Radical Retropubic Prostatectomy for Prostate Cancer Technique

Updated: Nov 28, 2016
  • Author: Reza Ghavamian, 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), apply a sequential compression device to the patient’s lower extremities.

Make a lower midline incision (see the first video below). Perform an extraperitoneal bilateral pelvic lymph node dissection (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 2-0 polyglactin suture just underneath the dorsal venous complex and anterior to the urethra. Control backbleeding by placing 2 figure-8 sutures of 2-0 polyglactin (ie, bunching sutures) on the proximal aspect of the dorsal vein complex (see the videos below).

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 with the electrocautery, leaving a defect in the prostatic fascia (see the video 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).

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.

Place the index finger of the left hand in the plane between the mobilized prostatic fascia and the prostatic capsule, and advance it under the posterior aspect of the prostate. This maneuver separates the anterior Denonvilliers fascia adhering to the posterior aspect of the prostate from the posterior Denonvilliers fascia adhering to the anterior rectum.

Move the tip of the left index finger toward the right prostatoapical junction, and extend it toward the lateral prostatic fascia on the contralateral side, anterior to and above the right neurovascular bundle. Guided by the tip of the left index finger, pierce the right lateral prostatic fascia above the neurovascular bundle with a right-angle clamp.

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.

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.

After the urethra is divided, mobilize the prostate cephalad, and ligate the lateral vascular pedicles close to the prostate with small hemostatic clips. Divide the anterior layer of Denonvilliers fascia, and identify the ampullae of the vas deferens.

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 (see the image below), and dissect them free of the bladder base and the posterior aspect of the bladder with the electrocautery. Start this dissection at the tip of the visceral bladder fascia, which is an extension of the posterior Denonvilliers fascia.

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 continuous 3-0 poliglecaprone suture is used to reconstruct the bladder neck (see the image below). 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).

(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.

A critical aspect of the operation is the use of intraoperative frozen-section analysis of the surgical margins. 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

Postoperatively, the authors routinely use 2 Jackson-Pratt (JP) drains that are positioned bilaterally in the pelvis, with the tips pointed up to avoid slipping and suctioning the vesicourethral anastomosis. These drains are removed when the cumulative output from each is less than or equal to 30 mL over 24 hours.

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, the JP 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.

After radical prostatectomy, undue tension and traction should not be applied to the urethral catheter. This is a rare event after radical prostatectomy.

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.

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Adjuvant Treatment

Hormonal therapy

The value of neoadjuvant hormonal therapy in the treatment of clinical stage T3 prostate cancer has been debated. It is generally accepted that there is a benefit to such therapy before radiation treatment, but the same treatment benefit has been difficult to demonstrate in prostatectomy series.

Gomella et al demonstrated that pathologic downstaging to T2c or lower was achieved in 48% of patients with 4 months of neoadjuvant hormonal therapy. [27] However, the actuarial 3-year biochemical failure rate was 75%. All patients had undergone a laparoscopic lymph node dissection before neoadjuvant hormonal therapy. Questions exist regarding the importance of the duration of neoadjuvant hormonal therapy.

Gleave et al reported that the serum prostate-specific antigen (PSA) nadir was reached in only 22% of patients when neoadjuvant hormonal therapy was instituted 3 months in advance. [28] However, 84% of patients achieved nadir PSA after 8 months of neoadjuvant hormonal therapy. The surgical margin positivity rate was only 4%.

In this series of 50 patients, 68% of the cancers were organ-confined, and 24% were specimen-confined. [28] These findings should be regarded with caution, because only 6 of the 50 patients (12%) had clinical stage T3 tumors, and 15 (30%) had well-differentiated disease. The study, however, indicated that longer durations of neoadjuvant hormonal therapy might produce more favorable results.

It must be kept in mind that even if neoadjuvant hormonal therapy reduces the rate of margin positivity, no evidence exists to suggest that long-term survival will be improved.

In a study of patients with clinical stage T3 disease who underwent radical prostatectomy, patients who received neoadjuvant hormonal therapy had a 5-year disease-specific survival rate of 89%, whereas those who did not had a 5-year survival rate of 97%. The 5-year progression-free rates also did not differ significantly (48% and 62%, respectively).

Amling et al reviewed the outcomes of 72 patients with clinical T3 disease who received at least an 8-week course of neoadjuvant hormonal therapy and compared them to the outcomes of a matched cohort of 144 patients with clinical stage T3 disease who underwent only radical prostatectomy. [29] Extracapsular extension was observed in 61% of the patients who received neoadjuvant hormonal therapy and 81% of the patients in the untreated group.

The authors’ approach to the finding of positive seminal vesicles and lymph nodes after prostatectomy has been to administer early adjuvant hormonal therapy. Early adjuvant hormonal therapy after radical prostatectomy shortens the interval to disease progression. The difference is specifically palpable in patients with positive nodes and diploid tumors.

Although the Mayo Clinic has long been a proponent of this approach, others have been skeptical regarding whether hormonal therapy has advantages in this setting. The value of immediate hormonal therapy after radical prostatectomy was demonstrated in a prospective randomized study of 98 men by Messing et al. [30] After a median of 7.1 years of follow-up, 7 of 47 men who received immediate hormonal therapy died, compared with 18 of 51 men in the observation group.

Radiation therapy

The role of adjuvant therapy in the setting of a positive margin after radical prostatectomy is controversial.

Leibovich et al, studying 76 patients with T2N0 disease with a single site of margin positivity (most commonly, the apex) who received radiation treatment, found that these patients had a better overall 5-year biochemical progression-free survival rate (88%) than 76 control subjects who did not undergo radiation treatment (59%). [31] None of the patients in the radiation group experienced local or distant recurrence, whereas 16% of the control subjects had recurrences.

Generally, as the interval to PSA recurrence lengthens, the likelihood of response to radiation treatment increases substantially. Valicenti et al, studying the efficacy of early adjuvant radiotherapy for T3N0 prostate cancer after radical prostatectomy in 72 optimally compared patients, reported an 88% reduction in the risk of PSA relapse associated with radiotherapy. [32] The 5-year rate of freedom from biochemical failure was 89% for patients undergoing adjuvant radiotherapy and 55% for those undergoing radical prostatectomy alone.

Patients who have multiple gross positive margins, especially at the bladder neck or the prostatic base, are more likely to have systemic disease. In a pathologic analysis of anatomic site-specific positive margins, time to PSA recurrence was significantly shorter in patients with seminal vesicle invasion, those with more than 1 positive margin, and those with positive margins at the bladder neck or the posterolateral surface of the prostate. [33] These findings are in agreement with those of Blute et al. [34]

A positive margin at the bladder neck is usually associated with other adverse pathologic characteristics, such as high Gleason score or preoperative PSA levels and margin positivity at other sites; it can also indicate occult metastatic disease. As a single site, the bladder neck was responsible for only 5% of the positive margins in the University of Miami series, and these might be the patients who can benefit from adjuvant irradiation of the site. In the other diffuse scenario, the patients may benefit from early adjuvant hormonal treatment.

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Complications

Intraoperative complications

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

The incidence of hemorrhage, the most common intraoperative complication, has decreased with improved surgical technique and increased experience, according to large contemporary radical prostatectomy series. Mean estimated blood loss in these series ranged from 300-2000 mL, with most experienced centers reporting blood loss amounting to less than 1000 mL.

In the authors’ personal experience, transfusion of any kind is necessary in less than 2% of patients undergoing RRP. Consequently, autologous blood donation, with its obvious cost-saving advantages, is unnecessary in most cases.

Postoperative complications

The incidence of late complications has decreased as well. In a comparison of morbidity between the authors’ contemporary radical prostatectomy series and an earlier study, there was no mortality, and the rates of bowel injury, colostomy, total incontinence, pulmonary embolism, and urethral stricture necessitating long-term therapy were 0.6%, 0%, 0.8%, 0.6%, and 8.7%, respectively.

The contemporary series revealed improvements in postoperative continence and reductions in blood transfusions (77% before 1989 vs 22% after 1989). The average patient is discharged from the hospital on postoperative day 2 as part of a carefully planned pre-RRP and post-RRP patient care pathway.

Urinary incontinence

Urinary incontinence is a troubling complication of radical prostatectomy. 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 incontinence rate of less than 10%; this figure includes occasional stress incontinence. The true rate of total incontinence with no urinary control is generally less than 5%; for the authors, it is less than 1%.

In patients who experience this complication, improvement is likely after 1 year. Therefore, any invasive treatment should be deferred until at least 1 year has elapsed after RRP.

Searching for the cause of incontinence is an important aspect of therapy. Dribbling incontinence can develop with a bladder neck contracture (ie, overflow incontinence). Flexible cystoscopy and dilatation or transurethral resection of the contracture is often necessary. In patients with no anatomic abnormalities, urodynamic testing is warranted.

A study that used a novel cluster modeling technique to determine predictors of postprostatectomy urinary incontinence identified 3 distinct postoperative continence recovery patterns. [35] Increased patient age and a greater number of comorbid conditions were predictive of a worse outcome. These findings have implications for preoperative patient counseling and early intervention for postprostatectomy urinary incontinence.

A retrospective study by Chiang and Liu comparing outcomes of RRP, high–dose-rate brachytherapy (HDRBT), cryoablation, and high-intensity focused ultrasound for the treatment of localized prostate cancer found higher rates of urethral stricture and urinary incontinence (29.9% and 11.3%, respectively) in association with RRP at almost 3-year follow-up. However, oncologic outcomes for patients in D’Amico intermediate- and high-risk groups were worse for patients who underwent HDRBT than for those who were treated with the other procedures. [36]

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. [37]

A study by Walsh et al of patients who underwent radical prostatectomy and who were potent before the procedure indicated that sildenafil improved the quality of erections. [38] Patients surveyed in the study reported a high (86%) overall potency rate at 18 months; 84% of respondents reported no or minimal sexual bother.

The numbers in this study may also reflect a stage migration for prostate cancer, in which more cancers are of lower volume and are organ-confined and in which both (89% in this series) or at least 1 neurovascular bundle can be saved. Therefore, both neurovascular bundles should be saved when feasible, and saving even 1 neurovascular bundle is justified.

Advanced pathologic stage and patient age also adversely affect the return of potency. Quinlan et al reported that 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. [39] In this series, 90% of men younger than 50 years were potent postoperatively if 1 or both bundles were preserved.

The availability of oral sildenafil, alprostadil suppositories, and intracavernous injection therapy allows adequate postoperative treatment of erectile dysfunction, so that quality of life is preserved in most patients.

Zippe et al, studying the effects of bilateral, unilateral, and non–nerve-sparing techniques, found sildenafil to be efficacious in the bilateral nerve-sparing group, with 72% of the patients reporting rigidity that was sufficient for penetration. [40] Only 50% of the patients in the unilateral nerve-sparing group responded to sildenafil.

In a study by Marks et al, in which patients were grouped according to the severity of their impotence based on the International Index of Erectile Function (IIEF), [41] all patients undergoing prostatectomy were in the most severe group, with only 40% achieving sufficient tumescence with sildenafil.

In the absence of contraindications, sildenafil should be the first agent administered in the treatment of postprostatectomy impotence. 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 has been shown to increase sexual activity and to facilitate the return of natural erections after radical prostatectomy. Combination therapy also allows a lower dose of intracavernosal injections, thereby decreasing morbidity and discomfort. [42]

Some researchers have suggested that pharmacologic treatment begun earlier after prostatectomy increases the likelihood of ultimate spontaneous return of potency, though some carefully conducted studies have disagreed with this finding.

Zippe et al determined that the interval between prostatectomy and the initiation of sildenafil therapy did not significantly influence the positive response rate. [40] However, the dose did influence the positive response rate, with 71% of the patients requiring a 100-mg dose.

Zagaja et al reported that patients who had not yet regained sexual function did not respond to sildenafil before 9 months after the procedure. [43] Considering this latency, which is probably due to prolonged neurapraxia, these authors suggest starting the patient on topical alprostadil or intracavernosal injections to stimulate penile vasculature and to prevent loss of elasticity and, ultimately, cavernosal fibrosis.

Quality-of-life studies have evaluated functional outcomes and bother factors after radical prostatectomy and radiation-based therapies. In one study, treatment did not appear to affect health-related quality of life. [44] Obstructive and urinary symptoms were more common after brachytherapy. Radiation-based therapies (eg, brachytherapy and EBRT) were superior to radical prostatectomy in terms of urinary control and sexual function.

However, among men in the study who were potent before treatment, radical prostatectomy and brachytherapy yielded equivalent rates of sexual-function recovery. Bilateral nerve-sparing surgery diminished the differences in functional outcomes between surgery and EBRT.

In another study, although urinary incontinence was significantly worse after radical prostatectomy than after brachytherapy or high-dose EBRT, patients who had undergone brachytherapy reported more irritative symptoms. [45] Radical prostatectomy was associated with superior bowel function and fewer irritative functions. All 3 therapies were associated with impaired sexual function, but higher scores were seen in men who selected brachytherapy.

Retrospective studies have revealed a definite change in the patients’ disease-targeted quality of life.

A study by Litwin et al examining sexual bother and function after radical prostatectomy and radiation therapy, using the CaPSURE database, [46] found that whereas sexual function declined after surgical treatment, it improved over time in the first year, as it did after radiation therapy. However, during the second year, sexual function declined in patients undergoing radiation therapy.

An analysis of functional outcomes after radical prostatectomy revealed that only a small portion of men report a return of normal sexual activity when a strict definition of potency—that is, return to baseline sexual function—is used. [47] Whereas 85% of men who had bilateral nerve-sparing prostatectomy reported potency, only 27% reported a return to baseline function.

Such findings show that optimal sexual function recovery after radical prostatectomy is difficult to quantify uniformly and that outcomes can often be exaggerated when a strict definition is not utilized. Educating prospective prostate surgery patients in this regard can help decrease unrealistic expectations. It should be noted that quality of life as a whole after radical prostatectomy is not worse than quality of life after interstitial seed implantation.

When Krupski et al directly assessed the quality of life and symptoms of patients with localized prostate cancer who had been treated with radical prostatectomy against those of patients who had been treated with brachytherapy alone or in combination with EBRT, [48] they found an overall lower quality of life in the combination-treatment group than in the radical prostatectomy and brachytherapy groups.

In the study, radical prostatectomy was also found to be superior to brachytherapy alone, in that patients who underwent surgery had decreased irritative and obstructive voiding symptoms as measured with the American Urological Association (AUA)/International Prostate Symptom Score (IPSS). [48]

Alemozaffar et al predicted long-term erectile function on the basis of pretreatment patient characteristics and treatment details after prostatectomy, EBRT, or brachytherapy for prostate cancer. Functional erections were associated with pretreatment sexual health–related quality-of-life score, age, serum PSA level, race or ethnicity, body mass index, and intended treatment details 2 years after treatment. [49]

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