Sections

Radical Retropubic Prostatectomy for Prostate Cancer

Sections Radical Retropubic Prostatectomy for Prostate Cancer
Overview
Periprocedural Care
Technique
Media Gallery
References

Technique

Retropubic Approach to Radical Prostatectomy

Before beginning a radical retropubic prostatectomy (RRP), antibiotics are given and measures are taken to avoid lower extremity deep venous clots. These include the application of a sequential compression device to the patient’s lower extremities and use of heparin 5000U subcutaneously.

Make a lower midline incision (see the first video below). Perform an extraperitoneal bilateral pelvic lymph node dissection if necessary (PLND; see the second video below).

Radical retropubic prostatectomy. Preparation, positioning, and incision. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

View Media Gallery

Radical retropubic prostatectomy. Bilateral pelvic lymph node dissection. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

View Media Gallery

Remove the retropubic fat, and isolate and cauterize the superficial branch of the dorsal venous complex. Bluntly incise the endopelvic fascia bilaterally (see the first video and the image below). Sweep all residual muscle fibers (ie, levator ani, pubococcygeus, and puborectalis) off the lateral aspect of the prostate laterally to expose the prostatic fascia and the dorsal venous complex. The puboprostatic ligaments will have to be divided (see the second video below).

Radical retropubic prostatectomy. Incision in endopelvic fascia. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

View Media Gallery

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.

View Media Gallery

Radical retropubic prostatectomy. Division of puboprostatic ligaments. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

View Media Gallery

Using a suture carrier, pass a 0 polyglactin suture just underneath the dorsal venous complex and anterior to the urethra in a figure-8 fashion and tie. Control backbleeding by placing 2 figure-8 sutures of 0 polyglactin (ie, bunching sutures) on the proximal aspect of the dorsal vein complex one at the bladder neck and another midway between the apex and bladder neck.

Radical retropubic prostatectomy. Bunching suture placement on edge of endopelvic fascia. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

View Media Gallery

Radical retropubic prostatectomy. Control of dorsal vein complex. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

View Media Gallery

Divide the dorsal venous complex sharply leaving a defect in the prostatic fascia (see below). Make an inverted-V incision in the exposed prostatic fascial edge, carrying the line of the incision distally and proximally (see the image below) using a right angle. The complex may be further oversewn with a 3.0 Monocryl if needed.

Radical retropubic prostatectomy. Transection of dorsal vein complex. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

View Media Gallery

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.

View Media Gallery

Using a spreading maneuver with Satinsky scissors, carry the incision parallel to the neurovascular bundle toward the urethra and the bladder (see the image below). In this fashion, the lateral prostatic fascia containing the neurovascular bundles is mobilized posteriorly and out of harm’s way.

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.

View Media Gallery

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 with the electrocautery (see the video below). Hold the electrocautery probe at a 45° angle toward the apex (see the image below). In this fashion, the 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. In the manner of Walsh, 6 evenly placed absorbable sutures (eg, 2-0 poliglecaprone) are placed, 3 anterior and 3 posterior. These are tagged and covered with a towel. The posterior urethra is then incised as is Denonvilliers fascia and a finger gently inserted under the prostate to develop this plane.

The prostate is gently retracted with a sponge stick and mobilization of the prostate cephalad begins first on one side. Ligate the lateral vascular pedicles close to the prostate with small hemostatic clips. Sweep the right neurovascular bundle off the prostate working cranially clipping and sharply dividing small perforators. Divide the anterior layer of Denonvilliers fascia, and identify the ampullae of the vas deferens (Figure below).

Radical retropubic prostatectomy. Division of urethra. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

View Media Gallery

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.

View Media Gallery

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 with the electrocautery.

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.

View Media Gallery

Taking care to preserve the circular fibers of the bladder neck, remove the surgical specimen en bloc.

With careful bladder neck preservation, extensive bladder neck reconstruction is not necessary. A 3-0 poliglecaprone suture is used to reconstruct the bladder neck and evert the mucosa. 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.

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.

View Media Gallery

Lock the suture at the 5-o’clock position, and incorporate the visceral bladder fascia in the suture between the 5- and 7-o’clock positions (see the image below). Perform a direct vesicourethral anastomosis using 6 evenly placed absorbable sutures (eg, 2-0 poliglecaprone) and a urethral sound (see the videos below). Alternatively, interrupted sutures placed at 12, 3, 6 and 9 o clock can also be used to advance bladder mucosa over the raw bladder neck muscle to ensure a mucosa to mucosa anastomosis. The urethral sutures are then placed through the bladder neck. The anterior anastomotic sutures are tied first. There should be no tension. If there is, the bladder should be released from the peritoneum. The 12-, 10-, 2-, 4-, 8-, and 6-o’clock sutures are tied sequentially. A 20F Foley catheter is placed and inflated to 15cc. After the operative site is irrigated vigorously with saline, a small suction drain is placed next to the anastomosis. The fascia is closed with No. 2 Prolene and skin with metallic clips.

(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.

View Media Gallery

Radical retropubic prostatectomy. Placement of anterior anastomotic sutures. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

View Media Gallery

Radical retropubic prostatectomy. Placement of posterior anastomotic sutures. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

View Media Gallery

Intraoperative frozen-section analysis of the surgical margins is used in some situations. In the event of a positive margin, prostatic induration, or suspected locally advanced prostate cancer, the ipsilateral neurovascular bundle can be excised.

Postoperative Care

Ambulation is encouraged on the evening of procedure. Sips and a clear liquid diet is started on the same day evening and low fat diet is started on the next day. Narcotics are administered using a patient controlled pump overnight and in patients with normal renal function and low intraoperative blood loss, parenteral NSAIDs can be substituted for narcotics.

Postoperatively, drains are removed when output from suction drain falls below 50ml. In some patients, drain input increases initially. The drain is left in to prevent lymphocele formation. If drainage is significant, consider the possibility of urine leakage; if the increased drainage continues, suction drains are taken off bulb suction. This allows the anastomotic leak to seal in most cases. If this measure does not suffice (an extremely rare scenario), a Foley catheter can be hooked up to low wall suction through a drainage system to allow 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 for assessing the extent of the extravasation.

Other potential mechanical problems can occur. Clot retention can be managed with gentle bladder irrigation.

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 coudé-tip catheter is reasonable. However, if the attempt is possibly or certainly unsuccessful, flexible cystoscopy at the bedside with passage of a Councill-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, a new catheter need not be inserted. Urinary catheter removal should be done between 7 -14 days after surgery.

Hormonal therapy

The effect of neoadjuvant ADT on survival outcomes has been controversial. Several randomized trials failed to show a survival benefit with neoadjuvant hormonal therapy for localized prostate cancer. A prospective randomized trial showed no difference in biochemical recurrence rate in cT2B patients who received neoadjuvant hormonal therapy at 5 years of follow up.^[47]Another phase III study analyzed effects of 3 months vs 8 months of neoadjuvant ADT. Positive margin rates were significantly lower in the 8 than in the 3-month group (12% versus 23%, respectively), but there was higher incidence of adverse events in the 8-month group.^[48]A phase II SWOG trial included 62 patients with locally advanced disease (97% with T3, 3% with T4 and 39% with bulky nodal disease, a majority of whom would have been otherwise candidates for radiation. After a course of neoadjuvant hormonal therapy 55 (90%) of patients underwent surgery and had a 5 – year progression-free and overall survival of 70% and 90%.^[49]

A recently concluded retrospective multiinstitutional study compared propensity matched high risk prostate cancer patients defined as clinical stage T3-4, PSA >20 ng / ml or biopsy Gleason score 8-10 treated with surgery alone or neoadjuvant ADT + surgery. Neoadjuvant ADT reduced the risk of prostate cancer related death (HR 0.5; 95% confidence interval (CI) 0.32-0.80; P=0.0014).^[50]Further prospective studies with well-defined high risk population are needed to define the role of neoadjuvant hormonal therapy in localized PCa.

Radiation therapy

The risk of local failure and biochemical progression depends on Gleason score, initial prostate-specific antigen (PSA) level, positive seminal vesicles, and positive margins.^{[51, 52]}Radiation therapy is effective in reducing biochemical recurrence and for achieving local control in patients with local failure.^{[53, 54]}There has been considerable debate about the timing of radiation therapy. Proponents of adjuvant therapy emphasize the adjuvant radiation therapy of 60–64 Gy administered soon after wound healing, typically within 3 months after surgery for pathologically confirmed predictors of recurrence like capsule penetration, seminal vesicle invasion, margin positivity or for high risk T3 disease. This approach reduces biochemical recurrence and improves local control, as evidenced from three large randomized trials.^{[53, 54, 55]}

Opponents of this approach cite the lack of improvement in survival indices at 5 years, (overall, cancer specific and metastasis free survival) and the increased rates of acute and late gastrointestinal toxicity, urinary stricture and incontinence as reasons for opting for a salvage approach. Salvage radiotherapy offers a chance of cure for patients with biochemical recurrence. Using ultrasensitive PSA for early detection and using dosages of up to 75 Gy,^[56]60% of the patients can reach an undetectable PSA and 80% of these can be progression-free after 5 years.^{[57, 58]}PSA is a very sensitive marker of recurrence and to date no difference in radiation outcomes has been reported between patients with low versus lower PSA values.

Thus, the literature would support adjuvant radiotherapy be reserved for infrequent patients at very high risk of local recurrence (e.g. multiple positive surgical margins), with the rest being monitored for recurrence and treated with salvage radiotherapy if needed.^[59]Adding a short course of hormone therapy to salvage radiation therapy has recently been shown to improve biochemical progression and clinical progression at 5 years, compared to radiation alone in randomized phase III trial (GETUG-AFU16). No additional late adverse events occurred in patients receiving short-term androgen suppression compared with those who received radiotherapy alone.^[60]

Intraoperative complications

Radical prostatectomy is a well-tolerated procedure that is associated with low morbidity and few intraoperative complications in experienced hands.

Hemorrhage is the most common intraoperative complication, with venous bleeding the most likely source. Venous bleed can occur during endopelvic fascia incision, puboprostatic ligament division and during exposure of the apex of the prostate with transection of the dorsal vein complex (DVC). Bleeding from the DVC can be profuse and difficult to control. Division of the DVC over the urethra and oversewing can is used to manage bleeding from DVC.

With improved surgical technique and experience, the incidence of hemorrhage has decreased with mean estimated blood loss ranging from 300-1000 ml in most of the contemporary prostatectomy cohorts.^{[61, 62]}

Transfusion rates vary from 2-20% for patients undergoing RRP. Autologous blood donation is an option to avoid transfusion risk. An alternate approach has been to utilize epoetin alpha injection to stimulate and boost red cell production prior to the operation. 2 preoperative doses 600 IU/kg given on days (-14) and (-7) are safe for significantly increasing hematocrit in men before radical retropubic prostatectomy.^[63]

Less common intraoperative complications are rectal injury, obturator nerve injury and ureteral injury.

Postoperative complications

Delayed hemorrhage is a rare complication of radical prostatectomy. Expectant management is employed, along with blood transfusion. However, large pelvic hematomas can drain through urethrovesical anastomosis causing bladder neck contracture or incontinence later.^[64]Hence it is prudent to explore and drain large hematomas that require blood transfusion.

Thromboembolic events including deep vein thrombosis (DVT) and pulmonary embolism occur in the early post-operative period. Open radical prostatectomy (compared to RALP) and lymph node dissection increase the odds of thromboembolic events.^[65]Using sequential compression devices, proper lower extremity positioning and early ambulation can prevent DVT development.

Bladder neck contracture is reported in 1 – 5 % of contemporary prostatectomy series.^{[66, 67]}Excessive blood loss, persistent urinary extravasation, prior radiation, prior bladder outlet procedures, BMI, age, and smoking status have all been suggested as factors contributing to BNC development.^[68]Simple dilatation is tried initially typically in the clinic setting, followed by bladder neck incision at 3, 6, and 9 o clock positions if recurrent. Injection of steroid (triamcinolone acetate) after bladder neck incision can be effective for recurrent cases.^[69]

Urinary incontinence

Urinary incontinence is a troubling complication of radical prostatectomy. Clinically incontinence symptoms can range from occasional stress leakage to total incontinence. Occasional stress incontinence is significantly more common. Comparison of its incidence across different series is difficult because of variations in how incontinence is defined. Most centers with expertise in RRP report a postoperative stress incontinence rates of less than 10%.

Incontinence after surgery depends on patient parameters including the patient’s body mass index (BMI), age, urethral length, preoperative continence status and prostatic volume. Surgeon factors like experience and surgical technique also correlate with incontinence rate.^[70] Striated sphincter damage during ligation and division of DVC can cause intrinsic sphincter deficiency and is a significant contributor to incontinence. Damage to intrinsic smooth muscle of urethra during vesicourethral anastomosis and functional hindrance by an altered bladder neck caliber are other etiologies for incontinence. Meticulous surgical technique can reduce the incidence and severity of incontinence. Tension free vesicourethral anastomosis and adequate mucosal cooptation between the bladder neck and urethra help preserve an adequate bladder neck function post operatively. Buttressing sutures to intussuscept bladder neck has been shown to improve continence rates at 1-year follow up.^{[71, 72]}

A study that used a novel cluster modeling technique to determine predictors of post prostatectomy urinary incontinence identified 3 distinct postoperative continence recovery patterns. The first group of patients had a significant postoperative decrease with only one third recovery of function at 1 year. The second group had moderately decreased urinary function at 3 months with improvement to 76.8% of optimum function at 1 year. Group 3 patients had minimum impairment of continence post-operatively. Old age, major depression, peripheral vascular disease, smoking history and comorbidities were predictors of poor continence recovery in group 1.^[73]These findings have implications for preoperative patient counseling and early intervention for post prostatectomy urinary incontinence.

Management strategy of incontinence begins with quantification of incontinence by calculating number of pads used in a day and the extent to which the symptoms affect the quality of life. Patients must be counselled about likelihood of improvement up to one year following surgery and deferring invasive treatment until at least 1 year has elapsed after RRP.^[74]Life style modifications and pelvic floor exercises have been shown to be effective for early continence recovery. Biofeedback, pelvic floor stimulation, pharmacotherapy (duloxetine), and urethral bulking agents have limited evidence in this setting.^[75]A large population based analysis of 16,348 men treated with radical prostatectomy showed only 1,057 (6%) had 1 incontinence procedure by a median of 20 months after the procedure, indicating that a majority of incontinence are minor and could be medically managed.^[76]

Surgical options for management of post prostatectomy incontinence include artificial urinary sphincter and the male sling.^[77]The artificial urinary sphincter has a success rate in the range of 58% to 90%. Potential complications include incontinence (due to poor compliance in neurogenic bladders), urethral atrophy, mechanical failure, device erosion, and infection.^[78]The male sling is designed for men with low volume incontinence (1-3 pads/ day).^[77]In properly selected patient population slings have a success rate of 40%-90% without the risk of device failure.^[77]

Erectile dysfunction

Whether and to what degree erectile dysfunction develops after RRP is governed by 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 better postoperative potency rates. Surgical technique is of great importance in this regard, and the data on postoperative return of potency reported from centers of excellence differ substantially from those reported in population surveys. The goals of adequate cancer surgery 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 those 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 those who have undergone prostatectomy with unilateral neurovascular bundle preservation.^[79]

Return of erectile function occurs gradually after RRP and depends to a large extent on the age and preoperative potency status. Sexual function returns gradually after surgery, with 38% potent at 3 months, 54% at 6 months, 73% at 12 months, and 86% at 18 months in large series.^[72]Age has a critical role in the return of sexual function with 100 % of men in 30 -39 years age group and only 75% men above 60 – 67 years regaining sexual function after surgery in the same series.^[72]There is some evidence for correlation for return of sexual function with the pathological stage. Erectile function returned at least partially in 70% of men with organ-confined disease who had bilateral neurovascular preservation, compared with 50% of men with seminal vesicle invasion.^[80]

Management of impotence after RRP includes oral phosphodiesterase 5 inhibitors (PDE5I), intra corporeal injections, vacuum erection device, and penile prosthesis. In the absence of contraindications, an oral PDE5I should be the first agent administered in the treatment of post prostatectomy impotence. Sildenafil was efficacious in bilateral nerve-spared patients compared to unilateral and non-nerve sparing patients, with 72% of the patients reporting rigidity that was sufficient for penetration.^[81]Only 50% of the patients in the unilateral nerve-sparing group responded to sildenafil. However, the response may be poor, depending on the operation performed and the presence of other comorbidities, such as vascular disease or diabetes.

Early combination therapy with intracavernosal injections and sildenafil may increase sexual activity and to facilitate the return of natural erections after radical prostatectomy but further research is needed. Combination therapy also allows a lower dose of intracavernosal injections, thereby decreasing morbidity and discomfort.^[82]

The concept of erection rehabilitation has been proposed by researchers based on preclinical evidence of potential positive effect of PDE5I on erectile function recovery.^[83]Two large double-blind placebo controlled trials assessed the effect of early administration of oral PDE5 inhibitors vardenafil and tadalafil for erection rehabilitation. Both studies showed that PDE5 inhibitors were only effective in potentiating erections post RP, with no clear positive effect on erection rehabilitation in the long term setting off drug.^{[84, 85]}Improvements in morning erections and penile length were noted in the drug groups. Thus, oral PDE5 inhibitors have a role for on demand usage to improve erection quality post RRP.

Vacuum erection devices have shown promise for improving erectile function and for penile rehabilitation. In a prospective randomized trial, 80% of men using vacuum erection device daily after a nerve-sparing radical prostatectomy had erections sufficient for intercourse.^[86]Of those patients who were unsatisfied with the device, the addition of sildenafil to device usage led to significant improvement in satisfaction in 77% of patients.

Penile prosthesis are used as last resort if above measures fail. Data from a population based study indicates penile implant utilization rate of 2.3% after RP.^[87]Penile prosthesis have a high rate of patient satisfaction (86%) with acceptable complications (5%) of infection, revision, or mechanical failure.^[88]

Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol. 1982 Sep. 128(3):492-7. [QxMD MEDLINE Link].
Ghavamian R, Knoll A, Boczko J, Melman A. Comparison of operative and functional outcomes of laparoscopic radical prostatectomy and radical retropubic prostatectomy: single surgeon experience. Urology. 2006 Jun. 67 (6):1241-6. [QxMD MEDLINE Link].
Schuessler WW, Schulam PG, Clayman RV, Kavoussi LR. Laparoscopic radical prostatectomy: initial short-term experience. Urology. 1997 Dec. 50(6):854-7. [QxMD MEDLINE Link].
Alemozaffar M, Sanda M, Yecies D, Mucci LA, Stampfer MJ, Kenfield SA. Benchmarks for operative outcomes of robotic and open radical prostatectomy: results from the Health Professionals Follow-up Study. Eur Urol. 2015 Mar. 67 (3):432-8. [QxMD MEDLINE Link].
Tewari A, El-Hakim A, Rao S, Raman JD. Identification of the retrotrigonal layer as a key anatomical landmark during robotically assisted radical prostatectomy. BJU Int. 2006 Oct. 98 (4):829-32. [QxMD MEDLINE Link].
Patel VR, Thaly R, Shah K. Robotic radical prostatectomy: outcomes of 500 cases. BJU Int. 2007 May. 99 (5):1109-12. [QxMD MEDLINE Link].
Laurila TA, Huang W, Jarrard DF. Robotic-assisted laparoscopic and radical retropubic prostatectomy generate similar positive margin rates in low and intermediate risk patients. Urol Oncol. 2009 Sep-Oct. 27 (5):529-33. [QxMD MEDLINE Link].
U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008 Aug 5. 149 (3):185-91. [QxMD MEDLINE Link]. [Full Text].
Ohmann EL, Loeb S, Robinson D, Bill-Axelson A, Berglund A, Stattin P. Nationwide, population-based study of prostate cancer stage migration between and within clinical risk categories. Scand J Urol. 2014 Oct. 48 (5):426-35. [QxMD MEDLINE Link].
Vellekoop A, Loeb S. More aggressive prostate cancer in elderly men. Rev Urol. 2013. 15 (4):202-4. [QxMD MEDLINE Link].
Jemal A, Fedewa SA, Ma J, Siegel R, Lin CC, Brawley O, et al. Prostate Cancer Incidence and PSA Testing Patterns in Relation to USPSTF Screening Recommendations. JAMA. 2015 Nov 17. 314 (19):2054-61. [QxMD MEDLINE Link].
Bibbins-Domingo K, Grossman DC, Curry SJ. The US Preventive Services Task Force 2017 Draft Recommendation Statement on Screening for Prostate Cancer: An Invitation to Review and Comment. JAMA. 2017 May 16. 317 (19):1949-1950. [QxMD MEDLINE Link].
Overholser S, Nielsen M, Torkko K, Cwilka D, Weaver B, Shi X, et al. Active Surveillance is an Appropriate Management Strategy for a Proportion of Men Diagnosed with Prostate Cancer by Prostate Specific Antigen Testing. J Urol. 2015 Sep. 194 (3):680-4. [QxMD MEDLINE Link].
Eggener SE, Scardino PT, Walsh PC, Han M, Partin AW, Trock BJ, et al. Predicting 15-year prostate cancer specific mortality after radical prostatectomy. J Urol. 2011 Mar. 185 (3):869-75. [QxMD MEDLINE Link].
Cancer Stat Facts: Prostate Cancer. National Cancer Institute: Surveillance, Epidemiology, and End Results Program. Available at https://seer.cancer.gov/statfacts/html/prost.html. Accessed: September 10, 2021.
Shimizu H, Ross RK, Bernstein L, Yatani R, Henderson BE, Mack TM. Cancers of the prostate and breast among Japanese and white immigrants in Los Angeles County. Br J Cancer. 1991 Jun. 63 (6):963-6. [QxMD MEDLINE Link].
Petimar J, Wilson KM, Wu K, Wang M, Albanes D, van den Brandt PA et al. A Pooled Analysis of 15 Prospective Cohort Studies on the Association between Fruit, Vegetable, and Mature Bean Consumption and Risk of Prostate Cancer. Cancer Epidemiol Biomarkers Prev. 2017 Aug. 26 (8):1276-1287. [QxMD MEDLINE Link].
Steinberg GD, Carter BS, Beaty TH, Childs B, Walsh PC. Family history and the risk of prostate cancer. Prostate. 1990. 17 (4):337-47. [QxMD MEDLINE Link].
Al Olama AA, Kote-Jarai Z, Berndt SI, Conti DV et al. A meta-analysis of 87,040 individuals identifies 23 new susceptibility loci for prostate cancer. Nat Genet. 2014 Oct. 46 (10):1103-9. [QxMD MEDLINE Link].
Giri VN, Gross L, Gomella LG, Hyatt C. How I Do It: Genetic counseling and genetic testing for inherited prostate cancer. Can J Urol. 2016 Apr. 23 (2):8247-53. [QxMD MEDLINE Link].
Agalliu I, Gern R, Leanza S, Burk RD. Associations of high-grade prostate cancer with BRCA1 and BRCA2 founder mutations. Clin Cancer Res. 2009 Feb 1. 15 (3):1112-20. [QxMD MEDLINE Link].
Ryan S, Jenkins MA, Win AK. Risk of prostate cancer in Lynch syndrome: a systematic review and meta-analysis. Cancer Epidemiol Biomarkers Prev. 2014 Mar. 23 (3):437-49. [QxMD MEDLINE Link].
Walz J, Gallina A, Saad F, Montorsi F, Perrotte P, Shariat SF, et al. A nomogram predicting 10-year life expectancy in candidates for radical prostatectomy or radiotherapy for prostate cancer. J Clin Oncol. 2007 Aug 20. 25 (24):3576-81. [QxMD MEDLINE Link].
Abdollah F, Sun M, Schmitges J, Tian Z, Jeldres C, Briganti A, et al. Cancer-specific and other-cause mortality after radical prostatectomy versus observation in patients with prostate cancer: competing-risks analysis of a large North American population-based cohort. Eur Urol. 2011 Nov. 60 (5):920-30. [QxMD MEDLINE Link].
Yacoub JH, Oto A, Miller FH. MR imaging of the prostate. Radiol Clin North Am. 2014 Jul. 52 (4):811-37. [QxMD MEDLINE Link].
Nezolosky MD, Dinh KT, Muralidhar V, Mahal BA, Chen YW, Beard CJ, et al. Significant increase in prostatectomy and decrease in radiation for clinical T3 prostate cancer from 1998 to 2012. Urol Oncol. 2016 Feb. 34 (2):57.e15-22. [QxMD MEDLINE Link].
Akakura K, Suzuki H, Ichikawa T, Fujimoto H, Maeda O, Usami M, et al. A randomized trial comparing radical prostatectomy plus endocrine therapy versus external beam radiotherapy plus endocrine therapy for locally advanced prostate cancer: results at median follow-up of 102 months. Jpn J Clin Oncol. 2006 Dec. 36 (12):789-93. [QxMD MEDLINE Link].
Lennernäs B, Majumder K, Damber JE, Albertsson P, Holmberg E, Brandberg Y, et al. Radical prostatectomy versus high-dose irradiation in localized/locally advanced prostate cancer: A Swedish multicenter randomized trial with patient-reported outcomes. Acta Oncol. 2015 Jun. 54 (6):875-81. [QxMD MEDLINE Link].
Cristini C, Di Pierro GB, Leonardo C, De Nunzio C, Franco G. Safe digital isolation of the santorini plexus during radical retropubic prostatectomy. BMC Urol. 2013 Feb 27. 13:13. [QxMD MEDLINE Link].
Palisaar RJ, Graefen M, Karakiewicz PI, Hammerer PG, Huland E, Haese A, et al. Assessment of clinical and pathologic characteristics predisposing to disease recurrence following radical prostatectomy in men with pathologically organ-confined prostate cancer. Eur Urol. 2002 Feb. 41 (2):155-61. [QxMD MEDLINE Link].
Zincke H, Oesterling JE, Blute ML, Bergstralh EJ, Myers RP, Barrett DM. Long-term (15 years) results after radical prostatectomy for clinically localized (stage T2c or lower) prostate cancer. J Urol. 1994 Nov. 152 (5 Pt 2):1850-7. [QxMD MEDLINE Link].
Ghavamian R, Blute ML, Bergstralh EJ, Slezak J, Zincke H. Comparison of clinically nonpalpable prostate-specific antigen-detected (cT1c) versus palpable (cT2) prostate cancers in patients undergoing radical retropubic prostatectomy. Urology. 1999 Jul. 54 (1):105-10. [QxMD MEDLINE Link].
Boxer RJ, Kaufman JJ, Goodwin WE. Radical prostatectomy for carcinoma of the prostate: 1951-1976. A review of 329 patients. J Urol. 1977 Feb. 117 (2):208-13. [QxMD MEDLINE Link].
Elder JS, Jewett HJ, Walsh PC. Radical perineal prostatectomy for clinical stage B2 carcinoma of the prostate. J Urol. 1982 Apr. 127 (4):704-6. [QxMD MEDLINE Link].
Bekelman JE, Mitra N, Handorf EA, Uzzo RG, Hahn SA, Polsky D, et al. Effectiveness of androgen-deprivation therapy and radiotherapy for older men with locally advanced prostate cancer. J Clin Oncol. 2015 Mar 1. 33 (7):716-22. [QxMD MEDLINE Link].
Greene KL, Meng MV, Elkin EP, Cooperberg MR, Pasta DJ, Kattan MW, et al. Validation of the Kattan preoperative nomogram for prostate cancer recurrence using a community based cohort: results from cancer of the prostate strategic urological research endeavor (capsure). J Urol. 2004 Jun. 171 (6 Pt 1):2255-9. [QxMD MEDLINE Link].
Kattan MW. Should physicians use the updated Partin tables to predict pathologic stage in patients with prostate cancer?. Nat Clin Pract Urol. 2007 Nov. 4 (11):592-3. [QxMD MEDLINE Link].
Kattan MW, Eastham JA, Stapleton AM, Wheeler TM, Scardino PT. A preoperative nomogram for disease recurrence following radical prostatectomy for prostate cancer. J Natl Cancer Inst. 1998 May 20. 90 (10):766-71. [QxMD MEDLINE Link].
Abdollah F, Schmitges J, Sun M, Thuret R, Djahangirian O, Tian Z, et al. Head-to-head comparison of three commonly used preoperative tools for prediction of lymph node invasion at radical prostatectomy. Urology. 2011 Dec. 78 (6):1363-7. [QxMD MEDLINE Link].
Partin AW, Kattan MW, Subong EN, Walsh PC, Wojno KJ, Oesterling JE, et al. Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update. JAMA. 1997 May 14. 277 (18):1445-51. [QxMD MEDLINE Link].
Blute ML, Bergstralh EJ, Partin AW, Walsh PC, Kattan MW, Scardino PT, et al. Validation of Partin tables for predicting pathological stage of clinically localized prostate cancer. J Urol. 2000 Nov. 164 (5):1591-5. [QxMD MEDLINE Link].
Cooperberg MR, Pasta DJ, Elkin EP, Litwin MS, Latini DM, Du Chane J, et al. The University of California, San Francisco Cancer of the Prostate Risk Assessment score: a straightforward and reliable preoperative predictor of disease recurrence after radical prostatectomy. J Urol. 2005 Jun. 173 (6):1938-42. [QxMD MEDLINE Link].
Crawford ED, Stone NN, Yu EY, Koo PJ, Freedland SJ, Slovin SF, et al. Challenges and recommendations for early identification of metastatic disease in prostate cancer. Urology. 2014 Mar. 83 (3):664-9. [QxMD MEDLINE Link].
Beresford MJ, Gillatt D, Benson RJ, Ajithkumar T. A systematic review of the role of imaging before salvage radiotherapy for post-prostatectomy biochemical recurrence. Clin Oncol (R Coll Radiol). 2010 Feb. 22 (1):46-55. [QxMD MEDLINE Link].
Patel A, Dorey F, Franklin J, deKernion JB. Recurrence patterns after radical retropubic prostatectomy: clinical usefulness of prostate specific antigen doubling times and log slope prostate specific antigen. J Urol. 1997 Oct. 158 (4):1441-5. [QxMD MEDLINE Link].
Pound CR, Partin AW, Eisenberger MA, Chan DW, Pearson JD, Walsh PC. Natural history of progression after PSA elevation following radical prostatectomy. JAMA. 1999 May 5. 281 (17):1591-7. [QxMD MEDLINE Link].
Soloway MS, Pareek K, Sharifi R, Wajsman Z, McLeod D, Wood DP Jr, et al. Neoadjuvant androgen ablation before radical prostatectomy in cT2bNxMo prostate cancer: 5-year results. J Urol. 2002 Jan. 167 (1):112-6. [QxMD MEDLINE Link].
Gleave ME, Goldenberg SL, Chin JL, Warner J, Saad F, Klotz LH, et al. Randomized comparative study of 3 versus 8-month neoadjuvant hormonal therapy before radical prostatectomy: biochemical and pathological effects. J Urol. 2001 Aug. 166 (2):500-6; discussion 506-7. [QxMD MEDLINE Link].
Powell IJ, Tangen CM, Miller GJ, Lowe BA, Haas G, Carroll PR, et al. Neoadjuvant therapy before radical prostatectomy for clinical T3/T4 carcinoma of the prostate: 5-year followup, Phase II Southwest Oncology Group Study 9109. J Urol. 2002 Nov. 168 (5):2016-9. [QxMD MEDLINE Link].
Tosco L, Laenen A, Briganti A, Gontero P et al. The survival impact of neoadjuvant hormonal therapy before radical prostatectomy for treatment of high-risk prostate cancer. Prostate Cancer Prostatic Dis. 2017 May 9. [QxMD MEDLINE Link].
Kupelian PA, Katcher J, Levin HS, Klein EA. Stage T1-2 prostate cancer: a multivariate analysis of factors affecting biochemical and clinical failures after radical prostatectomy. Int J Radiat Oncol Biol Phys. 1997 Mar 15. 37 (5):1043-52. [QxMD MEDLINE Link].
Pinto F, Prayer-Galetti T, Gardiman M, Sacco E, Ciaccia M, Fracalanza S, et al. Clinical and pathological characteristics of patients presenting with biochemical progression after radical retropubic prostatectomy for pathologically organ-confined prostate cancer. Urol Int. 2006. 76 (3):202-8. [QxMD MEDLINE Link].
Wiegel T, Bottke D, Steiner U, Siegmann A, Golz R, Störkel S, et al. Phase III postoperative adjuvant radiotherapy after radical prostatectomy compared with radical prostatectomy alone in pT3 prostate cancer with postoperative undetectable prostate-specific antigen: ARO 96-02/AUO AP 09/95. J Clin Oncol. 2009 Jun 20. 27 (18):2924-30. [QxMD MEDLINE Link].
Bolla M, van Poppel H, Tombal B, Vekemans K et al. Postoperative radiotherapy after radical prostatectomy for high-risk prostate cancer: long-term results of a randomised controlled trial (EORTC trial 22911). Lancet. 2012 Dec 8. 380 (9858):2018-27. [QxMD MEDLINE Link].
Thompson IM Jr, Tangen CM, Paradelo J, Lucia MS, Miller G, Troyer D, et al. Adjuvant radiotherapy for pathologically advanced prostate cancer: a randomized clinical trial. JAMA. 2006 Nov 15. 296 (19):2329-35. [QxMD MEDLINE Link].
Ost P, Lumen N, Goessaert AS, Fonteyne V, De Troyer B, Jacobs F, et al. High-dose salvage intensity-modulated radiotherapy with or without androgen deprivation after radical prostatectomy for rising or persisting prostate-specific antigen: 5-year results. Eur Urol. 2011 Oct. 60 (4):842-9. [QxMD MEDLINE Link].
Wiegel T, Lohm G, Bottke D, Höcht S, Miller K, Siegmann A, et al. Achieving an undetectable PSA after radiotherapy for biochemical progression after radical prostatectomy is an independent predictor of biochemical outcome--results of a retrospective study. Int J Radiat Oncol Biol Phys. 2009 Mar 15. 73 (4):1009-16. [QxMD MEDLINE Link].
Stephenson AJ, Scardino PT, Kattan MW, Pisansky TM, Slawin KM, Klein EA, et al. Predicting the outcome of salvage radiation therapy for recurrent prostate cancer after radical prostatectomy. J Clin Oncol. 2007 May 20. 25 (15):2035-41. [QxMD MEDLINE Link].
Bartkowiak D, Bottke D, Wiegel T. Adjuvant radiotherapy or early salvage radiotherapy in pT3R0 or pT3R1 prostate cancer. Curr Opin Urol. 2013 Jul. 23 (4):360-5. [QxMD MEDLINE Link].
Carrie C, Hasbini A, de Laroche G, Richaud P, Guerif S, Latorzeff I, et al. Salvage radiotherapy with or without short-term hormone therapy for rising prostate-specific antigen concentration after radical prostatectomy (GETUG-AFU 16): a randomised, multicentre, open-label phase 3 trial. Lancet Oncol. 2016 Jun. 17 (6):747-756. [QxMD MEDLINE Link].
Alemozaffar M, Regan MM, Cooperberg MR, Wei JT, Michalski JM, Sandler HM, et al. Prediction of erectile function following treatment for prostate cancer. JAMA. 2011 Sep 21. 306 (11):1205-14. [QxMD MEDLINE Link].
Lim SK, Kim KH, Shin TY, Rha KH. Current status of robot-assisted laparoscopic radical prostatectomy: how does it compare with other surgical approaches?. Int J Urol. 2013 Mar. 20 (3):271-84. [QxMD MEDLINE Link].
Rosenblum N, Levine MA, Handler T, Lepor H. The role of preoperative epoetin alfa in men undergoing radical retropubic prostatectomy. J Urol. 2000 Mar. 163 (3):829-33. [QxMD MEDLINE Link].
Hedican SP, Walsh PC. Postoperative bleeding following radical retropubic prostatectomy. J Urol. 1994 Oct. 152 (4):1181-3. [QxMD MEDLINE Link].
Tyritzis SI, Wallerstedt A, Steineck G, Nyberg T, Hugosson J, Bjartell A, et al. Thromboembolic complications in 3,544 patients undergoing radical prostatectomy with or without lymph node dissection. J Urol. 2015 Jan. 193 (1):117-25. [QxMD MEDLINE Link].
Elliott SP, Meng MV, Elkin EP, McAninch JW, Duchane J, Carroll PR, et al. Incidence of urethral stricture after primary treatment for prostate cancer: data From CaPSURE. J Urol. 2007 Aug. 178 (2):529-34; discussion 534. [QxMD MEDLINE Link].
Erickson BA, McAninch JW, Eisenberg ML, Washington SL, Breyer BN. Management for prostate cancer treatment related posterior urethral and bladder neck stenosis with stents. J Urol. 2011 Jan. 185 (1):198-203. [QxMD MEDLINE Link].
Herschorn S, Elliott S, Coburn M, Wessells H, Zinman L. SIU/ICUD Consultation on Urethral Strictures: Posterior urethral stenosis after treatment of prostate cancer. Urology. 2014 Mar. 83 (3 Suppl):S59-70. [QxMD MEDLINE Link].
Eltahawy E, Gur U, Virasoro R, Schlossberg SM, Jordan GH. Management of recurrent anastomotic stenosis following radical prostatectomy using holmium laser and steroid injection. BJU Int. 2008 Sep. 102 (7):796-8. [QxMD MEDLINE Link].
Adamakis I, Vasileiou I, Constantinides CA. The treatment of iatrogenic male incontinence: latest results and future perspectives. Rev Recent Clin Trials. 2013 Mar. 8 (1):36-41. [QxMD MEDLINE Link].
Walsh PC, Marschke PL. Intussusception of the reconstructed bladder neck leads to earlier continence after radical prostatectomy. Urology. 2002 Jun. 59 (6):934-8. [QxMD MEDLINE Link].
Walsh PC, Marschke P, Ricker D, Burnett AL. Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. Urology. 2000 Jan. 55 (1):58-61. [QxMD MEDLINE Link].
Anderson CB, Kaufman MR, Dietrich MS, Barocas DA, Chang SS, Cookson MS, et al. Recovery of urinary function after radical prostatectomy: identification of trajectory cluster groups. J Urol. 2012 Apr. 187 (4):1346-51. [QxMD MEDLINE Link].
Haab F, Yamaguchi R, Leach GE. Postprostatectomy incontinence. Urol Clin North Am. 1996 Aug. 23 (3):447-57. [QxMD MEDLINE Link].
Singla N, Singla AK. Post-prostatectomy incontinence: Etiology, evaluation, and management. Turk J Urol. 2014 Mar. 40 (1):1-8. [QxMD MEDLINE Link].
Kim PH, Pinheiro LC, Atoria CL, Eastham JA, Sandhu JS, Elkin EB. Trends in the use of incontinence procedures after radical prostatectomy: a population based analysis. J Urol. 2013 Feb. 189 (2):602-8. [QxMD MEDLINE Link].
Trost L, Elliott DS. Male stress urinary incontinence: a review of surgical treatment options and outcomes. Adv Urol. 2012. 2012:287489. [QxMD MEDLINE Link].
Herschorn S. Update on management of post-prostatectomy incontinence in 2013. Can Urol Assoc J. 2013 Sep. 7 (9-10 Suppl 4):S189-91. [QxMD MEDLINE Link].
Catalona WJ, Carvalhal GF, Mager DE, Smith DS. Potency, continence and complication rates in 1,870 consecutive radical retropubic prostatectomies. J Urol. 1999 Aug. 162 (2):433-8. [QxMD MEDLINE Link].
Quinlan DM, Epstein JI, Carter BS, Walsh PC. Sexual function following radical prostatectomy: influence of preservation of neurovascular bundles. J Urol. 1991 May. 145 (5):998-1002. [QxMD MEDLINE Link].
Zippe CD, Jhaveri FM, Klein EA, Kedia S, Pasqualotto FF, Kedia A, et al. Role of Viagra after radical prostatectomy. Urology. 2000 Feb. 55 (2):241-5. [QxMD MEDLINE Link].
Nandipati K, Raina R, Agarwal A, Zippe CD. Early combination therapy: intracavernosal injections and sildenafil following radical prostatectomy increases sexual activity and the return of natural erections. Int J Impot Res. 2006 Sep-Oct. 18 (5):446-51. [QxMD MEDLINE Link].
Sirad F, Hlaing S, Kovanecz I, Artaza JN, Garcia LA, Rajfer J, et al. Sildenafil promotes smooth muscle preservation and ameliorates fibrosis through modulation of extracellular matrix and tissue growth factor gene expression after bilateral cavernosal nerve resection in the rat. J Sex Med. 2011 Apr. 8 (4):1048-60. [QxMD MEDLINE Link].
Montorsi F, Brock G, Lee J, Shapiro J, Van Poppel H, Graefen M, et al. Effect of nightly versus on-demand vardenafil on recovery of erectile function in men following bilateral nerve-sparing radical prostatectomy. Eur Urol. 2008 Oct. 54 (4):924-31. [QxMD MEDLINE Link].
Montorsi F, Brock G, Stolzenburg JU, Mulhall J, Moncada I, Patel HR, et al. Effects of tadalafil treatment on erectile function recovery following bilateral nerve-sparing radical prostatectomy: a randomised placebo-controlled study (REACTT). Eur Urol. 2014 Mar. 65 (3):587-96. [QxMD MEDLINE Link].
Raina R, Agarwal A, Ausmundson S, Lakin M, Nandipati KC, Montague DK, et al. Early use of vacuum constriction device following radical prostatectomy facilitates early sexual activity and potentially earlier return of erectile function. Int J Impot Res. 2006 Jan-Feb. 18 (1):77-81. [QxMD MEDLINE Link].
Tal R, Jacks LM, Elkin E, Mulhall JP. Penile implant utilization following treatment for prostate cancer: analysis of the SEER-Medicare database. J Sex Med. 2011 Jun. 8 (6):1797-804. [QxMD MEDLINE Link].
Menard J, Tremeaux JC, Faix A, Pierrevelcin J, Staerman F. Erectile function and sexual satisfaction before and after penile prosthesis implantation in radical prostatectomy patients: a comparison with patients with vasculogenic erectile dysfunction. J Sex Med. 2011 Dec. 8 (12):3479-86. [QxMD MEDLINE Link].

Media Gallery

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.
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.
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.
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.
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.
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.
(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.
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.
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.
Radical retropubic prostatectomy. Preparation, positioning, and incision. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Radical retropubic prostatectomy. Bilateral pelvic lymph node dissection. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Radical retropubic prostatectomy. Incision in endopelvic fascia. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Radical retropubic prostatectomy. Division of puboprostatic ligaments. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Radical retropubic prostatectomy. Bunching suture placement on edge of endopelvic fascia. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Radical retropubic prostatectomy. Control of dorsal vein complex. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Radical retropubic prostatectomy. Transection of dorsal vein complex. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Radical retropubic prostatectomy. Division of urethra. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Radical retropubic prostatectomy. Placement of anterior anastomotic sutures. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Radical retropubic prostatectomy. Placement of posterior anastomotic sutures. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

of 19

Author

David F Jarrard, MD Professor of Urologic Surgery and Molecular and Environmental Toxicology, Clinical Vice Chair, John P Livesey Chair in Urologic Oncology, Associate Director for Translational Reserach, Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health

David F Jarrard, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Shivashankar Damodaran, MB, MCh Fellow in Urologic Oncology, Department of Urology, University of Wisconsin School of Medicine and Public Health

Shivashankar Damodaran, MB, MCh is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Urology, Department of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Antares.

Additional Contributors

Reza Ghavamian, MD Professor of Clinical Urology, Albert Einstein College of Medicine; Director of Urologic Oncology, Director of Minimally Invasive and Robotic Urologic Surgery, Montefiore Medical Center

Reza Ghavamian, MD is a member of the following medical societies: American Urological Association, Society of Urologic Oncology

Disclosure: Nothing to disclose.

Acknowledgements

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Dan Theodorescu, MD, PhD Paul A Bunn Professor of Cancer Research, Professor of Surgery and Pharmacology, Director, University of Colorado Comprehensive Cancer Center

Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology

Disclosure: Key Genomics Ownership interest Co-Founder-50% Stock Ownership; KromaTiD, Inc Stock Options Board membership

Acknowledgments

Medscape Reference thanks Dennis G Lusaya, MD, Associate Professor II, Department of Surgery (Urology), University of Santo Tomas; Head of Urology Unit, Benavides Cancer Institute, University of Santo Tomas Hospital; Chief of Urologic Oncology, St Luke’s Medical Center Global City, Bonifacio Global City, Philippines, for the video contribution to this article.

Medscape Reference also thanks Edgar V Lerma, MD, FACP, FASN, FAHA, Clinical Associate Professor of Medicine, Section of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine; Research Director, Internal Medicine Training Program, Advocate Christ Medical Center; Consulting Staff, Associates in Nephrology, SC, for his assistance with the video contribution to this article.