Radical Retropubic Prostatectomy for Prostate Cancer Periprocedural Care

Updated: Nov 28, 2016
  • Author: Reza Ghavamian, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Periprocedural Care

Patient Education and Consent

Informed consent must be obtained. Discuss the risks of the procedure, including erectile dysfunction, incontinence, risk of transfusion, and other acute surgical morbidities, with the patient before the operation.

For patient education information, see the Prostate Health Center, the Cancer and Tumors Center, and the Kidneys and Urinary System Center, as well as Prostate Cancer and Bladder Control Problems.

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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. [14, 15, 16, 17, 18]

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, which was proposed by Partin et al in 1997, made use of a multinomial log-linear analysis in 3 major institutions, including the John Hopkins Hospital, Baylor College of Medicine, and the University of Michigan. [19]

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. [20]

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. The authors do not routinely advocate autologous blood donation, because they do not find it cost-effective. In this setting, the decision for or against such donation is generally governed by the surgeon’s individual technique and average blood loss. Certainly, if the patient adamantly requests autologous blood donation, the authors usually comply. [21]

Imaging studies

Electrocardiography and chest radiography are performed.

Because prostate cancer tends to metastasize to bone, many physicians once routinely performed bone scans for the detection of metastases in localized prostate cancer. However, careful review of the literature since the advent of PSA testing revealed that a bone scan is not always necessary.

A study from the Mayo Clinic addressed this issue, finding that serum PSA testing was the most accurate clinical indicator of whether a bone scan finding is likely to be positive. [22] Of 306 patients with a serum PSA level below 20 ng/mL, only 1 patient had skeletal metastases. Of 209 patients with a PSA level below 10 ng/mL, none had metastases. This yields a negative predictive value of 100% for the latter group (PSA level < 10 ng/mL) and 99.7% for the former (PSA < 20 ng/mL). These results have been validated by other institutions.

The authors perform a bone scan in patients with a serum PSA level higher than 20 ng/mL. This modality is also is justified in patients with a biopsy Gleason score of 7 and a PSA level higher than 10 ng/mL. The authors also perform a bone scan in patients with high Gleason scores (8-10) because the serum PSA level in these patients may not accurately reflect disease burden.

Computed tomography (CT) and magnetic resonance imaging (MRI) are used to assess nodal size to detect possible nodal metastases. However, CT is not accurate in the detection of nodal disease: sensitivity ranges from 33% to 50%, but even these sensitivities are limited to series in which patients have locally advanced disease. Currently, CT has a very low yield in the detection of metastases for the average patient with localized prostate cancer who presents to the office.

In a 1995 study, CT findings were positive in only 13 of 861 patients (1.5%), all with a PSA level higher than 20 ng/mL. [23] During surgical staging of 409 patients with normal CT scans, 15 were found to have nodal metastases, 13 of which were microscopic. Therefore, CT scanning would not have changed the ultimate management, which suggests that it should not be considered an essential component of staging clinically localized prostate cancer in low-risk patients.

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.

Pelvic MRI also has a low sensitivity (20-30% at best) in the detection of nodal metastases. The decision whether to perform pelvic MRI in patients with prostate cancer should be based on the same rationale used in deciding whether to perform CT (ie, calculation of risk on the basis of other clinical variables in conjunction with appropriate patient selection).

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. The overall sensitivity is 50-60%.

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%. Positive and negative predictive values have been approximately 60% and 70%, respectively.

These values, although superior to those of CT for evaluation of lymph nodes, are not accurate enough to justify routine use of this modality. Many clinicians perform CT in poor-risk patients (Gleason score ≥7, PSA level >20 ng/mL, or both), mostly to rule out bulky obvious nodal disease. In the absence of such findings, many argue that lymph node dissection is mandatory and unavoidable and that a ProstaScint scan does not provide an added benefit.

ProstaScint scanning is also used to detect recurrent disease in the prostatic fossa in patients who have undergone prostatectomy.

Kahn et al reviewed the relationship between prostatic fossa biopsies and scan results and found that the sensitivity of ProstaScint scanning in this setting was 49%, the specificity was 70%, the positive predictive value was 50%, and the negative predictive value was 70%. [24]

In the decision whether to institute salvage radiotherapy, other factors (eg, Gleason score, onset, and the slope of the postoperative rise in the PSA level) are important as well. These factors, in association with the above results, indicate that a ProstaScint scan is not always crucial for clinical decision-making in this setting.

Considerable expertise is required for proper interpretation of ProstaScint scans, contributing to the suboptimal value of this modality.

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Monitoring and Follow-up

In treating prostate cancer, physicians have the luxury of an 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, 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. [25] 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. [26]

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