Radical Retropubic Prostatectomy for Prostate Cancer Technique

Updated: Nov 28, 2016
  • Author: David F Jarrard, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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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.
Radical retropubic prostatectomy. Bilateral pelvic lymph node dissection. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

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.
Fascial anatomy after division of endopelvic fasci 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.
Radical retropubic prostatectomy. Division of puboprostatic ligaments. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

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

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.
Incision in prostatic fascia (PF) from defect in P 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.

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 paral 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.

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 Denovilliers 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.
Division of membranous urethra (MU) just distal to 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.

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 ve 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.

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 poliglecapron 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.

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 anastamotic 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, incorp (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.
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.

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.

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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. 

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Adjuvant Treatment

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. (48) 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 3-month group (12% versus 23%, respectively), but there was higher incidence of adverse events in the 8 month group.(49) 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%.(50)

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).(51) 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. (52, 53) Radiation therapy is effective in reducing biochemical recurrence and for achieving local control in patients with local failure. (54, 55) 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. (54-56)

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,(57) 60% of the patients can reach an undetectable PSA and 80% of these can be progression-free after 5 years.(58, 59) 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.(60)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. (61)

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Complications

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.(62, 63)

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.(64)

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.(65) 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.(66) 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. (67, 68) 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. (69) 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.(70)

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.(71)  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. (72, 73) 

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. (74)   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.(75) 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. (76) 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.(77)

Surgical options for management of post prostatectomy incontinence include artificial urinary sphincter and the male sling.(78) 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. (79)  The male sling is designed for men with low volume incontinence (1-3 pads/ day). (78)In properly selected patient population slings have a success rate of 40%-90% without the risk of device failure. (78)

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.(80) 

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.(73) 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. (73) 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.(81)

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.(82) 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.(83)

The concept of erection rehabilitation has been proposed by researchers based on preclinical evidence of potential positive effect of PDE5I on erectile function recovery. (84) 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.(85, 86)  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. (87) 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.(88) Penile prosthesis have a high rate of patient satisfaction (86%) with acceptable complications (5%) of infection, revision, or mechanical failure.(89)

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