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Radical Retropubic Prostatectomy for Cancer: A 20-Year Experience
THE JOURNAL OF UROLOGY
Vol. 117, March Printed in U.S.A.
Copyright© 1977 by The Williams & Wilkins Co.
RADICAL RETROPUBIC PROSTATECTOMY FOR CANCER: A 20-YEAR EXPERIENCE R. J. VEENEMA, EROL 0. GURSEL
AND
JOHN K. LATTIMER
From the Columbia University, College of Physicians and Surgeons, Squier Urological Clinic, New York, New York
ABSTRACT
A review of 159 patients treated by radical retropubic prostatovesiculectomy from 1951 through 1970 has reinforced our belief that this is a satisfactory method of treatment for prostatic cancer confined to the prostate. A 10-year survival of 55 per cent and a 15-year survival of 45 per cent compare well to the results reported for perineal prostatectomy. The postoperative mortality rate was 2.5 per cent and total incontinence was 12.5 per cent after radical retropubic prostatectomy. Completely normal voiding occurred in 108 of the 159 patients. Stress incontinence but no need for an incontinence device occurred in 31 patients. Improved methods for preoperative staging of the disease give promise for even higher cure rates in the future. Radical retropubic prostatovesiculectomy has been our done in 6 patients and other forms of transperineal needle treatment of choice for cancer of the prostate since 1951. This biopsy were done in 3. There were 28 patients who had simple form of surgical treatment is used only when the cancer is prostatectomies for benign disease in which carcinoma of the clinically limited to the prostate and the patients have an prostate was found. It is our policy in such patients to advise average 10-year life expectancy. From 1951 through 1975 there radical prostatectomy whenever the patient is physically and have been 201 radical prostatectomies done for stage A or B psychologically suitable for it, has a 10-year life expectancy prostatic cancer, that is cancer limited to the prostate. A and the pathologist indicates that it is indeed a real prostatic detailed analysis was done on the 159 patients who were cancer rather than a tiny occult microscopic focus or "patholoperated on during the 20-year span from 1951 to 1970. There ogist's cancer". This decision, of course, is one of the most were 6 additional patients similarly operated on during this difficult and numerous microscopic sections and special microperiod but lost to followup before they were adequately evalu- scopic studies, such as electron microscopic' and evaluation of ribonucleic and deoxyribonucleic acid content in tumors, 5 may ated. The over-all crude survival rates in this group of 159 patients be helpful in arriving at it. Whenever a decision is made not to were 84 per cent at 5 years, 52 per cent at 10 years and 45 per do a radical prostatectomy after an incidental prostate cancer cent at 15 years. Of the 14 patients eligible for 20-year followup is found in a simple prostatectomy specimen we do advise a 5 have survived the entire 20-year span and have remained free followup cystoscopy in 3 months and endoscopic biopsies from of cancer. Three patients died of other causes at 16, 18 and 20 the remaining peripheral prostatic tissue. The time elapsed years. Six patients were lost to followup before they reached 20 between simple prostatectomy and radical prostatectomy in years but they had no evidence of recurrent cancer when last the 28 patients in this review ranged from 4 weeks to 11 seen (3 patients at 8 years, 2 at 13 years and 1 at 16 years). months. Eighteen followed transurethral resection of the prosDuring the 20-year period 40 of the 159 patients died. Nine tate and 10 were after open prostatectomies (4 suprapubic, 5 deaths were owing to disseminated cancer of the prostate, 4 retropubic and 1 perineal). Bilateral orchiectomy or estrogen patients died postoperatively and there were 27 deaths not treatment usually was instituted in the interval. related to prostatic cancer. In most instances these were The surgical technique for radical retropubic prostatectomy cardiovascular problems of advanced age. has been well outlined in earlier publications. e-s We advocate a The surgical pathology microscopic sections confirmed the 4-suture anastomosis of the urethra to the bladder. Sutures are stages A and B clinical staging in 93 of the 159 specimens. In placed in the urethra when it is being divided and the tagged this group the 5-year crude survival was 90 per cent, 10 years 55 long ends of the sutures are left hanging over the pubis until per cent and 15 years 39 per cent. Of the remaining 66 patients the closure is begun. An inverted Y closure at the bladder neck the histology indicated capsular invasion by the prostatic usually is used in order to recess the ureteral orifices further carcinoma in 42 patients, seminal vesicle involvement in 16 from the urethral bladder anastomosis. Ureteral catheters are and bladder neck invasion in 8. left in place until the anastomosis is almost completed to The histopathology was well differentiated prostatic carci- assure maintenance of ureteral patency. Mattress sutures noma in 146 patients. The remaining 13 patients had either (chromic 1 or 2-zero) are used for the anastomosis. These are poorly differentiated prostatic neoplasms or combined areas of placed in such a manner that the knots will be on the outside, cribiform patterns and anaplastic changes. and at the time the sutures are tied, the tie is on the bladder Diagnosis of prostatic cancer was always documented histo- side of the anastomosis. This permits better approximation logically prior to the radical prostatectomy. In 122 patients this and there is less chance of the suture pulling through. The was done by perineal prostatic cup biopsy,* which we have anastomosis is made over a 20 to 22F urethral catheter. Troublesome bleeding from the area of the urethral stump designed and described previously. 1 • 3 Open perineal biopsy was after the puboprostatic ligaments have been cut and the urethra has been transected can be controlled by passing a Accepted for publication June 18, 1976. Read at annual meeting of American Urological Association, Las catheter through the urethra and uniting the 2 ends of the Vegas, Nevada, May 16-20, 1976. catheter above the pubis. Upward traction on this catheter Supported by the Urology Neoplasm Research Fund at Columbia then compresses the dorsal vein of the penis and the periureUniversity, New York, New York. * Prostatic Cup Biopsy, J. Sklar Mfg. Co., Long Island County, New thral veins against the underside of the pubis, which readily York, distributed by V. Mueller Co., Chicago, Illinois. controls the bleeding. 330
RADICAL RETRGPUBIC PROSTt,.TECTOl\l'.::Y FOR CANC~SR
The urethrovesical anastomosis can be made more secure by using a suprapubic sump drain, which keeps the bladder decompressed and permits healing to occur without undue tension or extravasation of urine at the anastomosis. A multi-holed 20 or 22F whistle-tip catheter in the urethra usually drains better than a Foley catheter. In addition to taping the catheter to the penis, to be certain the catheter is not inadvertently dislodged, we loop a heavy silk suture through the eye of the catheter and out suprapubically where it is tied. This suture is removed after 5 days, since after this period union of the urethra and bladder is sufficiently secure to permit reinsertion of a catheter that may become dislodged. The suprapubic sump is removed after 5 to 7 days and the urethral catheter after 10 to 14 days, depending upon the satisfaction with the anastomosis. Pelvic lymphadenectomy has not been done in this series of patients but at preliminary exploration to determine operability selected nodes were removed for pathology examination when indicated. Whenever positive nodes are found it is our practice to consider the patient inoperable and marking metallic clips are placed to aid in future possible radiotherapy. Adjunctive hormonal treatment was used in 131 of the 159 pati~nts. Orchiectomy and stilbestrol were used in 85 patients, orch1ectomy alone in 28 and stilbestrol alone in 18 patients. Estrogens were given selectively only after the final pathology was obtained and if there were no cardiovascular or hepatic contraindications. Since a third of the pathology specimens usually showed capsular or seminal vesicle involvement and the testes were considered expendable after a radical prostatovesiculectomy, it was theorized that therapy should be directed to place the host in a hormonal environment that was hostile to tumor development. It was thought that small foci of tumor were less likely to take or proliferate in such an environment. The 15-year survival rate in the group given no adjunctive treatment was 25 per cent but it was 53 per cent in those who received hormonal control treatment. However, the number of patients who have reached the 15-year evaluation level is too few to draw any real conclusion from this difference. With the increased use of surgical implantation of penile prostheses fewer bilateral orchiectomies in conjunction with radical prostatectomies have been done between 1971 and 1975. . Function_al results in the 159 patients were 1) normal voiding m 108 patients, 2) stress incontinence and no incontinence device in 31 and 3) total incontinence in 20 patients. All patients were impotent. Our patients are prepared psychologically for the operative procedure and have presented no psychological problems. Complications following radical retropubic prostatectomy are listed in the table. Of the 13 patients who had rectal injury 8 had colostomies performed. The decision of whether to do a colostomy depends on the degree of rectal injury and the 9-u~lity of the rectal repair. Our management of rectal injury mc1dental to extensive pelvic surgery has been reported previously. 9 Strictures at the anastomosis can be troublesome but in 25 of the 29 patients they could be readily passed and dilated. In 4 of the patients subsequent cystostomy was necessary. Complications
Postoperative death Pulmonary emboli Stricture at anastmnosis Total incontinence Rectal injury Fecal fistula Osteitis pubis
4
(2 5)
6 (:l.7) 29 (17) 20 (12.5) J;l
:l
(7)
(2.5) (0.6)
DISCUSSION
Radical retropubic prostatectomy permits a wide exposure of the operative area and an opportunity to assess carefully the routes of metastasis of prostatic carcinoma. The lymph nodes and seminal vesicles can be explored readily to determine operability before extensive dissection is underway and before the urethra is transected. Although the operation can be followed by incontinence and other complications associated with extensive pelvic surgery, we believe the risks are warranted for possible cure of cancer of the prostate. With improved techniques of staging we believe the 10 and 15-vear cure rates can be even higher. For example, the bone ·acid phosphatase determinations give promise of being valuable in this regard. 10- 12 It is becoming increasingly evident that many of our past failures were probably the result of understaging of the disease. Whether radical prostatectomy is done retropubically or perineally the cure rates are about the same. 13 It seems unwise to us to rely on hormonal control therapy alone or to withhold treatment from patients when a prostatic cancer is clinically limited to the prostate and when the patient has a life expectancy of at least 10 years. We are well aware of the fact that prostatic cancer is slow growing but one never knows how long it had been present when it was detected nor which cancers are just about to escape from control and metastasize. In general, one can say that if a patient lives long enough he will die of the prostatic cancer if no treatment is given or when hormonal treatment alone is used. With radical prostatectomy there is a chance to cure the disease. We realize that a small percentage of patients are ideal candidates for radical prostatectomy. Hopefully, radiotherapy will give an increasing chance for curative treatment in a greater number of patients who have clinically borderline stage B to C prostatic cancers. REFERENCES
1. Veenema, R. J.: A simplified prostatic perinea! biopsy punch. J.
Urol., 69: 320, 1953. 2. Veenema, R. J.: Perinea! prostatic cup biopsy: technique and evaluation. J. Urol., 87: 585, 1962. 3. Veenema, R. J. and Lattimer, ,J. K.: Early diagnosis of carcinoma of the prostate. Periodic rectal examination is recommended and biopsy of any palpably suspicious area. J.A.M.A., 186: 127, 1963. 4. Tannenbaum, M.: A biological evaluation of cancers of the bladder and prostate by means of electron microscopy. In: Proceedings of the Clinical Conference on Carcinoma of the Bladder, Prostate and Testes. Ontario, Canada, pp. 189-201, 1970. 5. Fingerhut, B., Veenema, R. J., Graff, 8. and Butler, M. P.: Observations on RNA in prostate and bladder neoplasms. J. Urol., 101: 608, 1969. 6. Memmelaar, ,J.: Total prostatovesiculectomy-retropu bic approach. J. Urol., 62: 340, 1949. 7. Lattimer, ,J. K., Dean, A. L., Veenema, R ,J. and Rafferty, E.: Radical prostatectomy for cancer. J.A.M.A., 153: 1347, 1953. 8. Chute, R.: Radical retropubic prostatectomy for cancer. J. Ural., 71: 347, 1954. 9. Smith, A. M. and Veenema, R. J.: Management of rectal injury and recto urethral fistulas following radical retropu bic prostatectomy. J. Urol., 108: 778, 1972. 10. Chua, D. T., Veenema, R. J., Muggia, F. and Graff, A.: Acid phosphatase levels in bone marrow: value in detecting early bcne metastasis from carcinoma of the prostate. J. Urol., 103: 462, 1970. 11. Veenema, R. J., Gursel, E. 0., Romas, N., Wechsler, M. and Lattimer, J. K.: Bone marrow acid phosphatase: prognostic value in patients undergoing radical prostatectotny. J. Urol., 117: 81, 1977. 12. Veenema, R. J.: Bone marrow acid phosphatase determination for prostate cancer metastasis. J.A.M.A., 235: 1615, 1976. 13. Jewett, H.J.: The case for radical perinea! prostatectomy. J. Urol., 103: 195, 1970.
Vol. 117, March Printed in U.S.A.
Copyright© 1977 by The Williams & Wilkins Co.
RADICAL RETROPUBIC PROSTATECTOMY FOR CANCER: A 20-YEAR EXPERIENCE R. J. VEENEMA, EROL 0. GURSEL
AND
JOHN K. LATTIMER
From the Columbia University, College of Physicians and Surgeons, Squier Urological Clinic, New York, New York
ABSTRACT
A review of 159 patients treated by radical retropubic prostatovesiculectomy from 1951 through 1970 has reinforced our belief that this is a satisfactory method of treatment for prostatic cancer confined to the prostate. A 10-year survival of 55 per cent and a 15-year survival of 45 per cent compare well to the results reported for perineal prostatectomy. The postoperative mortality rate was 2.5 per cent and total incontinence was 12.5 per cent after radical retropubic prostatectomy. Completely normal voiding occurred in 108 of the 159 patients. Stress incontinence but no need for an incontinence device occurred in 31 patients. Improved methods for preoperative staging of the disease give promise for even higher cure rates in the future. Radical retropubic prostatovesiculectomy has been our done in 6 patients and other forms of transperineal needle treatment of choice for cancer of the prostate since 1951. This biopsy were done in 3. There were 28 patients who had simple form of surgical treatment is used only when the cancer is prostatectomies for benign disease in which carcinoma of the clinically limited to the prostate and the patients have an prostate was found. It is our policy in such patients to advise average 10-year life expectancy. From 1951 through 1975 there radical prostatectomy whenever the patient is physically and have been 201 radical prostatectomies done for stage A or B psychologically suitable for it, has a 10-year life expectancy prostatic cancer, that is cancer limited to the prostate. A and the pathologist indicates that it is indeed a real prostatic detailed analysis was done on the 159 patients who were cancer rather than a tiny occult microscopic focus or "patholoperated on during the 20-year span from 1951 to 1970. There ogist's cancer". This decision, of course, is one of the most were 6 additional patients similarly operated on during this difficult and numerous microscopic sections and special microperiod but lost to followup before they were adequately evalu- scopic studies, such as electron microscopic' and evaluation of ribonucleic and deoxyribonucleic acid content in tumors, 5 may ated. The over-all crude survival rates in this group of 159 patients be helpful in arriving at it. Whenever a decision is made not to were 84 per cent at 5 years, 52 per cent at 10 years and 45 per do a radical prostatectomy after an incidental prostate cancer cent at 15 years. Of the 14 patients eligible for 20-year followup is found in a simple prostatectomy specimen we do advise a 5 have survived the entire 20-year span and have remained free followup cystoscopy in 3 months and endoscopic biopsies from of cancer. Three patients died of other causes at 16, 18 and 20 the remaining peripheral prostatic tissue. The time elapsed years. Six patients were lost to followup before they reached 20 between simple prostatectomy and radical prostatectomy in years but they had no evidence of recurrent cancer when last the 28 patients in this review ranged from 4 weeks to 11 seen (3 patients at 8 years, 2 at 13 years and 1 at 16 years). months. Eighteen followed transurethral resection of the prosDuring the 20-year period 40 of the 159 patients died. Nine tate and 10 were after open prostatectomies (4 suprapubic, 5 deaths were owing to disseminated cancer of the prostate, 4 retropubic and 1 perineal). Bilateral orchiectomy or estrogen patients died postoperatively and there were 27 deaths not treatment usually was instituted in the interval. related to prostatic cancer. In most instances these were The surgical technique for radical retropubic prostatectomy cardiovascular problems of advanced age. has been well outlined in earlier publications. e-s We advocate a The surgical pathology microscopic sections confirmed the 4-suture anastomosis of the urethra to the bladder. Sutures are stages A and B clinical staging in 93 of the 159 specimens. In placed in the urethra when it is being divided and the tagged this group the 5-year crude survival was 90 per cent, 10 years 55 long ends of the sutures are left hanging over the pubis until per cent and 15 years 39 per cent. Of the remaining 66 patients the closure is begun. An inverted Y closure at the bladder neck the histology indicated capsular invasion by the prostatic usually is used in order to recess the ureteral orifices further carcinoma in 42 patients, seminal vesicle involvement in 16 from the urethral bladder anastomosis. Ureteral catheters are and bladder neck invasion in 8. left in place until the anastomosis is almost completed to The histopathology was well differentiated prostatic carci- assure maintenance of ureteral patency. Mattress sutures noma in 146 patients. The remaining 13 patients had either (chromic 1 or 2-zero) are used for the anastomosis. These are poorly differentiated prostatic neoplasms or combined areas of placed in such a manner that the knots will be on the outside, cribiform patterns and anaplastic changes. and at the time the sutures are tied, the tie is on the bladder Diagnosis of prostatic cancer was always documented histo- side of the anastomosis. This permits better approximation logically prior to the radical prostatectomy. In 122 patients this and there is less chance of the suture pulling through. The was done by perineal prostatic cup biopsy,* which we have anastomosis is made over a 20 to 22F urethral catheter. Troublesome bleeding from the area of the urethral stump designed and described previously. 1 • 3 Open perineal biopsy was after the puboprostatic ligaments have been cut and the urethra has been transected can be controlled by passing a Accepted for publication June 18, 1976. Read at annual meeting of American Urological Association, Las catheter through the urethra and uniting the 2 ends of the Vegas, Nevada, May 16-20, 1976. catheter above the pubis. Upward traction on this catheter Supported by the Urology Neoplasm Research Fund at Columbia then compresses the dorsal vein of the penis and the periureUniversity, New York, New York. * Prostatic Cup Biopsy, J. Sklar Mfg. Co., Long Island County, New thral veins against the underside of the pubis, which readily York, distributed by V. Mueller Co., Chicago, Illinois. controls the bleeding. 330
RADICAL RETRGPUBIC PROSTt,.TECTOl\l'.::Y FOR CANC~SR
The urethrovesical anastomosis can be made more secure by using a suprapubic sump drain, which keeps the bladder decompressed and permits healing to occur without undue tension or extravasation of urine at the anastomosis. A multi-holed 20 or 22F whistle-tip catheter in the urethra usually drains better than a Foley catheter. In addition to taping the catheter to the penis, to be certain the catheter is not inadvertently dislodged, we loop a heavy silk suture through the eye of the catheter and out suprapubically where it is tied. This suture is removed after 5 days, since after this period union of the urethra and bladder is sufficiently secure to permit reinsertion of a catheter that may become dislodged. The suprapubic sump is removed after 5 to 7 days and the urethral catheter after 10 to 14 days, depending upon the satisfaction with the anastomosis. Pelvic lymphadenectomy has not been done in this series of patients but at preliminary exploration to determine operability selected nodes were removed for pathology examination when indicated. Whenever positive nodes are found it is our practice to consider the patient inoperable and marking metallic clips are placed to aid in future possible radiotherapy. Adjunctive hormonal treatment was used in 131 of the 159 pati~nts. Orchiectomy and stilbestrol were used in 85 patients, orch1ectomy alone in 28 and stilbestrol alone in 18 patients. Estrogens were given selectively only after the final pathology was obtained and if there were no cardiovascular or hepatic contraindications. Since a third of the pathology specimens usually showed capsular or seminal vesicle involvement and the testes were considered expendable after a radical prostatovesiculectomy, it was theorized that therapy should be directed to place the host in a hormonal environment that was hostile to tumor development. It was thought that small foci of tumor were less likely to take or proliferate in such an environment. The 15-year survival rate in the group given no adjunctive treatment was 25 per cent but it was 53 per cent in those who received hormonal control treatment. However, the number of patients who have reached the 15-year evaluation level is too few to draw any real conclusion from this difference. With the increased use of surgical implantation of penile prostheses fewer bilateral orchiectomies in conjunction with radical prostatectomies have been done between 1971 and 1975. . Function_al results in the 159 patients were 1) normal voiding m 108 patients, 2) stress incontinence and no incontinence device in 31 and 3) total incontinence in 20 patients. All patients were impotent. Our patients are prepared psychologically for the operative procedure and have presented no psychological problems. Complications following radical retropubic prostatectomy are listed in the table. Of the 13 patients who had rectal injury 8 had colostomies performed. The decision of whether to do a colostomy depends on the degree of rectal injury and the 9-u~lity of the rectal repair. Our management of rectal injury mc1dental to extensive pelvic surgery has been reported previously. 9 Strictures at the anastomosis can be troublesome but in 25 of the 29 patients they could be readily passed and dilated. In 4 of the patients subsequent cystostomy was necessary. Complications
Postoperative death Pulmonary emboli Stricture at anastmnosis Total incontinence Rectal injury Fecal fistula Osteitis pubis
4
(2 5)
6 (:l.7) 29 (17) 20 (12.5) J;l
:l
(7)
(2.5) (0.6)
DISCUSSION
Radical retropubic prostatectomy permits a wide exposure of the operative area and an opportunity to assess carefully the routes of metastasis of prostatic carcinoma. The lymph nodes and seminal vesicles can be explored readily to determine operability before extensive dissection is underway and before the urethra is transected. Although the operation can be followed by incontinence and other complications associated with extensive pelvic surgery, we believe the risks are warranted for possible cure of cancer of the prostate. With improved techniques of staging we believe the 10 and 15-vear cure rates can be even higher. For example, the bone ·acid phosphatase determinations give promise of being valuable in this regard. 10- 12 It is becoming increasingly evident that many of our past failures were probably the result of understaging of the disease. Whether radical prostatectomy is done retropubically or perineally the cure rates are about the same. 13 It seems unwise to us to rely on hormonal control therapy alone or to withhold treatment from patients when a prostatic cancer is clinically limited to the prostate and when the patient has a life expectancy of at least 10 years. We are well aware of the fact that prostatic cancer is slow growing but one never knows how long it had been present when it was detected nor which cancers are just about to escape from control and metastasize. In general, one can say that if a patient lives long enough he will die of the prostatic cancer if no treatment is given or when hormonal treatment alone is used. With radical prostatectomy there is a chance to cure the disease. We realize that a small percentage of patients are ideal candidates for radical prostatectomy. Hopefully, radiotherapy will give an increasing chance for curative treatment in a greater number of patients who have clinically borderline stage B to C prostatic cancers. REFERENCES
1. Veenema, R. J.: A simplified prostatic perinea! biopsy punch. J.
Urol., 69: 320, 1953. 2. Veenema, R. J.: Perinea! prostatic cup biopsy: technique and evaluation. J. Urol., 87: 585, 1962. 3. Veenema, R. J. and Lattimer, ,J. K.: Early diagnosis of carcinoma of the prostate. Periodic rectal examination is recommended and biopsy of any palpably suspicious area. J.A.M.A., 186: 127, 1963. 4. Tannenbaum, M.: A biological evaluation of cancers of the bladder and prostate by means of electron microscopy. In: Proceedings of the Clinical Conference on Carcinoma of the Bladder, Prostate and Testes. Ontario, Canada, pp. 189-201, 1970. 5. Fingerhut, B., Veenema, R. J., Graff, 8. and Butler, M. P.: Observations on RNA in prostate and bladder neoplasms. J. Urol., 101: 608, 1969. 6. Memmelaar, ,J.: Total prostatovesiculectomy-retropu bic approach. J. Urol., 62: 340, 1949. 7. Lattimer, ,J. K., Dean, A. L., Veenema, R ,J. and Rafferty, E.: Radical prostatectomy for cancer. J.A.M.A., 153: 1347, 1953. 8. Chute, R.: Radical retropubic prostatectomy for cancer. J. Ural., 71: 347, 1954. 9. Smith, A. M. and Veenema, R. J.: Management of rectal injury and recto urethral fistulas following radical retropu bic prostatectomy. J. Urol., 108: 778, 1972. 10. Chua, D. T., Veenema, R. J., Muggia, F. and Graff, A.: Acid phosphatase levels in bone marrow: value in detecting early bcne metastasis from carcinoma of the prostate. J. Urol., 103: 462, 1970. 11. Veenema, R. J., Gursel, E. 0., Romas, N., Wechsler, M. and Lattimer, J. K.: Bone marrow acid phosphatase: prognostic value in patients undergoing radical prostatectotny. J. Urol., 117: 81, 1977. 12. Veenema, R. J.: Bone marrow acid phosphatase determination for prostate cancer metastasis. J.A.M.A., 235: 1615, 1976. 13. Jewett, H.J.: The case for radical perinea! prostatectomy. J. Urol., 103: 195, 1970.