Radical Perineal Prostatectomy for Prostate Cancer Periprocedural Care

Updated: Jul 08, 2020
  • Author: Howard J Korman, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
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Periprocedural Care

Patient Education and Consent

Patient instructions

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

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

Patient expectations

Dr Peter Scardino of the Memorial Sloan Kettering Cancer Center (MSKCC) in New York coined the term “trifecta” to summarize the 3 primary objectives facing patients undergoing prostate cancer treatment.

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

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

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

Institution

Procedure

1 year

2 years

3 years

4 years

Memorial Sloan-Kettering Cancer Center [21]

Radical retropubic prostatectomy

30%

42%

47%

53%

Northern Institute of Urology

Radical perineal prostatectomy

53.6%

71.7%

78.9%

81%

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Patient Preparation

Anesthesia

The operation can be performed with the patient under spinal or general anesthesia. Obese men who are in an exaggerated lithotomy position generally have shallower respirations. General anesthesia may be preferable to spinal anesthesia in order to control ventilation.

Positioning

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

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

Special care should be taken to pad the legs well and to avoid excessive torque on the hips. Excessive tension in positioning may cause sciatic neurapraxia or compromised circulation to the lower extremities and lower abdomen. Rhabdomyolysis has been reported in rare cases; it is usually related to prolonged operating time and improper positioning.

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Monitoring and Follow-up

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

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