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The Anatomic Radical Perineal Prostatectomy: An Outcomes-Based Evolution
european urology 52 (2007) 81–88
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Surgery in Motion
The Anatomic Radical Perineal Prostatectomy: An Outcomes-Based Evolution Michael J. Harris * Northern Institute of Urology, 4100 Park Forest Drive, Suite 200, Traverse City, MI 49684, United States
Article info
Abstract
Article history: Accepted October 19, 2006 Published online ahead of print on October 30, 2006
Objective: Radical prostatectomy is the most effective treatment for localized prostate cancer. With increasing use of minimally invasive treatment methods, clinical outcomes are becoming important assessment tools to compare one option to another. Perineal prostatectomy is modified to incorporate contemporary surgical ideas, including preservation of cavernosal nerve bundles, sphincteric urethra at the prostatic apex, and the bladder neck. Methods: Objective parameters and physician-reported clinical outcomes are collected prospectively on 704 consecutive patients undergoing radical perineal prostatectomy (RPP) by one surgeon. The technique described herein is the current state of evolution of RPP. The enclosed digital video is edited from two recent nerve-sparing RPPs. Results: Freedom from prostate-specific antigen (PSA) detectability by stage is 94.5%, 80.0%, and 81.5% for organ-confined, specimen-confined, and margin-positive disease with actual 5-yr follow-up. Margins are positive in 18% of cases. By 1, 3, 6 mo and 1 yr, 52%, 71%, 85%, and 94% of the men are free from using pads. Although >97% of nerve-spared patients have spontaneous erections, >80% can penetrate to complete intercourse. Conclusions: This method of prostatectomy is able to achieve complete cancer resection while preserving urinary and sexual function in the majority of men presenting with clinically localized prostate cancer. The simplicity and minimally invasive nature of this procedure contribute to a short recovery and low overall cost of therapy. The anatomic RPP is a cost-efficient, outcome-effective minimally invasive method of treating men with localized prostate cancer.
Keywords: Minimally invasive Outcomes Perineal prostatectomy Prostate cancer Radical prostatectomy
# 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Tel. +1 231 935 0935; Fax: +1 231 935 0940. E-mail address: [email protected]. URL: http://www.northernurology.com
0302-2838/$ – see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2006.10.041
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1.
european urology 52 (2007) 81–88
Introduction
With the widespread use of early detection practices, prostate cancer is usually detected while it is clinically localized and potentially curable. Radical prostatectomy is considered the most reliable method of eradication of localized prostate cancer. The perineal approach to radical prostatectomy has long been considered a less invasive method of prostatectomy [1]. Hugh Hampton Young used a perineal approach in 1904 [2]. Belt described a subsphincteric entry into the pelvis and early dissection of the vas and seminal vesicles in 1942 [3]. Walsh defined the anatomy of the paraprostatic cavernosal nerve bundles and described a method of nerve preservation during retropubic prostatectomy in 1982 [4]. In 1985, Weiss applied this information to develop a nerve-sparing technique during total perineal prostatectomy [5]. In 1988, Weldon described the nerve-sparing radical perineal prostatectomy (RPP) and a 56% success rate in nine patients [6]. We modified the technique of perineal prostatectomy to incorporate early dissection of the vasa and seminal vesicles, bladder-neck preservation, and nerve-sparing techniques in the early 1990s [7]. Over the past 13 yr, the anatomic RPP, herein described, has undergone modifications to reduce the burden of treatment on the patient while optimizing functional and oncologic outcomes. 2.
Methods
2.1.
Preparation
Following appropriate evaluation and counseling for management options for prostate cancer, an intraoperative management plan is outlined with regard to nerve preservation, wide excision, and bladder-neck preservation or excision. Since the realization that cavernosal nerve-sparing techniques result in improved urinary outcomes as well as sexual outcomes, tumor grade, volume, and location relative to erectile nerves are primary determinants whether to proceed with nerve preservation [8]. During prostate biopsy, the capsular ends of the tissue cores are inked with color-coded ink for location and orientation. Nerve bundles where tumor is palpable or present at the inked end of lateral cores are resected with wide excision. In general, and unless otherwise contraindicated, since late 2001, preservation of both cavernosal nerve bundles, the apical prostatic urethra up to the veru, and the bladder neck with a stump of proximal prostatic urethra is intended. Pelvic lymphadenectomy is rarely (1% of cases) performed in the absence of prior treatment with radiation or radiographic evidence of lymphadenopathy. Digital and ultrasonic prostate examination is used to evaluate the potential for invasion of neighboring tissue. A total of 11.2% of men received neoadjuvant hormone therapy of varied duration to either downsize or accommodate delay in surgical dates. Two men with prostates
>180 cc underwent transurethral resection of the prostate (TURP) for 65–100 g of benign prostatic hyperplasia (BPH), followed in 3 and 6 mo with successful nerve-sparing RPP.
2.2.
Technique
On the day before surgery, the patient self-administers a Fleet Phospho-Soda bowel prep and clear liquid diet. On the morning of surgery, he is given a 1% neomycin enema and a second-generation cephalosporin (or equivalent) intravenously. Antithrombotic stockings and pneumatic compression stockings are applied before surgery. Although regional anesthesia is possible, general anesthesia is most commonly used to avoid movement by the patient. The legs are supported, in the lithotomy position, with hydraulic leg supports and a 6-inch jell roll is placed under the sacrum. An O’Conor-Sullivan drape is used for anorectal access. A Lowsley tractor is placed in the urethra to assist in identification of landmarks and to facilitate manipulation of the prostate. The perineal incision is placed with the apex in the mid perineum and the ends medial to the ischial tuberosities and anterior to the anus to avoid compromise of anal canal function. By elevating the fibrous confluence found immediately posterior to the raphe of the bulbospongiosus muscle with a forceps, the rectourethralis muscle is easily visualized and divided, revealing Denonvilliers fascia. With elevation of the lateral aspect of the pelvic floor, the space inside the levator ani muscles and lateral to endopelvic fascia is developed. The rectum is swept off the lower aspect of the levator ani. A fixed retraction system, such as the Thompson retractor (Thompson Surgical, Traverse City, MI), greatly facilitates exposure and frees up the surgical assistant’s hands. Denonvilliers fascia is opened transversely between the seminal vesicals; the vas and seminal vesicle dissection is completed. The posterior aspect of the prostate–vesicle junction is developed. When wide excision is intended, the fascia on the lateral aspect of the bladder neck is scored with electrocautery so that all of the periprostatic tissues are resected en bloc with the prostate. The neurovascular tissue at the base of the prostate is sealed to complete the wide excision. The lateral aspect of the prostatovesical junction is developed. In nerve-sparing cases, Denonvilliers fascia is incised from the midpoint of the seminal vesicle to the mid apex. With careful sharp dissection the cavernosal nerve bundles and associated fascia are separated from the prostate from apex to adjacent to the seminal vesicles. Once the neurovascular bundles and associated tissues are separated laterally as far around the prostate as the bladder neck and puboprostatic ligaments, the proximal prostatic pedicle is sealed and divided. The urethra at the apex is dissected out of the prostatic apex up to the veru montanum where it is divided. The puboprostatic ligaments are then divided with cautery, keeping a sufficient margin away from the prostate. Dorsal complex bleeding is controlled with a figure-eight stitch, if necessary. At the bladder neck, the proximal urethra is dissected out of the base of the prostate and divided. If resection of the bladder neck is desired, it is entered in the midline and excised
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under direct vision of the ureteral orifices. A running anastomosis is completed. If necessary, a two-layered cystoplasty is performed to reduce a large bladder-neck opening. The bladder-neck urothelium is not everted but rather incorporated into the anastomotic sutures. The levator ani muscles are reapproximated in the midline with a Penrose drain overlying the rectum. Ambulation and diet are advanced on the day of surgery. The Penrose drain is removed prior to discharge on the morning of postoperative day 1. The catheter is removed 8 d later and activities are no longer restricted.
2.3.
Data management
All data are accumulated prospectively on a database by the surgeon during follow-up visits at 2, 6, 9, 12, 18, and 24 mo, then annually after surgery. Technique variations are coded numerically and recorded prospectively, and follow-up results are entered as available during office visits or telephone calls. Patients are called periodically for long-term follow-up if they are no longer seen in the surgeon’s practice. Statistical analysis was performed using SPSS version 12.0.2 software. From January 2002 through February 2006, patients completed the Expanded Prostate Cancer Index Composite (EPIC) qualityof-life questionnaire preoperatively and at 2, 6, 12, 18, 24, 36, and 48 mo after the surgery. The office nurse enters the EPIC data into a database, which is sent to a third party for analysis periodically. The operating surgeon is not in contact with this data collection. Although patient-reported outcomes have correlated well with physician-reported outcomes in this series, current analysis concurrent to the present 704 is not available for direct comparison. Earlier EPIC outcomes have been previously published [9]. Biochemical recurrence is defined as any PSA 0.2 ng/ml. The operative technique and clinical practice have evolved over the 13-yr study period. Later modifications of technique are based on earlier data assessment, such that recent outcomes are better than initial outcomes. The above technique is the current manifestation of this evolution. Cancer control is based on 704 consecutive patients undergoing RPP with or without pelvic lymphadenectomy for clinically localized prostate cancer in a solo urologist’s community practice. Patients with obviously locally advanced disease or radiation salvage cases are excluded from this analysis. Continence and potency data are based on 210 patients from January 2002 through February 2006 after changing to a running anastomotic suture, revised nerve-sparing technique, and a median 8-d postoperative catheterization. Oncologic features of the groups of 704 and recent 210 patients are compared. Socially dry is defined as ‘‘essentially dry, but using 1 pad/24 h for minimal stress incontinence.’’ Totally dry is when the patient states that he does not leak and no longer wears pads. Continence data with interrupted suture anastomosis are previously published [10]. Partial erections are defined as erectile function with arousal regardless of degree of rigidity. Adequate erections are firm enough for vaginal penetration to complete intercourse with or without phosphodiesterase inhibitors (PDEIs). Complications are compiled from all 704 patients. Complexity of data and limitations of this report preclude a more detailed
assessment of each technical nuance and associated outcomes.
3.
Results
3.1.
Patient characteristics
The 704 consecutive cases performed by a single surgeon have been prospectively accumulated over the past 13 yr. Average patient age is 64.5 yr. The average prebiopsy PSA is 6.1 ng/ml (range: 0.3– 29.9 ng/ml). Preoperative Gleason scores and clinical stages are shown in Table 1. Table 2 reveals the pathologic Gleason scores. Table 3 breaks down pathologic staging and biochemical status for 704 and 210 patients from 1993 to 2006 and 2002 to 2006, respectively. Average follow-up is >50 mo and just under 20 mo, respectively. 3.2.
Cancer control
The pathologic features are broken down into three eras in Table 4. The most recent era is associated with more frequent and bilateral nerve sparing. Although the margin positivity difference is not statistically different, however, taken in light of decreasing average tumor size, the difference may be considered more clinically significant. Whereas the increased use of nerve sparing is associated with a slight increase in positive margins, the sites of margin positivity are usually on the anterior aspect not at the site of nerve preservation (posterolateral) (unpubl. data, M.J.H.) Detailed analysis of the margins is beyond the scope of this report. Table 5 outlines the percent of men with undetectable PSA at actual follow-up of 3, 5, and 7 yr postoperatively by grade classification. The average age, prebiopsy PSA level, and tumor size are listed by
Table 1 – Biopsy Gleason score and clinical stage for all 704 men (1993–2006) and for 210 men (2002–2006) Preop
1993–2006
2002–2006
n
n
Gleason score
2–5 6 7–9
73 371 260
10.4% 52.7% 36.9%
4 131 75
1.9% 62.4% 35.7%
Stage
cT1c cT2a cT2b,c
281 222 201
39.9% 31.5% 28.6%
151 28 31
71.9% 13.3% 14.8%
Total
704
210
The differences between the biopsy Gleason scores and clinical stages between the two groups are statistically significant (X, 95%CI, p < 0.05).
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Table 2 – Pathologic Gleason scores
Pathologic Gleason score
2–5 6 7–9
3.4.
1993–2006
2002–2006
n
n
59 295 350
8.4% 41.9% 49.7%
3 102 105
1.4% 48.6% 50%
Pathologic Gleason scores of 704 and 210 men from 1993 to 2006 and from 2002 to 2006, respectively. The differences in pathologic Gleason scores between the two eras are statistically significant (X, 95%CI, p < 0.05).
category of minimal years of follow-up. Patients treated with adjuvant radiation or hormonal therapies are categorized as recurrent disease even if their PSA is undetectable. 3.3.
Urinary continence
Continence is defined in two degrees. Socially dry refers to minimal stress urinary incontinence requiring no more than one pad in 24 h. Totally dry patients are confident enough in their control to stop using any pad protection. The percent of men dry is measured in weeks after catheter removal. Nerve sparing has a greater influence on continence than preservation of the bladder neck; however, preservation of both yields the best continence results, as shown in Figs. 1 and 2.
Return of erectile function
Partial erections are defined as any degree of erectile function associated with sexual arousal and indicate intact neural pathways and successful nerve preservation. Adequate erections are defined as erections of sufficient rigidity to penetrate vaginally to complete intercourse with or without the use of PDEIs (Figs. 3 and 4). Two nerves spared were not significantly more effective than one nerve spared after 12 mo. Before 12 mo after surgery, there are temporary advantages to sparing both bundles in terms of regaining both partial and adequate erections. 3.5.
Complications
Distal urethral strictures and anastomotic strictures have occurred in 0.5% and 1.0%, respectively, since incorporating a running anastomosis. Office cystoscopic evaluation and dilation resolved most strictures with three patients undergoing internal urethrotomy under anesthesia. One patient developed a recurrent urethrocutaneous fistula, which required excision and gracilis muscle interposition flap. He is continent and cancer-free 11 yr postoperatively. One man has experienced anal incompetence, whereas 2% note mild fecal urgency or Valsalva-related flatus. One man experienced a transient ischemic event and another a mild stroke
Table 3 – Pathologic stage and biochemical status Stage
1993–2006
2002–2006
n
bNED
Recurrence
n
bNED
Recurrence
pT2a, negative margin pT2b,c, negative margin pT2a, focal margin pT2a, nonfocal margin pT2b,c, focal margin pT2b,c, nonfocal margin pT3a, negative margin pT3a, focal margin pT3a, nonfocal margin pT3c, +SV, negative margin pT3c, +SV, focal margin pT3c, +SV, nonfocal margin N+/M+
130 343 3 1 31 13 79 28 42 15 9 5 4
128 332 3 0 28 7 63 24 23 5 4 1 0
2 12 0 1 3 6 16 4 19 10 5 4 4
34 121 1 0 13 9 14 5 9 1 2 1 0
34 121 1 0 12 7 13 5 7 1 1 1 0
0 0 0 0 1 2 1 0 2 0 1 0 0
Total
704
618
86
210
203
7
Average follow-up
50.3 mo (3–132 mo)
19.4 mo (2–52 mo)
bNED = biochemical freedom from disease. Pathologic stage and biochemical status are shown for 704 and 210 men from 1993 to 2006 and 2002 to 2006, respectively. Focal positive margins are solitary and <1 mm2, whereas nonfocal are either >1 mm2 or multiple. Differences in pathologic stages are not significant between time frames. Statistical differences are noted within pT2 and pT3 groups by margin status and between pT2 and pT3 groups with regard to bNED status in both time frames (X, 95%CI, p < 0.05).
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Table 4 – Pathologic features Era
n
Age
NHT
PSA
GS > 6
Cancer size
Nerve spare
Positive margin
July 1993–Mar 1998 Apr 1998–Jul 2001 Aug 2001–Feb 2006
231 236 237
65.9 65.9 61.8
17.7% 11.4% 4.6%
7.3 6.4 4.7
42.4% 53.8% 52.7%
11.1 g 8.2 g 4.1 g
11.7% 6.4% 62.0%
17.7% 17.8% 20.6%
Total
704
64.5
11.2%
6.1
49.7%
7.8 g
26.8%
18.6%
NHT = neoadjuvant hormone therapy; PSA = prostate-specific antigen; GS = Gleason score. The trend toward lower PSA and smaller tumors is seen by dividing the 704 patients into similar-sized groupings by era. The increase in nerve sparing resulted in a trend toward increased positive margins despite smaller average tumor size. The differences in rates of positive margins between eras is not statistically significant (X, 95%CI, p > 0.05).
on the day of discharge, requiring an extra day of neurologic tests and initiation of rehabilitation. One man ruptured plaque in his main coronary artery and suffered a heart attack on the day after surgery, but recovered well following coronary artery stent placement. No pulmonary complications occurred. There were no perioperative deaths. No patients developed lower extremity neuropraxia. Two percent of patients had rectal injuries that were all identified and repaired with a two-layer closure. One of these men developed antibiotic-associated colitis and developed a rectocutaneous fistula that
healed during temporary fecal diversion. No specific alteration in postoperative management is undertaken in men with repaired proctotomies because all men are prepped for this possible complication. 3.6.
Cost issues
Operative time is not abstracted from operative notes; however, most cases are completed in 60– 110 min with <10% taking a longer or shorter time. The length of hospital stay declined throughout the study period because a nursing care pathway was
Table 5 – Undetectable PSA at follow-up Undetectable PSA at follow-up of:
3 yr
5 yr
7 yr
Average age, yr Average prebiopsy PSA, ng/ml Average cancer size, g
65.0 6.4 8.8
65.6 6.8 10.2
65.0 7.3 10.9
Pathologic stage
Grade
n (%)
n
PSA = 0
n
PSA = 0
n
PSA = 0
pT2, negative margin
2–6 7–10 ALL
275 (58.1%) 198 (41.9%) 473
196 128 324
97.4% 96.9% 97.2%
147 90 237
95.9% 92.2% 94.5%
75 36 117
94.7% 88.9% 92.8%
pT3a-4, negative margin
2–6 7–10 ALL
28 (35.4%) 51 (64.6%) 79
24 37 61
83.3% 81.1% 82.0%
20 30 50
80.0% 80.0% 80.0%
16 19 35
81.3% 52.6% 65.7%
pT2-4, negative SV, focal + margin
2–6 7–10 ALL
25 (40.3%) 37 (59.7%) 62
17 25 42
88.2% 88.0% 88.1%
10 17 27
90.0% 76.5% 81.5%
6 9 15
83.3% 33.3% 73.3%
pT2-4, negative SV, nonfocal + margin
2–6 7–10 ALL
22 (39.3%) 34 (60.7% 56
16 25 41
50.0% 44.0% 45.2%
13 18 31
30.8% 38.9% 35.5%
9 9 18
66.7% 66.7% 66.7%
pT3-4, +SV, NxMx
2–6 7–10 ALL
3 (10%) 27 (90%) 30
3 21 24
33.3% 19.0% 25.0%
2 16 18
50.0% 0.0% 5.6%
1 8 9
100.0% 0.0% 11.1%
pT2-4, N+ or M+
2–6 7–10 ALL
1 (25%) 3 (75%) 4
1 3 4
0.0% 0.0% 0.0%
1 3 4
0.0% 0.0% 0.0%
1 3 4
0.0% 0.0% 0.0%
Total
ALL
704
496
367
198
PSA = prostate-specific antigen; SV = seminal vesicle. Biochemical freedom from disease or undetectable PSA by worst pathologic staging feature in patients with actual 3, 5,and 7 yr of follow-up. Focally positive margins are <1 mm2 and solitary. Nonfocal positive margins are either multiple or >1 mm2.
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european urology 52 (2007) 81–88
Fig. 1 – Socially dry (0–1 pad daily, solid squares) and totally dry (no pad use, open circles) by weeks after catheter removal. This graph represents 210 patients from 2002–2006 who underwent a running anastomosis with a median 8-d catheter period. The number of patients at each length of follow-up is indicated in the table.
Fig. 3 – Partial erections by nerve-sparing status in months after surgery. The table shows the number of men with available outcomes and statistical differences by months after surgery (one-sided p test, 95%CI).
Fig. 4 – Adequate erections by nerve-sparing status in months after surgery. The difference reaches statistical significance at 0–4, 12, and nearly so at 10 and 14 mo after surgery (one-sided p test, 95%CI).
Fig. 2 – Total continence is graphed by bladder-neck technique and nerve-sparing status. Totally dry patients are not using any protective pads (in weeks following catheter removal). BNS = bladder neck spared; BNR = bladder neck reconstructed; NS = nerves spared; WR = wide resection (not nerve sparing). Nerve sparing was the most significant variable for urinary continence; preservation of the bladder neck was a less significant contributor to urinary continence. The number of patients available with outcomes at weeks after catheter removal and the statistical analysis are shown in the table (one-sided p test, 95%CI).
instituted and improvements in preoperative teaching resulted in a steady decline in the length of stay. In the past 400 patients, the average hospitalization has been 1.1 d with 95% being discharged on the morning after surgery. Blood banking of autologous blood, typing, and screening for potential transfusion are not performed. Postoperative laboratory testing of any type is rare. Charges for cash-paying patients presenting for RPP at the Munson Medical Center (Traverse City, MI), RRP at the Mayo Clinic (Rochester, MN), and robotic laparoscopic RP at Henry Ford Hospital (Detroit, MI) are $11,600, $34,000, and $42,000, respectively (information obtained from patient invoices and telephone calls).
european urology 52 (2007) 81–88
4.
Discussion
The anatomic RPP is cost effective, safe, and versatile. The exceptionally low risk of lymph node metastasis obviates the need for lymphadenectomy in the majority of patients undergoing prostatectomy, thus avoiding abdominal surgery [11]. In many centers, lymphadenectomy generally does not preclude prostatectomy even if nonpalpably positive. Therefore, performance of lymphadenectomy in this population is of questionable benefit. This method of perineal prostatectomy results in excellent cancer control by incorporating all periprostatic tissues to the levator ani muscles in wide excision cases. Despite relatively large average cancer volumes (7.8 g), with 33% having extraprostatic invasion, the rate of positive margins is 18%. Gibbons and Iselin have demonstrated excellent cancer control in men followed for 20 yr after RPP [12,13]. Whether the retropubic, perineal, or laparoscopic approach is used for radical prostatectomy, clean margin excision in the absence of metastatic disease is the basis for long-term disease-specific survival. Weldon et al. [14] reported a 25%, 7%, and 16% incidence of anterior, apical, and posterolateral positive margins during radical perineal prostatectomy, respectively. Overall they noted 44% positive margins. They felt that at least 45% of the anterior positive margins were the result of avulsing the puboprostatic ligaments off the anterior surface of the prostate. In the present series, the puboprostatic ligaments and associated anterior tissue is divided with electrocautery at least 2 mm anterior to the prostate. Apical margins are the most common site of positivity in this series (5.8%) primarily because of the relative absence of positive margins at other locations. The increased use of bilateral nerve preservation results in more dissection at the apex and anterior apex and may explain the increased incidence of positive margins in these locations. On examination of these specimens, many focal apical margins are artifactual and do not suffer biochemical recurrence (unpubl. data, M.J.H.) Perineal exposure facilitates easy dissection and anastomosis of the urethra. The use of end-to-end urethrourethrostomy was first used in this series in 1995 [15]. Gaker et al. applied dissection of proximal urethra and a urethrourethrostomy during retropubic prostatectomy in 1996 [16]. Coakley and colleagues described a relationship between the length of urethra preserved and return of continence following radical retropubic prostatectomy [17]. The perineal approach provides unmatched exposure to facilitate urethral dissection and anastomosis. The
87
running anastomosis is associated with a 1% incidence of anastomotic strictures compared with a 1.9% incidence when using an 8–10 sutureinterrupted anastomosis. Median catheter time with a running versus interrupted anastomosis is 8 versus 17 d, respectively. Although body habitus and prior abdominopelvic surgery have a negative impact on a given patient’s candidacy for laparoscopic prostatectomy and to some extent retropubic prostatectomy, essentially all men who are candidates for prostatectomy can undergo perineal prostatectomy. This series includes men with prior aborted laparoscopic and retropubic prostatectomies, prior renal transplantation, abdominal–perineal resections, morbid obesity, superior vena cava syndrome, and many other relative contraindications to an abdominal approach. The use of TURP to downsize large prostates prior to RPP has not been described. When a 400-lb man, with prostate cancer in a 220-cc prostate, developed urinary retention after gastric bypass surgery, a TURP for 100 g of BPH was performed. He was able to void while losing 100 lb before undergoing successful nerve-sparing RPP. This technique was later used with excellent results in a similar situation. Considering the high cost of hormonal therapy, marginal downsizing of massive prostates, and the negative effect on potency, associated with hormonal downsizing, the technique of TURP followed by nerve-sparing RPP has been less expensive and more effective. Patient acceptance is very high because the treatment and recovery times are short and well tolerated. RPP is a minimally invasive, outcomeeffective, and cost-efficient method of managing localized prostate cancer.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/ j.eururo.2006.10.041 and via www.europeanurology. com. Subscribers to the printed journal will find the supplementary data attached (DVD).
References [1] Frazier HA, Robertson JE, Paulson DF. Radical prostatectomy: the pros and cons of the perineal versus retropubic approach. J Urol 1992;47:888–90. [2] Young H. The early diagnosis and radical cure of carcinoma of the prostate. J Urol 1905;16:315–21.
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[3] Belt E. Radical perineal prostatectomy in early carcinoma of the prostate. J Urol 1942;78:287–97. [4] Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol 1982;128:492–7. [5] Weiss JP, Schlecker BA, Wein AJ, Hanno PM. Preservation of periprostatic autonomic nerves during total perineal prostatectomy by intrafascial dissection. Urology 1985;26: 160–3. [6] Weldon VE, Tavel FR. Potency-sparing radical perineal prostatectomy: anatomy, surgical technique and initial results. J Urol 1988;140:559–62. [7] Harris MJ, Thompson IM. The anatomic radical perineal prostatectomy: a contemporary and anatomical approach. Urology 1996;48:762–8. [8] Kuebler HR, Tseng TY, Vieweg J, Harris MJ, Dahm P. Impact of nerve-sparing technique on patients’ self-assessed functional outcomes in radical perineal prostatectomy. J Urol 2006;175(AUA Suppl):519 (abstract no. 1610). [9] Wiygul J, Harris MJ, Dahm P. Early patient self-assessed outcomes of nerve-sparing radical perineal prostatectomy. Urology 2005;66:582–6. [10] Harris MJ. Radical perineal prostatectomy: cost efficient, outcome effective, minimally invasive prostate cancer management. Eur Urol 2003;44:303–8.
[11] Partin AW, Walsh PC, Kattan MW, 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;277:1445–51. [12] Gibbons RP, Correa RJ, Brannen GE, Weissman RM. Total prostatectomy for clinically localized prostatic cancer: Long-term results. J Urol 1989;141:564–6. [13] Iselin CE, Robertson JE, Paulson DF. Radical perineal prostatectomy: oncological outcome during a 20-year period. J Urol 1999;161:163–8. [14] Weldon VE, Tavel FR, Neuwirth H, Cohen R. Patterns of positive specimen margins and detectable prostate specific antigen after radical perineal prostatectomy. J Urol 1995;153:1565–9. [15] Harris MJ. Urethral sparing radical perineal prostatectomy: the end of post-prostatectomy incontinence. J Urol 1997;157(AUA Suppl):389 (abstract no. 1523). [16] Gaker DL, Gaker LB, Stewart JF, Gillenwater JY. Radical prostatectomy with preservation of urinary continence. J Urol 1996;156:445–9. [17] Coakley FV, Eberhardt S, Kattan MW, Wei DC, Scardino PT, Hricak H. Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging. J Urol 2002;168:1032–5.
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Surgery in Motion
The Anatomic Radical Perineal Prostatectomy: An Outcomes-Based Evolution Michael J. Harris * Northern Institute of Urology, 4100 Park Forest Drive, Suite 200, Traverse City, MI 49684, United States
Article info
Abstract
Article history: Accepted October 19, 2006 Published online ahead of print on October 30, 2006
Objective: Radical prostatectomy is the most effective treatment for localized prostate cancer. With increasing use of minimally invasive treatment methods, clinical outcomes are becoming important assessment tools to compare one option to another. Perineal prostatectomy is modified to incorporate contemporary surgical ideas, including preservation of cavernosal nerve bundles, sphincteric urethra at the prostatic apex, and the bladder neck. Methods: Objective parameters and physician-reported clinical outcomes are collected prospectively on 704 consecutive patients undergoing radical perineal prostatectomy (RPP) by one surgeon. The technique described herein is the current state of evolution of RPP. The enclosed digital video is edited from two recent nerve-sparing RPPs. Results: Freedom from prostate-specific antigen (PSA) detectability by stage is 94.5%, 80.0%, and 81.5% for organ-confined, specimen-confined, and margin-positive disease with actual 5-yr follow-up. Margins are positive in 18% of cases. By 1, 3, 6 mo and 1 yr, 52%, 71%, 85%, and 94% of the men are free from using pads. Although >97% of nerve-spared patients have spontaneous erections, >80% can penetrate to complete intercourse. Conclusions: This method of prostatectomy is able to achieve complete cancer resection while preserving urinary and sexual function in the majority of men presenting with clinically localized prostate cancer. The simplicity and minimally invasive nature of this procedure contribute to a short recovery and low overall cost of therapy. The anatomic RPP is a cost-efficient, outcome-effective minimally invasive method of treating men with localized prostate cancer.
Keywords: Minimally invasive Outcomes Perineal prostatectomy Prostate cancer Radical prostatectomy
# 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Tel. +1 231 935 0935; Fax: +1 231 935 0940. E-mail address: [email protected]. URL: http://www.northernurology.com
0302-2838/$ – see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2006.10.041
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1.
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Introduction
With the widespread use of early detection practices, prostate cancer is usually detected while it is clinically localized and potentially curable. Radical prostatectomy is considered the most reliable method of eradication of localized prostate cancer. The perineal approach to radical prostatectomy has long been considered a less invasive method of prostatectomy [1]. Hugh Hampton Young used a perineal approach in 1904 [2]. Belt described a subsphincteric entry into the pelvis and early dissection of the vas and seminal vesicles in 1942 [3]. Walsh defined the anatomy of the paraprostatic cavernosal nerve bundles and described a method of nerve preservation during retropubic prostatectomy in 1982 [4]. In 1985, Weiss applied this information to develop a nerve-sparing technique during total perineal prostatectomy [5]. In 1988, Weldon described the nerve-sparing radical perineal prostatectomy (RPP) and a 56% success rate in nine patients [6]. We modified the technique of perineal prostatectomy to incorporate early dissection of the vasa and seminal vesicles, bladder-neck preservation, and nerve-sparing techniques in the early 1990s [7]. Over the past 13 yr, the anatomic RPP, herein described, has undergone modifications to reduce the burden of treatment on the patient while optimizing functional and oncologic outcomes. 2.
Methods
2.1.
Preparation
Following appropriate evaluation and counseling for management options for prostate cancer, an intraoperative management plan is outlined with regard to nerve preservation, wide excision, and bladder-neck preservation or excision. Since the realization that cavernosal nerve-sparing techniques result in improved urinary outcomes as well as sexual outcomes, tumor grade, volume, and location relative to erectile nerves are primary determinants whether to proceed with nerve preservation [8]. During prostate biopsy, the capsular ends of the tissue cores are inked with color-coded ink for location and orientation. Nerve bundles where tumor is palpable or present at the inked end of lateral cores are resected with wide excision. In general, and unless otherwise contraindicated, since late 2001, preservation of both cavernosal nerve bundles, the apical prostatic urethra up to the veru, and the bladder neck with a stump of proximal prostatic urethra is intended. Pelvic lymphadenectomy is rarely (1% of cases) performed in the absence of prior treatment with radiation or radiographic evidence of lymphadenopathy. Digital and ultrasonic prostate examination is used to evaluate the potential for invasion of neighboring tissue. A total of 11.2% of men received neoadjuvant hormone therapy of varied duration to either downsize or accommodate delay in surgical dates. Two men with prostates
>180 cc underwent transurethral resection of the prostate (TURP) for 65–100 g of benign prostatic hyperplasia (BPH), followed in 3 and 6 mo with successful nerve-sparing RPP.
2.2.
Technique
On the day before surgery, the patient self-administers a Fleet Phospho-Soda bowel prep and clear liquid diet. On the morning of surgery, he is given a 1% neomycin enema and a second-generation cephalosporin (or equivalent) intravenously. Antithrombotic stockings and pneumatic compression stockings are applied before surgery. Although regional anesthesia is possible, general anesthesia is most commonly used to avoid movement by the patient. The legs are supported, in the lithotomy position, with hydraulic leg supports and a 6-inch jell roll is placed under the sacrum. An O’Conor-Sullivan drape is used for anorectal access. A Lowsley tractor is placed in the urethra to assist in identification of landmarks and to facilitate manipulation of the prostate. The perineal incision is placed with the apex in the mid perineum and the ends medial to the ischial tuberosities and anterior to the anus to avoid compromise of anal canal function. By elevating the fibrous confluence found immediately posterior to the raphe of the bulbospongiosus muscle with a forceps, the rectourethralis muscle is easily visualized and divided, revealing Denonvilliers fascia. With elevation of the lateral aspect of the pelvic floor, the space inside the levator ani muscles and lateral to endopelvic fascia is developed. The rectum is swept off the lower aspect of the levator ani. A fixed retraction system, such as the Thompson retractor (Thompson Surgical, Traverse City, MI), greatly facilitates exposure and frees up the surgical assistant’s hands. Denonvilliers fascia is opened transversely between the seminal vesicals; the vas and seminal vesicle dissection is completed. The posterior aspect of the prostate–vesicle junction is developed. When wide excision is intended, the fascia on the lateral aspect of the bladder neck is scored with electrocautery so that all of the periprostatic tissues are resected en bloc with the prostate. The neurovascular tissue at the base of the prostate is sealed to complete the wide excision. The lateral aspect of the prostatovesical junction is developed. In nerve-sparing cases, Denonvilliers fascia is incised from the midpoint of the seminal vesicle to the mid apex. With careful sharp dissection the cavernosal nerve bundles and associated fascia are separated from the prostate from apex to adjacent to the seminal vesicles. Once the neurovascular bundles and associated tissues are separated laterally as far around the prostate as the bladder neck and puboprostatic ligaments, the proximal prostatic pedicle is sealed and divided. The urethra at the apex is dissected out of the prostatic apex up to the veru montanum where it is divided. The puboprostatic ligaments are then divided with cautery, keeping a sufficient margin away from the prostate. Dorsal complex bleeding is controlled with a figure-eight stitch, if necessary. At the bladder neck, the proximal urethra is dissected out of the base of the prostate and divided. If resection of the bladder neck is desired, it is entered in the midline and excised
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under direct vision of the ureteral orifices. A running anastomosis is completed. If necessary, a two-layered cystoplasty is performed to reduce a large bladder-neck opening. The bladder-neck urothelium is not everted but rather incorporated into the anastomotic sutures. The levator ani muscles are reapproximated in the midline with a Penrose drain overlying the rectum. Ambulation and diet are advanced on the day of surgery. The Penrose drain is removed prior to discharge on the morning of postoperative day 1. The catheter is removed 8 d later and activities are no longer restricted.
2.3.
Data management
All data are accumulated prospectively on a database by the surgeon during follow-up visits at 2, 6, 9, 12, 18, and 24 mo, then annually after surgery. Technique variations are coded numerically and recorded prospectively, and follow-up results are entered as available during office visits or telephone calls. Patients are called periodically for long-term follow-up if they are no longer seen in the surgeon’s practice. Statistical analysis was performed using SPSS version 12.0.2 software. From January 2002 through February 2006, patients completed the Expanded Prostate Cancer Index Composite (EPIC) qualityof-life questionnaire preoperatively and at 2, 6, 12, 18, 24, 36, and 48 mo after the surgery. The office nurse enters the EPIC data into a database, which is sent to a third party for analysis periodically. The operating surgeon is not in contact with this data collection. Although patient-reported outcomes have correlated well with physician-reported outcomes in this series, current analysis concurrent to the present 704 is not available for direct comparison. Earlier EPIC outcomes have been previously published [9]. Biochemical recurrence is defined as any PSA 0.2 ng/ml. The operative technique and clinical practice have evolved over the 13-yr study period. Later modifications of technique are based on earlier data assessment, such that recent outcomes are better than initial outcomes. The above technique is the current manifestation of this evolution. Cancer control is based on 704 consecutive patients undergoing RPP with or without pelvic lymphadenectomy for clinically localized prostate cancer in a solo urologist’s community practice. Patients with obviously locally advanced disease or radiation salvage cases are excluded from this analysis. Continence and potency data are based on 210 patients from January 2002 through February 2006 after changing to a running anastomotic suture, revised nerve-sparing technique, and a median 8-d postoperative catheterization. Oncologic features of the groups of 704 and recent 210 patients are compared. Socially dry is defined as ‘‘essentially dry, but using 1 pad/24 h for minimal stress incontinence.’’ Totally dry is when the patient states that he does not leak and no longer wears pads. Continence data with interrupted suture anastomosis are previously published [10]. Partial erections are defined as erectile function with arousal regardless of degree of rigidity. Adequate erections are firm enough for vaginal penetration to complete intercourse with or without phosphodiesterase inhibitors (PDEIs). Complications are compiled from all 704 patients. Complexity of data and limitations of this report preclude a more detailed
assessment of each technical nuance and associated outcomes.
3.
Results
3.1.
Patient characteristics
The 704 consecutive cases performed by a single surgeon have been prospectively accumulated over the past 13 yr. Average patient age is 64.5 yr. The average prebiopsy PSA is 6.1 ng/ml (range: 0.3– 29.9 ng/ml). Preoperative Gleason scores and clinical stages are shown in Table 1. Table 2 reveals the pathologic Gleason scores. Table 3 breaks down pathologic staging and biochemical status for 704 and 210 patients from 1993 to 2006 and 2002 to 2006, respectively. Average follow-up is >50 mo and just under 20 mo, respectively. 3.2.
Cancer control
The pathologic features are broken down into three eras in Table 4. The most recent era is associated with more frequent and bilateral nerve sparing. Although the margin positivity difference is not statistically different, however, taken in light of decreasing average tumor size, the difference may be considered more clinically significant. Whereas the increased use of nerve sparing is associated with a slight increase in positive margins, the sites of margin positivity are usually on the anterior aspect not at the site of nerve preservation (posterolateral) (unpubl. data, M.J.H.) Detailed analysis of the margins is beyond the scope of this report. Table 5 outlines the percent of men with undetectable PSA at actual follow-up of 3, 5, and 7 yr postoperatively by grade classification. The average age, prebiopsy PSA level, and tumor size are listed by
Table 1 – Biopsy Gleason score and clinical stage for all 704 men (1993–2006) and for 210 men (2002–2006) Preop
1993–2006
2002–2006
n
n
Gleason score
2–5 6 7–9
73 371 260
10.4% 52.7% 36.9%
4 131 75
1.9% 62.4% 35.7%
Stage
cT1c cT2a cT2b,c
281 222 201
39.9% 31.5% 28.6%
151 28 31
71.9% 13.3% 14.8%
Total
704
210
The differences between the biopsy Gleason scores and clinical stages between the two groups are statistically significant (X, 95%CI, p < 0.05).
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Table 2 – Pathologic Gleason scores
Pathologic Gleason score
2–5 6 7–9
3.4.
1993–2006
2002–2006
n
n
59 295 350
8.4% 41.9% 49.7%
3 102 105
1.4% 48.6% 50%
Pathologic Gleason scores of 704 and 210 men from 1993 to 2006 and from 2002 to 2006, respectively. The differences in pathologic Gleason scores between the two eras are statistically significant (X, 95%CI, p < 0.05).
category of minimal years of follow-up. Patients treated with adjuvant radiation or hormonal therapies are categorized as recurrent disease even if their PSA is undetectable. 3.3.
Urinary continence
Continence is defined in two degrees. Socially dry refers to minimal stress urinary incontinence requiring no more than one pad in 24 h. Totally dry patients are confident enough in their control to stop using any pad protection. The percent of men dry is measured in weeks after catheter removal. Nerve sparing has a greater influence on continence than preservation of the bladder neck; however, preservation of both yields the best continence results, as shown in Figs. 1 and 2.
Return of erectile function
Partial erections are defined as any degree of erectile function associated with sexual arousal and indicate intact neural pathways and successful nerve preservation. Adequate erections are defined as erections of sufficient rigidity to penetrate vaginally to complete intercourse with or without the use of PDEIs (Figs. 3 and 4). Two nerves spared were not significantly more effective than one nerve spared after 12 mo. Before 12 mo after surgery, there are temporary advantages to sparing both bundles in terms of regaining both partial and adequate erections. 3.5.
Complications
Distal urethral strictures and anastomotic strictures have occurred in 0.5% and 1.0%, respectively, since incorporating a running anastomosis. Office cystoscopic evaluation and dilation resolved most strictures with three patients undergoing internal urethrotomy under anesthesia. One patient developed a recurrent urethrocutaneous fistula, which required excision and gracilis muscle interposition flap. He is continent and cancer-free 11 yr postoperatively. One man has experienced anal incompetence, whereas 2% note mild fecal urgency or Valsalva-related flatus. One man experienced a transient ischemic event and another a mild stroke
Table 3 – Pathologic stage and biochemical status Stage
1993–2006
2002–2006
n
bNED
Recurrence
n
bNED
Recurrence
pT2a, negative margin pT2b,c, negative margin pT2a, focal margin pT2a, nonfocal margin pT2b,c, focal margin pT2b,c, nonfocal margin pT3a, negative margin pT3a, focal margin pT3a, nonfocal margin pT3c, +SV, negative margin pT3c, +SV, focal margin pT3c, +SV, nonfocal margin N+/M+
130 343 3 1 31 13 79 28 42 15 9 5 4
128 332 3 0 28 7 63 24 23 5 4 1 0
2 12 0 1 3 6 16 4 19 10 5 4 4
34 121 1 0 13 9 14 5 9 1 2 1 0
34 121 1 0 12 7 13 5 7 1 1 1 0
0 0 0 0 1 2 1 0 2 0 1 0 0
Total
704
618
86
210
203
7
Average follow-up
50.3 mo (3–132 mo)
19.4 mo (2–52 mo)
bNED = biochemical freedom from disease. Pathologic stage and biochemical status are shown for 704 and 210 men from 1993 to 2006 and 2002 to 2006, respectively. Focal positive margins are solitary and <1 mm2, whereas nonfocal are either >1 mm2 or multiple. Differences in pathologic stages are not significant between time frames. Statistical differences are noted within pT2 and pT3 groups by margin status and between pT2 and pT3 groups with regard to bNED status in both time frames (X, 95%CI, p < 0.05).
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Table 4 – Pathologic features Era
n
Age
NHT
PSA
GS > 6
Cancer size
Nerve spare
Positive margin
July 1993–Mar 1998 Apr 1998–Jul 2001 Aug 2001–Feb 2006
231 236 237
65.9 65.9 61.8
17.7% 11.4% 4.6%
7.3 6.4 4.7
42.4% 53.8% 52.7%
11.1 g 8.2 g 4.1 g
11.7% 6.4% 62.0%
17.7% 17.8% 20.6%
Total
704
64.5
11.2%
6.1
49.7%
7.8 g
26.8%
18.6%
NHT = neoadjuvant hormone therapy; PSA = prostate-specific antigen; GS = Gleason score. The trend toward lower PSA and smaller tumors is seen by dividing the 704 patients into similar-sized groupings by era. The increase in nerve sparing resulted in a trend toward increased positive margins despite smaller average tumor size. The differences in rates of positive margins between eras is not statistically significant (X, 95%CI, p > 0.05).
on the day of discharge, requiring an extra day of neurologic tests and initiation of rehabilitation. One man ruptured plaque in his main coronary artery and suffered a heart attack on the day after surgery, but recovered well following coronary artery stent placement. No pulmonary complications occurred. There were no perioperative deaths. No patients developed lower extremity neuropraxia. Two percent of patients had rectal injuries that were all identified and repaired with a two-layer closure. One of these men developed antibiotic-associated colitis and developed a rectocutaneous fistula that
healed during temporary fecal diversion. No specific alteration in postoperative management is undertaken in men with repaired proctotomies because all men are prepped for this possible complication. 3.6.
Cost issues
Operative time is not abstracted from operative notes; however, most cases are completed in 60– 110 min with <10% taking a longer or shorter time. The length of hospital stay declined throughout the study period because a nursing care pathway was
Table 5 – Undetectable PSA at follow-up Undetectable PSA at follow-up of:
3 yr
5 yr
7 yr
Average age, yr Average prebiopsy PSA, ng/ml Average cancer size, g
65.0 6.4 8.8
65.6 6.8 10.2
65.0 7.3 10.9
Pathologic stage
Grade
n (%)
n
PSA = 0
n
PSA = 0
n
PSA = 0
pT2, negative margin
2–6 7–10 ALL
275 (58.1%) 198 (41.9%) 473
196 128 324
97.4% 96.9% 97.2%
147 90 237
95.9% 92.2% 94.5%
75 36 117
94.7% 88.9% 92.8%
pT3a-4, negative margin
2–6 7–10 ALL
28 (35.4%) 51 (64.6%) 79
24 37 61
83.3% 81.1% 82.0%
20 30 50
80.0% 80.0% 80.0%
16 19 35
81.3% 52.6% 65.7%
pT2-4, negative SV, focal + margin
2–6 7–10 ALL
25 (40.3%) 37 (59.7%) 62
17 25 42
88.2% 88.0% 88.1%
10 17 27
90.0% 76.5% 81.5%
6 9 15
83.3% 33.3% 73.3%
pT2-4, negative SV, nonfocal + margin
2–6 7–10 ALL
22 (39.3%) 34 (60.7% 56
16 25 41
50.0% 44.0% 45.2%
13 18 31
30.8% 38.9% 35.5%
9 9 18
66.7% 66.7% 66.7%
pT3-4, +SV, NxMx
2–6 7–10 ALL
3 (10%) 27 (90%) 30
3 21 24
33.3% 19.0% 25.0%
2 16 18
50.0% 0.0% 5.6%
1 8 9
100.0% 0.0% 11.1%
pT2-4, N+ or M+
2–6 7–10 ALL
1 (25%) 3 (75%) 4
1 3 4
0.0% 0.0% 0.0%
1 3 4
0.0% 0.0% 0.0%
1 3 4
0.0% 0.0% 0.0%
Total
ALL
704
496
367
198
PSA = prostate-specific antigen; SV = seminal vesicle. Biochemical freedom from disease or undetectable PSA by worst pathologic staging feature in patients with actual 3, 5,and 7 yr of follow-up. Focally positive margins are <1 mm2 and solitary. Nonfocal positive margins are either multiple or >1 mm2.
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european urology 52 (2007) 81–88
Fig. 1 – Socially dry (0–1 pad daily, solid squares) and totally dry (no pad use, open circles) by weeks after catheter removal. This graph represents 210 patients from 2002–2006 who underwent a running anastomosis with a median 8-d catheter period. The number of patients at each length of follow-up is indicated in the table.
Fig. 3 – Partial erections by nerve-sparing status in months after surgery. The table shows the number of men with available outcomes and statistical differences by months after surgery (one-sided p test, 95%CI).
Fig. 4 – Adequate erections by nerve-sparing status in months after surgery. The difference reaches statistical significance at 0–4, 12, and nearly so at 10 and 14 mo after surgery (one-sided p test, 95%CI).
Fig. 2 – Total continence is graphed by bladder-neck technique and nerve-sparing status. Totally dry patients are not using any protective pads (in weeks following catheter removal). BNS = bladder neck spared; BNR = bladder neck reconstructed; NS = nerves spared; WR = wide resection (not nerve sparing). Nerve sparing was the most significant variable for urinary continence; preservation of the bladder neck was a less significant contributor to urinary continence. The number of patients available with outcomes at weeks after catheter removal and the statistical analysis are shown in the table (one-sided p test, 95%CI).
instituted and improvements in preoperative teaching resulted in a steady decline in the length of stay. In the past 400 patients, the average hospitalization has been 1.1 d with 95% being discharged on the morning after surgery. Blood banking of autologous blood, typing, and screening for potential transfusion are not performed. Postoperative laboratory testing of any type is rare. Charges for cash-paying patients presenting for RPP at the Munson Medical Center (Traverse City, MI), RRP at the Mayo Clinic (Rochester, MN), and robotic laparoscopic RP at Henry Ford Hospital (Detroit, MI) are $11,600, $34,000, and $42,000, respectively (information obtained from patient invoices and telephone calls).
european urology 52 (2007) 81–88
4.
Discussion
The anatomic RPP is cost effective, safe, and versatile. The exceptionally low risk of lymph node metastasis obviates the need for lymphadenectomy in the majority of patients undergoing prostatectomy, thus avoiding abdominal surgery [11]. In many centers, lymphadenectomy generally does not preclude prostatectomy even if nonpalpably positive. Therefore, performance of lymphadenectomy in this population is of questionable benefit. This method of perineal prostatectomy results in excellent cancer control by incorporating all periprostatic tissues to the levator ani muscles in wide excision cases. Despite relatively large average cancer volumes (7.8 g), with 33% having extraprostatic invasion, the rate of positive margins is 18%. Gibbons and Iselin have demonstrated excellent cancer control in men followed for 20 yr after RPP [12,13]. Whether the retropubic, perineal, or laparoscopic approach is used for radical prostatectomy, clean margin excision in the absence of metastatic disease is the basis for long-term disease-specific survival. Weldon et al. [14] reported a 25%, 7%, and 16% incidence of anterior, apical, and posterolateral positive margins during radical perineal prostatectomy, respectively. Overall they noted 44% positive margins. They felt that at least 45% of the anterior positive margins were the result of avulsing the puboprostatic ligaments off the anterior surface of the prostate. In the present series, the puboprostatic ligaments and associated anterior tissue is divided with electrocautery at least 2 mm anterior to the prostate. Apical margins are the most common site of positivity in this series (5.8%) primarily because of the relative absence of positive margins at other locations. The increased use of bilateral nerve preservation results in more dissection at the apex and anterior apex and may explain the increased incidence of positive margins in these locations. On examination of these specimens, many focal apical margins are artifactual and do not suffer biochemical recurrence (unpubl. data, M.J.H.) Perineal exposure facilitates easy dissection and anastomosis of the urethra. The use of end-to-end urethrourethrostomy was first used in this series in 1995 [15]. Gaker et al. applied dissection of proximal urethra and a urethrourethrostomy during retropubic prostatectomy in 1996 [16]. Coakley and colleagues described a relationship between the length of urethra preserved and return of continence following radical retropubic prostatectomy [17]. The perineal approach provides unmatched exposure to facilitate urethral dissection and anastomosis. The
87
running anastomosis is associated with a 1% incidence of anastomotic strictures compared with a 1.9% incidence when using an 8–10 sutureinterrupted anastomosis. Median catheter time with a running versus interrupted anastomosis is 8 versus 17 d, respectively. Although body habitus and prior abdominopelvic surgery have a negative impact on a given patient’s candidacy for laparoscopic prostatectomy and to some extent retropubic prostatectomy, essentially all men who are candidates for prostatectomy can undergo perineal prostatectomy. This series includes men with prior aborted laparoscopic and retropubic prostatectomies, prior renal transplantation, abdominal–perineal resections, morbid obesity, superior vena cava syndrome, and many other relative contraindications to an abdominal approach. The use of TURP to downsize large prostates prior to RPP has not been described. When a 400-lb man, with prostate cancer in a 220-cc prostate, developed urinary retention after gastric bypass surgery, a TURP for 100 g of BPH was performed. He was able to void while losing 100 lb before undergoing successful nerve-sparing RPP. This technique was later used with excellent results in a similar situation. Considering the high cost of hormonal therapy, marginal downsizing of massive prostates, and the negative effect on potency, associated with hormonal downsizing, the technique of TURP followed by nerve-sparing RPP has been less expensive and more effective. Patient acceptance is very high because the treatment and recovery times are short and well tolerated. RPP is a minimally invasive, outcomeeffective, and cost-efficient method of managing localized prostate cancer.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/ j.eururo.2006.10.041 and via www.europeanurology. com. Subscribers to the printed journal will find the supplementary data attached (DVD).
References [1] Frazier HA, Robertson JE, Paulson DF. Radical prostatectomy: the pros and cons of the perineal versus retropubic approach. J Urol 1992;47:888–90. [2] Young H. The early diagnosis and radical cure of carcinoma of the prostate. J Urol 1905;16:315–21.
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[3] Belt E. Radical perineal prostatectomy in early carcinoma of the prostate. J Urol 1942;78:287–97. [4] Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol 1982;128:492–7. [5] Weiss JP, Schlecker BA, Wein AJ, Hanno PM. Preservation of periprostatic autonomic nerves during total perineal prostatectomy by intrafascial dissection. Urology 1985;26: 160–3. [6] Weldon VE, Tavel FR. Potency-sparing radical perineal prostatectomy: anatomy, surgical technique and initial results. J Urol 1988;140:559–62. [7] Harris MJ, Thompson IM. The anatomic radical perineal prostatectomy: a contemporary and anatomical approach. Urology 1996;48:762–8. [8] Kuebler HR, Tseng TY, Vieweg J, Harris MJ, Dahm P. Impact of nerve-sparing technique on patients’ self-assessed functional outcomes in radical perineal prostatectomy. J Urol 2006;175(AUA Suppl):519 (abstract no. 1610). [9] Wiygul J, Harris MJ, Dahm P. Early patient self-assessed outcomes of nerve-sparing radical perineal prostatectomy. Urology 2005;66:582–6. [10] Harris MJ. Radical perineal prostatectomy: cost efficient, outcome effective, minimally invasive prostate cancer management. Eur Urol 2003;44:303–8.
[11] Partin AW, Walsh PC, Kattan MW, 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;277:1445–51. [12] Gibbons RP, Correa RJ, Brannen GE, Weissman RM. Total prostatectomy for clinically localized prostatic cancer: Long-term results. J Urol 1989;141:564–6. [13] Iselin CE, Robertson JE, Paulson DF. Radical perineal prostatectomy: oncological outcome during a 20-year period. J Urol 1999;161:163–8. [14] Weldon VE, Tavel FR, Neuwirth H, Cohen R. Patterns of positive specimen margins and detectable prostate specific antigen after radical perineal prostatectomy. J Urol 1995;153:1565–9. [15] Harris MJ. Urethral sparing radical perineal prostatectomy: the end of post-prostatectomy incontinence. J Urol 1997;157(AUA Suppl):389 (abstract no. 1523). [16] Gaker DL, Gaker LB, Stewart JF, Gillenwater JY. Radical prostatectomy with preservation of urinary continence. J Urol 1996;156:445–9. [17] Coakley FV, Eberhardt S, Kattan MW, Wei DC, Scardino PT, Hricak H. Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging. J Urol 2002;168:1032–5.