Patient Education and Consent
Informed consent must be obtained. Discuss the risks of the procedure, including erectile dysfunction, incontinence, risk of transfusion, infection, and other acute surgical morbidities, with the patient before the operation.
For patient education information, see the Prostate Health Center and Prostate Cancer.
Preprocedural Evaluation
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. [23, 36, 37, 38, 39]
Predictive nomograms
A model combining the preoperative prostate-specific antigen (PSA) level, the Gleason score, and the clinical stage has enhanced clinicians’ ability to predict the pathologic stage. This predictive model, initially proposed by Partin et al in 1997, made use of a multinomial log-linear analysis in three major institutions, including the John Hopkins Hospital, Baylor College of Medicine, and the University of Michigan. [40]
The sensitivity and specificity of the Partin tables were found to be similar when the validity of the Partin nomograms was tested at the Mayo Clinic. The test involved a large cohort of patients (2475 patients) treated with radical prostatectomy. [41]
The Cancer of the Prostate Risk assessment (CAPRA) score is based on age, serum PSA, Gleason score, Clinical stage and percentage of cancer in biopsy cores. It can predict an individual's likelihood of metastasis, cancer-specific mortality, and overall mortality. [42] The MSKCC risk calculator https://www.mskcc.org/nomograms/prostate/post-op/coefficients
can predict two, five, seven and ten year cancer recurrence free survival after radical prostatectomy and is the most widely used nomogram by clinicians for predicting recurrence after surgery.
Using readily available pocket software, the clinician can enter preoperative data and advise the patient concerning the likelihood of organ confinement and outcomes after radical prostatectomy. Chances for recurrence after radical prostatectomy can also be calculated by using the pathologic data. This guides the clinician and patient in devising a treatment strategy.
Laboratory studies
Routine preoperative laboratory studies are performed, including a complete blood count (CBC), blood chemistry (ie, CHEM 7), and urinalysis.
The patient’s blood also is typed and screened. Autologous blood transfusion is not necessary with improved surgical techniques
Imaging studies
Electrocardiography and chest radiography are performed.
AUA guidelines recommend a bone scan if PSA levels are more than 20ng/dl. Bone scan may be considered in patients with PSA levels of < 20 ng/mL, if the tumor is Gleason ≥8 on biopsy, if the clinical stage is ≥T3, or if the history and physical symptoms suggest possible bony metastasis. In cases of prostate cancer with the possibility of locally advanced disease or nodal metastases, risk can be reliably predicted on the basis of validated prostate-cancer nomogram data. The probability of positive lymph nodes is estimated by using the local clinical stage, primary Gleason grade, and serum PSA concentration. These nomograms can be used to identify high-risk patients in whom CT might be justified.
Cross sectional imaging in the form of CT/MRI is indicated in patients with PSA levels of >20 ng/mL, Gleason score ≥8, or clinically advanced disease, as few patients without these parameters harbor metastatic lymphadenopathy. Patients with a risk of lymph node metastasis of >20% according to Partins’s tables should also be offered imaging.
The Prostate Cancer Radiographic Assessments for Detection of Advanced Recurrence (RADAR) group recommends a bone scan and cross sectional imaging in newly diagnosed intermediate and high risk patients with any 2 of the 3 criteria are met, namely PSA >10 ng/ml, Gleason score greater/equal to 7 and palpable disease (³ T2a). [43]
The NCCN guidelines recommend pelvic CT or MRI should be used in patients with T3–T4 disease or those with T1–T2 disease, if nomogram-predicted probability of lymph node involvement is >10%. European Urology guidelines mention the low sensitivity of cross sectional imaging for detecting lymph (< 40%) and recommend for patients in whom curative treatment is planned and who have PSA levels of >10 ng/mL, Gleason score ≥8, or clinical stage ≥T3.
Whether positron emission tomography (PET) is useful in prostate cancer is debatable. Prostate cancer is not an active metabolic malignancy, and uptake of 18-fluorodeoxyglucose (FDG) may be suboptimal. At present, the data do not support an additional role for PET scanning in the staging and evaluation of de novo or recurrent prostate cancer.
Monoclonal antibody technology has been applied to the staging of prostate cancer. Indium (In)-111 labeled capromab pendetide (ProstaScint; EUSA Pharma [USA], Langhorne, PA) recognizes an epitope of the prostate-specific membrane antigen (PSMA) and can be useful for evaluation of nodal and distant metastases in prostate cancer. However the overall sensitivity is poor at 50-60%. [44]
ProstaScint scanning can be used to detect recurrence in previously treated patients or to stage patients with poor prognostic parameters (high Gleason grade and PSA level with negative results on bone scan and CT scanning) prior to definitive local therapy. One area of clinical utility may be the detection of lymph node metastases before radical prostatectomy; studies in this area have reported a sensitivity of about 60% and a specificity of about 70% with positive and negative predictive values approximately 60% and 70%, respectively. [44] These values, although superior to those of CT for evaluation of lymph nodes, are not accurate enough to justify routine use of this modality. Improved monoclonal imaging with alternate more sensitive tracers is currently in development.
Monitoring and Follow-up
In treating prostate cancer, physicians have the luxury of a very accurate marker for disease recurrence: the serum PSA level. Serum PSA is measured every 3 months for the first 2 years. If it is undetectable (or < 0.2), the interval is increased to every 6 months until 5 years after the operation, at which point the serum PSA level can be measured yearly.
If serum PSA is detectable after radical prostatectomy, it is important to determine the timing of the PSA level rise. Abnormal PSA levels must be confirmed with a repeat measurement. A confirmed rise in the PSA level less than 1 year after prostatectomy is more indicative of occult distant metastases at the time of the operation.
A confirmed rise in the PSA level that occurs later, however, is more compatible with local recurrence. Imaging studies, such as bone scanning, 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 (radiotherapy) is contemplated.
In a study by Patel et al, 80% of patients with a PSA-level doubling time of 6 months or longer remained clinically disease-free, compared with 64% of patients with a PSA-level doubling time shorter than 6 months. [45] Regardless of the time of PSA level recurrence, a short PSA-level doubling time (high log slope) was strongly associated with clinical recurrence.
In a study by Pound et al, the PSA-level doubling time, along with the Gleason score, was also predictive of probability and time to development of metastatic disease. [46]
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Fascial anatomy after division of 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. DDV = deep dorsal vein complex; PPL = puboprostatic ligaments; SDV = superficial dorsal vein.
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Incision in prostatic fascia (PF) from defect in PF after division of dorsal venous complex. Note neurovascular bundle (NVB) deep to PF. 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. DDV = deep dorsal vein; EF = endopelvic fascia; SDV = superficial dorsal vein.
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Incision in prostatic fascia (PF) is carried parallel to neurovascular bundle (NVB) toward bladder and 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.
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Division of membranous urethra (MU) just distal to prostatic apex. Note angle of division (inset), allowing preservation of outermost fibers of 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.
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Cephalad retraction of prostate (P) and seminal vesicles (SV) and ampullae of 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. B = bladder; MU = mucosal urethra; NVB = neurovascular bundle.
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Bladder neck reconstruction. (A) 3-0 poliglecaprone suture is placed, starting at 7-o'clock position. (B) Approximation and eversion of bladder mucosa to 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.
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(A) Suture is locked at 5-o'clock position, incorporating visceral bladder fascia. (B) 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.
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Kaplan-Meier clinical progression (ie, systemic/local) survival estimates for 4453 patients with clinically localized prostate cancer treated with radical prostatectomy with and without adjuvant therapy. Numbers in parentheses represent standard error and number of patients at risk at that point. Reprinted from Ghavamian R, Blute ML, Bergstralh EJ, et al. Comparison of clinically nonpalpable prostate-specific antigen-detected (cT1c) versus palpable (cT2) prostate cancers in patients undergoing radical retropubic prostatectomy. Urology. Jul 1999;54(1):105-10.
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Kaplan-Meier prostate-specific antigen (PSA) progression (systemic/local and/or PSA level >0.2 ng/mL) survival estimates for 4453 patients with clinically localized prostate cancer treated with radical prostatectomy with or without adjuvant therapy. Numbers in parentheses represent standard error and number of patients at risk at that point. Reprinted from Ghavamian R, Blute ML, Bergstralh EJ, et al. Comparison of clinically nonpalpable prostate-specific antigen-detected (cT1c) versus palpable (cT2) prostate cancers in patients undergoing radical retropubic prostatectomy. Urology. Jul 1999;54(1):105-10.
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Radical retropubic prostatectomy. Preparation, positioning, and incision. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Radical retropubic prostatectomy. Bilateral pelvic lymph node dissection. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Radical retropubic prostatectomy. Incision in endopelvic fascia. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Radical retropubic prostatectomy. Division of puboprostatic ligaments. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Radical retropubic prostatectomy. Bunching suture placement on edge of endopelvic fascia. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Radical retropubic prostatectomy. Control of dorsal vein complex. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Radical retropubic prostatectomy. Transection of dorsal vein complex. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Radical retropubic prostatectomy. Division of urethra. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Radical retropubic prostatectomy. Placement of anterior anastomotic sutures. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Radical retropubic prostatectomy. Placement of posterior anastomotic sutures. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
