Radical Perineal Prostatectomy for Prostate Cancer Technique

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

Approach Considerations

Radical perineal prostatectomy (RPP) is a well-tolerated and effective treatment for clinically organ-confined prostate cancer. It is associated with less perioperative morbidity, shorter hospitalization, lower costs, [23] and quicker recovery than radical retropubic prostatectomy (RRP) is. Its favorable profile as a minimally invasive treatment for prostate cancer endures, even as interest in robotic-assisted radical prostatectomy (RALP) and other minimally invasive procedures continues to grow.

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Perineal Approach to Radical Prostatectomy

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 procedure. 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 midperineum and the ends anterior to the midanal line and 1 cm medial to the ischial tuberosities (see the image below). Allis clamps are used to secure the transurethral resection drape to the skin.

Inverted-U incision is placed in midperineum, medi Inverted-U incision is placed in midperineum, medial to ischial tuberosities and anterior to midanus.

Various surgical approaches to RPP have been developed (see the image below). The authors prefer the Young suprasphincteric approach to the Belt subsphincteric approach. The ischiorectal fossa is developed on either side of the central tendon, and the central tendon is divided with the cautery.

Lateral view illustrates difference in surgical ap Lateral view illustrates difference in surgical approaches and proximity of rectum to apex of prostate. Authors use Young suprasphincteric approach.

Dissection continues to the fibrous confluence posterior to the raphe of the bulbospongiosus. 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, with care taken 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 vesicles. 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 RPP, 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 (see the image below).

Nerve-sparing radical perineal prostatectomy. Nerve-sparing radical perineal prostatectomy.

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

Thompson perineal retractor provides excellent sur Thompson perineal retractor provides excellent surgical exposure.

Nerve-sparing criteria vary from surgeon to surgeon; generally, however, potent men with low-volume, nonpalpable cancers and Gleason scores of 6 or lower 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 vesicle to the medial aspect of the other. Scissors are spread in this space to reveal the ampullae of vas deferens and the seminal vesicles. One vas is grasped and dissected to approximately 5 cm from the prostate, where it is sealed with a vessel-sealing device (eg, LigaSure) and divided. The other vas is managed similarly. A seminal vesicle is grasped with Russian forceps and retracted medially.

The Denonvilliers aponeurosis is swept laterally with the tips of the scissors to reveal the lateral aspect. Scissors are spread on the lateral aspect of the seminal vesicle, revealing the vessels at its tip. These vessels are sealed with the vessel sealer 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 to the midline, over the medial aspect of the ipsilateral seminal vesicle to the midline overlying the apex, and back down to the medial aspect of the contralateral seminal vesicle (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 the image below).

Denonvilliers aponeurosis (fascia) is carefully in Denonvilliers aponeurosis (fascia) is carefully incised, and cavernosal nerve bundles are delicately separated from 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 then sealed with a vessel-sealing device and divided, with care taken to avoid 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 (see below).

In a non–nerve-sparing RPP, 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 vessel sealer and divided. The posterolateral aspect of the prostatovesical junction is developed as previously described.

Next, attention is then turned to the prostatic apex. 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 the cautery, the Lowsley tractor is removed, and an additional length of urethra is dissected out of the apex up to the verumontanum (see the image below). The urethra is then divided sharply.

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

The next step in RPP is to divide the puboprostatic ligaments with the 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 so as to expose the anterior attachments to the bladder neck; alternatively, a straight Lowsley tractor can be used. Anterior attachments are divided with the cautery. Occasionally, venous bleeding from the dorsal venous complex necessitates ligation with an absorbable suture.

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

Length of urethra is dissected out of prostate bas Length of urethra is dissected out of prostate base, and bladder neck is left intact.

The operative field is irrigated, and any remaining bleeding points are controlled before the anastomosis is started. The urethral ends are anastomosed with 2 continuous 3-0 absorbable monofilament sutures placed near the anterior midline and run posteriorly, where they are tied with minimal tension so as not to reduce 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, urethrourethrostomy is performed so that the urethra is not anastomosed to the bladder neck (see the image below).

Urethrourethrostomy is completed with 2 continuous Urethrourethrostomy is completed with 2 continuous sutures to ensure optimally watertight anastomosis. Sutures are nearly ready to be tied together to complete anastomosis. Note cavernosal nerve bundles on each side of urethral anastomosis.

Once the anastomosis is complete, the urethra is injected with sterile saline in a retrograde fashion from the meatus, and the anastomosis is distended so as to identify any leaks that may necessitate placement of additional sutures. An 18-French catheter is then passed into the bladder, and the bladder is irrigated to free any clots.

In men who have previously undergone transurethral resection of the prostate (TURP), whose prostate is very large, or who have cancer near the bladder neck, bladder-neck preservation is not necessarily intended. In this situation, the bladder is entered anteriorly after the puboprostatic ligaments have been divided. The bladder neck is excised off the prostate, with care taken to stay a safe distance from the ureteral orifices. The bladder neck is then tailored to a snug 18-French opening without eversion of the urothelium.

The anastomosis is then accomplished in much the same manner as previously described, with care taken to include urothelium in each anastomotic suture. The “tennis-racquet” closure of the bladder neck is reinforced with another layer of continuous absorbable sutures.

Finally, the retractors are removed, and the rectum is inspected for injuries or thin areas, which are repaired or reinforced if present. 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 side and the left (see the image below).

Penrose drain in completed incision is removed on Penrose drain in completed incision is removed on postoperative day 1.

Optionally, a belladonna and opium suppository may 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.

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Postoperative Care

The patient starts ambulation and begins a regular diet and oral analgesia on the day of the procedure. Ketorolac may be used for postoperative pain. The patient and the home caregiver (eg, a partner or a family member) are instructed on incision care, dressing changes, and catheter care.

The Penrose drain is removed on the morning after the procedure, before the patient is discharged from the hospital. The catheter is removed within approximately 8 days, after which time the patient’s normal activities may be resumed without restriction, except for bicycle and horseback riding.

The patient is given instruction on pelvic muscle exercises to help reduce incontinence. Some physicians recommend a nightly low-dose phosphodiesterase inhibitor (eg, sildenafil) postoperatively to improve potency outcomes. [20]

Patients with severe hemorrhoid problems may experience increased hemorrhoidal discomfort for 1-3 months after RPP.

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Complications

Intraoperative complications

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 the learning curve [24] ; transfusion was not required for any of the subsequent 500 cases.

Rectal injury

The prevalence of rectal injury is inversely related to the surgeon’s experience and occurs in fewer 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 previously underwent radiation therapy for prostate cancer.

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

Neurapraxia

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

Rhabdomyolysis

A prolonged operating 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 on dipstick testing but negative for red blood cells on microscopic urinalysis.

Early, aggressive hydration and diuresis can lessen the associated renal failure and metabolic acidosis. Alkalization with sodium bicarbonate should also be instituted.

Cardiovascularcompromise

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.

Immediate postoperative complications

Bleeding

Signs of postoperative bleeding include bloody Penrose drainage, gross hematuria with clots, or an ecchymosis 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; accordingly, 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 warrant anticholinergic therapy.

Wound infections

Infections are rare if patients are given preoperative antibiotic coverage. According to a study of Medicare records by Lu-Yao et al, wound infections occur slightly more frequently with RPP than with the RRP. [25]

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 eliminates the need to open the entire wound if only 1 side is involved.

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 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 effects

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

Delayed complications

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 RPP and RRP.

Harris and Fischer reported good success rates using a running anastomosis and bladder neck–sparing techniques. [26] Social continence (0-1 pads/day) was maintained in 45%, 87%, and 98% of patients upon catheter removal, 4 months, and 1 year, respectively (see the image below). Weldon et al reported that 95% of their patients were dry 10 months after radical perineal prostatectomy, including all patients younger than 69 years. [27]

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

In a study of 825 patients, Parra reported continence rates of 94% for RPP and 93% for RRP. [19] 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 before strenuous activity, and avoidance of dietary irritants (eg, caffeine, spicy foods, and 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.

Anal sphincteric incontinence

Although transient fecal urgency is common during the first week after RPP, persistent anal incompetence is rare. It has been reported, however, that fecal incontinence can be problematic.

In a retrospective study designed to investigate this issue, Korman et al found no statistical difference in overall bowel function between patients who had undergone RPP (79 patients), patients who had undergone RRP (71 patients), and a control group (men undergoing prostate-specific antigen [PSA] screening who would be radical prostatectomy candidates if diagnosed with prostate cancer). [28]

In a prospective, longitudinal study on patients who underwent RPP, Dahm et al found that most patients returned to baseline fecal urgency less than 1 year after operation. [29] The report included data gathered using the bowel domain of the Expanded Prostate Cancer Index Composite questionnaire. Subjects were evaluated before RPP and at 3-month intervals afterward.

In this report, involuntary stool leakage and rectal urgency were present before RPP in 11.5% and 19.2% of patients, respectively. [29] 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 RPP.

Impotence

When prostate cancer is present near the erectile nerves, adequate cancer resection dictates wide excision of these nerves. 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.

Advances in nerve-sparing techniques have been applied to both RPP and RRP. In properly selected patients, these techniques can help to maintain the ability to achieve spontaneous erections satisfactory for penetration.

Harris reported that after 12 months, 50% of patients who underwent unilateral nerve-sparing RPP and 70% of patients who underwent bilateral nerve-sparing RPP were able to achieve an erection adequate for intercourse, with or without the use of phosphodiesterase inhibitors (see the image below). [16] Weldon et al reported potency rates as high as 70%, [27] and Parra reported a rate of 34% [19] for selected patients after nerve-sparing RPP.

Percentage of men reporting erectile function adeq Percentage of men reporting erectile function adequate for vaginal penetration with or without use of sildenafil in months following unilateral and bilateral cavernosal nerve-sparing radical perineal prostatectomy.

These numbers are comparable to reports from Catalona et al, [30] Parra, [19] and Stanford et al [31] for bilateral nerve-sparing procedures using a retropubic approach (71%, 47%, and 44%, respectively).

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 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 than older patients do.

Anastomotic stricture

Urethral strictures are less common with RPP than with RRP. Series have indicated that only 1-2% of patients who have undergone RPP develop anastomotic strictures. [27] 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. [16]

Perineal hernia

Perineal hernia is rare but can occur if the pelvic floor muscles are not reapproximated. Polyglactin mesh, cadaveric fascia, rectus fascia, or fascia lata may be used to strengthen the pelvic floor repair.

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