puboprostatic ligaments (PPL); deep dorsal vein complex (DDV); superficial dorsal vein (SDV).
Using a suture carrier, pass a 2.0-Vicryl suture just underneath the dorsal venous complex and anterior to the urethra. Control back-bleeders with two 2.0-Vicryl figure-8 sutures (ie, bunching sutures) on the proximal aspect of the dorsal vein complex.
Divide the dorsal venous complex using electrocautery, leaving a defect in the prostatic fascia. Make an inverted-V incision in the exposed prostatic fascial edge, carrying the line of the incision distally and proximally, as shown in Image 2.
An incision in the prostatic fascia from the defect in the prostatic fascia (PF) after division of the dorsal venous complex. Note the neurovascular bundle (NVB) deep to the prostatic fascia Reprinted with permission from Ghavamian R, Zincke H. An updated simplified approach to nerve-sparing radical retropubic prostatectomy. BJU Int. Jul 1999;84(1):160-3. Note the abbreviations: endopelvic fascia (EF); superficial dorsal vein (SDV); deep dorsal vein (DDV).
Using a spreading maneuver with Satinsky scissors, carry the incision parallel to the neurovascular bundle toward the urethra and the bladder (Image 3). In this fashion, the lateral prostatic fascia containing the neurovascular bundles is mobilized posteriorly and out of harm's way.
The incision in the prostatic fascia (PF) is carried parallel to the neurovascular bundle (NVB) toward the bladder and the membranous urethra (MU). Reprinted with permission from Ghavamian R, Zincke H. An updated simplified approach to nerve-sparing radical retropubic prostatectomy. BJU Int. Jul 1999;84(1):160-3.
Place the index finger of the left hand in the plane between the mobilized prostatic fascia and the prostatic capsule and advance it under the posterior aspect of the prostate. This maneuver separates the anterior Denonvilliers fascia adherent to the posterior aspect of the prostate from the posterior Denonvilliers fascia adherent to the anterior rectum.
Move the tip of the left index finger toward the right prostato-apical junction and extend it toward the lateral prostatic fascia on the contralateral side, anterior to and above the right neurovascular bundle. Guided by the tip of the left index finger, pierce the right lateral prostatic fascia above the neurovascular bundle with a right-angle clamp.
Spread the clamp and sweep the right neurovascular bundle off the prostate cranially and posteriorly. Divide the membranous urethra at the apex of the prostate using electrocautery. Hold the electrocautery probe at a 45° angle toward the apex. In this fashion, residual delicate fibers of the external urethral rhabdosphincter complex, which cover the anterior aspect of the prostatic apex in a fan-shaped manner, are divided and preserved on the eventual urethral stump (Image 4).
Division of the membranous urethra (MU) just distal to the prostatic apex. Note the angle of the division (inset), allowing the preservation of the outermost fibers of the external rhabdosphincter. Reprinted with permission from Ghavamian R, Zincke H. An updated simplified approach to nerve-sparing radical retropubic prostatectomy. BJU Int. Jul 1999;84(1):160-3.
After the urethra is divided, mobilize the prostate cephalad and ligate the lateral vascular pedicles close to the prostate with small hemoclips. Divide the anterior layer of Denonvilliers fascia and identify the ampullae of the vas deferens. Dissect the ampullae of the vas deferens off the medial aspect of the seminal vesicles and divide them after mobilizing them distally. Using sharp dissection, mobilize the seminal vesicles to their tips. Careful dissection at this juncture prevents injury to the neurovascular bundles and the pelvic plexus, which lie close to the lateral aspect of the seminal vesicles.
Retract the seminal vesicles and the ampullae of the vas deferens cephalad and dissect them free of the bladder base and the posterior aspect of the bladder using electrocautery. Start this dissection at the tip of the visceral bladder fascia, an extension of the posterior Denonvilliers fascia (Image 5).
Cephalad retraction of the prostate (P) and seminal vesicles (SV) and the ampullae of the vas deferens. Reprinted with permission from Ghavamian R, Zincke H. An updated simplified approach to nerve-sparing radical retropubic prostatectomy. BJU Int. Jul 1999;84(1):160-3. Note the abbreviations: bladder (B); neurovascular bundle (NVB); mucosal urethra (MU).
Preserve the circular fibers of the bladder neck and remove the specimen en bloc. With careful bladder neck preservation, extensive bladder neck reconstruction is not necessary. Use a running 3.0-monocryl suture to reconstruct the bladder neck. Start the suture on the right side at the 7-o'clock position and run it, everting the bladder mucosa onto the parietal bladder fascia (Image 6).
Bladder neck reconstruction. In Picture A, a 3.0-monocryl suture is placed, starting at the 7-o'clock position. Picture B shows approximation and eversion of the bladder mucosa to the overlying bladder fascia anteriorly. Reprinted with permission from Ghavamian R, Zincke H. An updated simplified approach to nerve-sparing radical retropubic prostatectomy. BJU Int. Jul 1999;84(1):160-3.
Lock the suture at the 5-o'clock position and incorporate in the suture the visceral bladder fascia between the 5- and 7-o'clock positions (Image 7). Perform a direct vesicourethral anastomosis using 6 evenly placed absorbable sutures (eg, 2.0-monocryl) utilizing a urethral sound.
In Picture A, the suture is locked at the 5-o'clock position, incorporating the visceral bladder fascia. In Picture B, the completed bladder neck reconstruction is pictured. Reprinted with permission from Ghavamian R, Zincke H. An updated simplified approach to nerve-sparing radical retropubic prostatectomy. BJU Int. Jul 1999;84(1):160-3.
A critical aspect of the operation is the use of intraoperative frozen-section analysis of the surgical margins. In the event of a positive margin, prostatic induration, or suspected locally advanced prostate cancer, the ipsilateral neurovascular bundle can be excised.
Postoperative Details
The authors routinely use two Jackson-Pratt (JP) drains that are positioned bilaterally in the pelvis with the tip pointed up to avoid slipping and suctioning the vesicourethral anastomosis. Postoperatively, the authors remove the patients' drains when the cumulative output from each is less than or equal to 30 mL over 24 hours. Drain input initially increases in some patients. The drain is left in to prevent lymphocele formation. If drainage is significant, consider the possibility of urine leakage; if the increased drainage continues, the JP drains are taken off bulb suction. This allows the anastomotic leak to seal in most cases. When this does not suffice (extremely rare), a Foley catheter can be hooked up to low wall suction through a Pleurovac to allow for a seal at the anastomotic site.
The drainage fluid can be sent for creatinine measurement. A drainage-fluid creatinine level that approximates the serum creatinine level indicates lymphatic drainage rather than urine. Cystography is sometimes helpful to assess the extent of the extravasation.
Other potential mechanical problems can occur. Clot retention can be managed with gentle bladder irrigation. Following radical prostatectomy, undue tension and traction should not be applied to the urethral catheter. This is a rare event after radical prostatectomy.
The management of a dislodged catheter depends on the timing of the event. At postoperative day 3, with a good anastomosis, a single attempt at reinsertion with a well-lubricated coude-tip catheter is reasonable. However, when in doubt or unsuccessful, flexible cystoscopy at the bedside and passage of a council tip catheter over a wire under direct vision is the safest approach. With a good anastomosis, if the catheter is dislodged after 1 week, the patient should be allowed to void; if he does so with no problems, the authors do not insert a new catheter.
Follow-up
In treating prostate cancer, physicians have the luxury of an accurate marker for disease recurrence: the PSA level. Serum PSA is measured every 3 months for the first 2 years. If undetectable, the interval is increased to every 6 months until 5 years postsurgery, when it can be measured yearly.
In patients with a detectable PSA level after surgery, the timing of the PSA level rise is important. Abnormal PSA levels need to be confirmed with a repeat measurement. A true PSA level rise less than 1 year after prostatectomy is more indicative of occult distant metastases at the time of surgery. On the other hand, a later PSA level rise is more compatible with local recurrence. Imaging studies, such as bone scan, can be repeated. In patients with a late PSA level rise in whom bone scan results are negative, a Prostascint scan can be considered or performed to rule out distant metastases before local salvage therapy (radiation) is contemplated.
In a study by Patel et al (1997), 80% of patients with a PSA level doubling time of 6 months or greater remained clinically disease-free, compared with 64% with PSA level doubling time of less than 6 months.14 Short PSA level doubling time (high log slope), regardless of the time of PSA level recurrence, was strongly associated with clinical recurrence. In a study by Pound et al (1999), PSA level doubling time, along with Gleason score, was also predictive of probability and time to development of metastatic disease.15
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
Radical prostatectomy is a well-tolerated procedure that is associated with low morbidity. The incidence of hemorrhage, the most common intraoperative complication, has decreased with improved surgical technique and increased experience in the large contemporary radical prostatectomy series. Mean estimated blood loss in these series ranges from 300-2000 mL, with most experienced centers reporting less than 1000 mL. In the authors' personal experience, transfusion of any kind is necessary in fewer than 2% of cases. This has made autologous blood donation, with its obvious cost-saving advantages, unnecessary in most cases.
The frequencies of intraoperative and late complications have also decreased. A comparison of morbidity from the authors' contemporary radical prostatectomy series to an earlier study revealed no mortalities. The rates of bowel injury, colostomy, total incontinence, pulmonary embolism, and urethral stricture requiring long-term therapy were 0.6%, 0%, 0.8%, 0.6%, and 8.7%, respectively. The contemporary series revealed improved continence and fewer blood transfusions (77% before 1989 vs 22% after 1989). The average patient is discharged from the hospital on the second postoperative day as part of a carefully planned pre- and post–radical prostatectomy patient-care pathway.
Urinary incontinence is a troubling complication of radical prostatectomy. The true incidence in different series is difficult to compare because of differences in the definition of incontinence. Most centers with expertise in the surgery report an incontinence rate of less than 10%; this figure includes occasional stress incontinence. The true rate of total incontinence with no urinary control is less than 5% and, for the authors, is less than 1%. In patients who experience this complication, improvement is likely after 1 year. Therefore, defer any invasive treatment until after 1 year. Searching for the cause of incontinence is an important aspect of therapy. Dribbling incontinence can develop with a bladder neck contracture (ie, overflow incontinence). Flexible cystoscopy and dilatation or transurethral resection of the contracture is often necessary. In patients with no anatomic abnormalities, urodynamic testing is warranted.
Erectile dysfunction following radical prostatectomy results from numerous factors, including potency before the operation, the age of the patient, the stage of the tumor, and the preservation of the neurovascular bundles. Preservation of the neurovascular bundles allows for better postoperative potency rates. In this regard, surgical techniques are important, and the data on postoperative return of potency differ between centers of excellence and population surveys. The goals of adequate cancer operation and retained potency should be balanced to maintain negative surgical margins. Return of erections is more common in patients who have undergone a bilateral nerve-sparing procedure than in patients who have undergone a unilateral procedure. Generally, potency is retained in 68% of patients who have undergone bilateral nerve-sparing prostatectomy and in 13-47% of men who have undergone a unilateral neurovascular bundle preservation.16
In 2000, Walsh et al administered a validated disease-targeted quality-of-life survey to patients who underwent radical prostatectomy and who were potent before the procedure.17 The study showed that sildenafil improved the quality of erections and that the surveyed patients reported high (86%) overall potency rate at 18 months. Eighty-four percent of respondents reported no or minimal sexual bother. These numbers may also reflect a stage migration in prostate cancer in which more cancers are of lower volume and are organ-confined and in which both (89% in this series) or at least one neurovascular bundle can be saved. Therefore, both neurovascular bundles should be saved when feasible, and saving even one neurovascular bundle is justified.
Advanced pathologic stage and patient age also adversely affect the return of potency. Quinlan et al (1991) reported that erectile function at least partially returned in 70% of men with organ-confined disease who had bilateral neurovascular preservation versus 50% in men with seminal vesicle invasion.18 In this series, 90% of men younger than 50 years were potent postsurgery if one or both bundles were preserved.
The availability of oral sildenafil, alprostadil suppositories, and intracavernous injection therapy allow adequate postoperative treatment of erectile dysfunction so that quality of life is preserved in most patients.
Two studies have addressed the efficacy of sildenafil in patients postprostatectomy. Zippe et al (2000) studied the effects of bilateral, unilateral, and non–nerve-sparing techniques.19 Sildenafil was efficacious in the bilateral nerve-sparing group, with 72% of the patients reporting rigidity that was sufficient for penetration. Only 50% of the patients in the unilateral nerve-sparing group responded to sildenafil. In a study by Marks et al (1999), patients were grouped according to the severity of their impotence based on the International Index of Erectile Function (IIEF).20 All patients undergoing prostatectomy were in the most severe group, with only 40% achieving sufficient tumescence with sildenafil.
Sildenafil should be the first agent administered in the treatment of postprostatectomy impotence in the absence of contraindications. However, the response may be poor based on the operation performed and the presence of other comorbidities, such as vascular disease or diabetes.
Recently, early combination therapy with intracavernosal injections and sildenafil has been shown to increase sexual activity and to facilitate the return of natural erections after radical prostatectomy. Combination therapy also allows a lower dose of intracavernosal injections, thereby decreasing morbidity and discomfort.21
Some researchers have suggested that pharmacologic treatment begun earlier postprostatectomy increases the likelihood of ultimate spontaneous return of potency. Some carefully conducted studies have disagreed with this finding. Zippe et al (2000) determined that the interval from surgery to the initiation of sildenafil therapy does not significantly influence the positive response rate. However, the dose did influence the positive response rate, with 71% of the patients requiring a 100-mg dose. Zagaja et al (2000) reported that patients who had not yet regained sexual function did not respond to sildenafil before 9 months postsurgery.22 Considering this latency, probably due to prolonged neurapraxia, these authors suggest starting the patient on topical alprostadil or intracavernosal injections to stimulate penile vasculature and to prevent loss of elasticity and, ultimately, cavernosal fibrosis.
Recent quality-of-life studies have evaluated the functional outcomes and bother factors after radical prostatectomy and radiation-based therapies. In one study, treatment did not appear to affect health-related quality of life.23 Obstructive and urinary symptoms were more common after brachytherapy. Radiation-based therapies (eg, brachytherapy, external beam radiotherapy) were superior to radical prostatectomy in terms of urinary control and sexual function. However, among men who were potent before treatment, radical prostatectomy and brachytherapy yielded equivalent rates of sexual-function recovery. Bilateral nerve-sparing surgery diminished the differences in functional outcomes between surgery and external beam radiotherapy.
In another study, although urinary incontinence was significantly worse after radical prostatectomy than after brachytherapy or high-dose external beam radiotherapy, patients who had undergone brachytherapy reported more irritative symptoms.24 Radical prostatectomy was associated with superior bowel function and fewer irritative functions. All 3 therapies were associated with impaired sexual function, but higher scores were seen in men who selected brachytherapy.
Retrospective studies have revealed a definite change in the patients' disease-targeted quality of life. Litwin et al (1999) examined sexual bother and function after radical prostatectomy and radiation using the CaPSURE database.25 Although sexual function declined after surgery, it improved over time in the first year, as it did after radiation. However, during the second year, sexual function declined in patients undergoing radiation therapy.
Note that quality of life as a whole after radical prostatectomy is not worse than quality of life after interstitial seed implantation. Krupski et al (2000) directly compared the quality of life and symptoms of patients with localized prostate cancer treated with radical prostatectomy with those treated with brachytherapy alone or in combination with external beam radiotherapy.26 An overall lower quality of life was found in the combination-treatment group than in the radical prostatectomy and brachytherapy groups. Radical prostatectomy was also superior to brachytherapy alone in that patients who underwent surgery had decreased irritative and obstructive voiding symptoms as measured with the American Urological Association (AUA)/International Prostate Symptom Score (IPSS).
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Keywords
radical retropubic prostatectomy, RRP, robotic-assisted laparoscopic radical prostatectomy, RALP, prostate cancer, prostate-specific antigen, PSA, adenocarcinoma of the prostate, perineal prostatectomy, urinary incontinence, impotence, erectile dysfunction, prostatic adenocarcinoma, prostate adenocarcinoma, radical prostatectomy, minimally invasive radical prostatectomy, robotic prostatectomy, laparoscopic radical prostatectomy
