Radical Retropubic Prostatectomy

The unprecedented increase in the incidence of carcinoma of the prostate that has occurred over the last decade has resulted in a corresponding increase in the rate with which radical prostatectomy is performed. Refinements in patient selection and surgical technique have diminished the morbidity of surgery. Nonetheless, many patients maintain concern about the risks and potential side effects of the operation. Knowledge of surgical anatomy and attention to operative technique can help diminish both the side effects and the overall expense of treatment.

DIAGNOSIS

Clinically localized carcinoma of the prostate is diagnosed most frequently in asymptomatic men who present for early detection or screening programs or during the course of a routine physical examination. Digital rectal examination and serum prostate-specific antigen (PSA) are accepted modalities for prostate cancer detection. Almost 20% of clinically diagnosed cancers are detected by digital rectal examination in the face of a normal serum PSA level. On the other hand, stage T1c cancers, i.e., those detected on a biopsy prompted by an abnormal PSA level in the face of a normal digital rectal examination, constitute the most common category of cancers diagnosed in most clinical series.

Tumor grade is one of the most important prognostic criteria, though in more recent studies, preoperative PSA may also be predictive. Computerized tomography scanning of the pelvis to identify lymph node metastasis is usually not indicated. A radioisotope bone scan is usually performed if the serum PSA level is greater than 20 ng/dl but rarely is positive for metastasis if the PSA is below that level.

INDICATIONS FOR SURGERY

Radical prostatectomy is indicated in patients with carcinoma of the prostate seemingly confined within the surgical capsule of the gland, who would be expected to have a life expectancy of at least 10 years. Thus, appropriate patient selection requires accurate tumor staging as well as an assessment of patient comorbidity.

Despite its well-recognized limitations, digital rectal examination (DRE) remains the standard method for assessing tumor extent within the prostate, though DRE often understages palpable tumors. Large, palpable tumors frequently are found to have histologic evidence of extracapsular extension. Transrectal ultrasonography (TRUS) is the most commonly used imaging modality for prostate cancer. Typically, carcinoma of the prostate is identifiable as a hypoechoic area in the peripheral zone of the prostate. However, prospective studies have not shown the superiority of TRUS compared with DRE for staging the local extent of prostate cancer. The serum PSA level is useful in identifying patients with localized disease. In general, a serum PSA level >20 ng/ml is highly suspicious for extracapsular extension.

Radical prostatectomy usually is not indicated in patients who otherwise have a life expectancy less than 10 years. Although clinical carcinoma of the prostate is a progressive disease, the rate of tumor growth is such that competing causes of death dominate in elderly patients or those with poor overall health. Both chronologic as well as physiological age must be taken into account. Life table analysis indicates that most men less than 70 years of age with good overall health can anticipate at least 10 years of additional life.

ALTERNATIVE THERAPY

The term “watchful waiting” has been applied to a nonaggressive treatment approach that consists primarily of intermittent monitoring of disease status with institution of delayed hormonal therapy on evidence of symptomatic disease progression. This is probably the preferred approach in most men with less than 10 years of life expectancy. External beam irradiation is an alternative treatment for clinically localized prostate cancer. Five- and ten-year survival figures are comparable to those obtained with radical prostatectomy, but good comparative figures beyond that time range are not available. Concerns frequently are expressed about a high rate of positive biopsies after radiation therapy and the failure of the treatment to suppress serum PSA levels to the undetectable range. Interstitial brachytherapy using radioactive seeds was abandoned in most centers during the early to mid-1980s because of inferior results. More recent series use a perineal template with ultrasound guidance for seed implantation, but there are insufficient patient numbers and follow-up to draw conclusions about the merits of this approach. Cryotherapy is being explored as a treatment approach, but only short-term results are available.

Once radical prostatectomy is chosen, either a retropubic or perineal approach is most often used. The advantages of a retropubic approach are the opportunity to simultaneously inspect or sample pelvic lymph nodes, the potential for wide excision of periprostatic tissues, and a very low risk of rectal injury.

SURGICAL TECHNIQUE

Radical retropubic prostatectomy is performed at our medical center with the patient in a supine position and the table slightly flexed. We prefer a general anesthetic and have not observed any advantage for the use of epidural catheters. Invasive anesthetic monitoring such as central venous catheters or arterial lines are not used. A 20-Fr Foley catheter is inserted in the bladder after the field has been prepped and draped sterilely.

A midline incision is made from the umbilicus to the pubis. The anterior rectus fascia is incised, and then the rectus muscles are retracted laterally. Blunt and sharp dissection are used to mobilize the peritoneal envelope superiorly. Blunt finger dissection can help create a pocket directly over the psoas muscle and just lateral to the common iliac artery, which facilitates superior retraction of the peritoneum. The vas deferens is retracted along with the peritoneum. Care should be taken to make certain that the epigastric vessels are not injured beneath the belly of the rectus muscle during this maneuver.

We use a Bookwalter self-retaining retractor. An oval ring is used, and bladder blades retract the skin and rectus muscle at the inferior and lateral aspect of the incision. Deeper retractors at this point can result in femoral neuropathy or compression of the iliac vein. At the superior and lateral portion of the incision, a malleable blade is used to retract the peritoneum.

Placement of the retractors in this manner provides excellent exposure of the operative field. Pelvic lymph node dissection, is performed if the serum PSA level is greater than 20 ng/ml or the Gleason sum of the tumor grade is 7 or greater. Otherwise, the iliac and obturator lymph nodes simply are inspected for any evidence of enlargement or induration.

A sponge stick is used to displace the prostate and bladder medially. A Kittner dissector is used to remove some of the loose fat overlying the endopelvic fascia and to expose the junction between the lateral prostate and the levator ani muscle. Electrocautery is used to incise the endopelvic fascia overlying this space. A Kittner dissector then separates the levator muscle from the lateral margin of the prostate. If the incision is made too close to the prostate, bleeding from the overlying venous plexus can occur on the lateral margin of the prostate. Under these circumstances, it is best to place a suture of 3-0 Vicryl along the lateral prostate in order to gain hemostasis.

After the endopelvic fascia has been incised bilaterally, a sponge stick is used to depress the bladder posteriorly. The fatty tissue overlying the anterior prostate is carefully teased away using forceps and the sucker tip. This exposes the superficial dorsal vein. We prefer to control this vein separately from the deep dorsal vein complex. If the superficial dorsal vein is small, it can simply be cauterized and then divided. A larger vein is ligated with 3-0 Vicryl. Care must be taken in applying the ligature to the distal end of the vein, as it is quite friable and can be avulsed from the underside of the pubis.

After the superficial dorsal vein is divided, a Kittner dissector is used to define the puboprostatic ligaments. These usually are evident as a distinct white ligamentous structure. Often, there is some adherent levator muscular tissue just lateral to the puboprostatic ligament, and this sometimes contains a small vein. A right-angle clamp passed just lateral to the puboprostatic ligament can define this tissue well and allow it to be dissected from the lateral prostatic apex using electrocautery.

It is important to define the puboprostatic ligaments precisely, as described above. This allows them to be divided with Metzenbaum scissors with little risk of bleeding. Also, this minimizes injury to the anterior sphincter mechanism. After the puboprostatic ligaments are divided, the anterior portion of the prostatic apex falls away partially from the pubic bone.

The deep dorsal vein complex runs parallel to the urethra at the prostatic apex and then fans out over the anterior of the prostate. We feel that it is important to control these vessels preemptively rather than simply to incise them and place sutures afterward. A McDougal clamp is useful for this purpose. The dorsal vein complex can be pinched partially off from the anterior urethra with the thumb and forefinger of the left hand, and the jaws of the McDougal clamp passed just anterior to the urethra. Bleeding is rare during this maneuver if the anatomic structures are carefully dissected and defined. Spreading the jaws of the clamp should be avoided so as not to injure the anterior sphincter mechanism. A #1 Vicryl ligature is then tied around the dorsal vein complex. The McDougal clamp is then passed through the same space again and held in position while a 2-0 Vicryl suture on an SH needle is passed through the center of the dorsal vein complex just distal to the previous ligature. After the anterior portion of this stick suture is tied, the McDougal clamp is used to pull the end of the suture around the posterior aspect of the dorsal vein complex, which is then controlled further by tying the two suture ends. Back bleeding is prevented by placing a 0 Vicryl suture on a CT 1 needle through the veins of the dorsal vein complex, where they fan out over the anterior prostate. Grasping the lateral margins of the veins with an Allis clamp helps to bunch them in the middle and facilitates placement of this hemostatic suture. The McDougal clamp is once again passed through the previously defined space. Electrocautery is then used to divide the dorsal vein complex just proximal to the 0 Vicryl ligature placed earlier. Sometimes this ligature becomes displaced during this process, but the backup 2-0 Vicryl fixed suture maintains hemostasis. As the electrocautery is used, the McDougal clamp is gently lifted to displace the electrical energy away from the sphincter muscle. This entire technique usually allows total hemostasis during division of the dorsal vein complex, and no additional hemostatic sutures generally are required.

At this point, the anterior sphincter muscle should be untouched and the prostatic apex and membranous urethra visible. Metzenbaum scissors are then used to incise directly over the anterior portion of the membranous urethra just at the prostatic apex. The Foley catheter is identified and withdrawn through the partially severed urethra after the injection port and connector end have been cut off. The Foley catheter is not used for traction, as this can injure the urinary sphincter complex or cavernous nerve. The posterior portion of the urethra is divided under direct vision using Metzenbaum scissors.

The sequence of the next maneuver depends on whether or not a nerve-sparing approach for potency preservation is to be used. If nerve sparing is attempted, a right-angle clamp is used to lift the thin reflection of the endopelvic fascia onto the lateral margin of the prostate. This is incised with a knife up to the level of the prostatic pedicle. A Kittner dissector is then used to displace this fascial leaf posterolaterally. This carries with it the blood vessels and nerves that can be displaced from the lateral margin of the prostate. Small bleeding vessels that may be encountered during this maneuver are usually left alone at this point to avoid injury to the neurovascular complex. After the neurovascular bundle has been satisfactorily displaced from the prostate, the layer of fascia and muscle tissue commonly termed the rectourethralis muscle is incised sharply. Excellent hemostasis is necessary in order to perform this maneuver under direct vision, which is highly preferable. Blunt finger dissection can then be used to develop the plane between the prostate and rectum, but it is important not to pull hard on the prostate. The remaining posterior attachment of the prostatic apex is divided sharply with Metzenbaum scissors immediately adjacent to the prostate.

If a nerve-sparing approach is not used, the incision in the rectourethralis muscle is performed without dissecting the neurovascular bundle from the lateral prostate. The plane between the prostate and rectum is developed bluntly, and then the neurovascular bundle is excised widely at the prostatic apex by ligating it with 2-0 Vicryl sutures before incising it as widely as possible from the prostatic apex. However, even if a non-nerve-sparing approach is used, care should be taken to avoid excessive traction on the prostate, which could tear sphincter muscle tissue.

At this point, the table is placed in partial Trendelenberg position to allow better visualization of the posterior prostate, the seminal vesicles, and the prostatic pedicle. An incision is made through the posterior layer of Denonvillier’s fascia with electrocautery. This exposes the seminal vesicles and ampulla of the vas deferens. A right-angle clamp can then be placed just lateral to the seminal vesicle and around virtually the entire prostatic vascular pedicle. Care should be taken to avoid going too far cephalad with the right-angle clamp, as this can cause bleeding in some of the veins in the perivesical fat. A 2-0 Vicryl suture is used to ligate the prostatic pedicle. Because it is difficult to place two ties far enough apart to allow an incision between them, we usually simply use electrocautery to incise the tissue on the prostate side of a single tie. Small back bleeders from the prostate can then be controlled individually with the electrocautery.

Complete division of the prostatic pedicle greatly facilitates visualization and dissection of the seminal vesicles. A right-angle clamp is passed around the ampulla of the vas deferens just medial to the seminal vesicle. The ampulla is divided with the electrocautery, and the proximal end of the vas deferens is clamped with the right angle. This can then be used for traction in dissecting the medial edge of the seminal vesicle with the electrocautery. A right-angle clamp is then passed around the seminal vesicle and used to help dissect the surrounding tissue down to the tip of the seminal vesicle. The artery to the seminal vesicle enters at the tip and usually can be coagulated with an electrocautery after it is individually identified. We prefer not to use clips at any point in the procedure, as these have been known to migrate through the urethrovesical anastomosis.

After both seminal vesicles have been divided, they are lifted superiorly to expose the junction between the posterior prostate and the bladder neck. This is developed partially with electrocautery, and any remaining lateral attachments are also taken down with electrocautery. This should provide good definition of the bladder neck so that the electrocautery can then be used to incise anteriorly. If the bladder neck is well defined, identification of the ureteral orifices is not necessary before the removal of the surgical specimen is completed by dividing the remainder of the bladder neck attachments. However, if there is a question of tumor encroachment toward the bladder neck, a wider margin should be taken. Under these circumstances, it is best to visualize the bladder trigone before incising the posterior bladder neck. In rare circumstances, 5-Fr pediatric feeding tubes are passed up the ureteral orifices to facilitate their identification and preservation during the dissection.

After the surgical specimen is removed, careful hemostasis is obtained. If a potency-sparing approach is used, small bleeding vessels along the neurovascular bundle are left alone. Larger bleeding vessels near the bundle are controlled with a 4-0 chromic suture. Otherwise, virtually all other vessels are controlled with electrocautery. In order to identify bleeding vessels in the pelvis, any bleeding from around the genitourinary diaphragm is compressed with a sponge held in place with a small Deaver retractor. Often, if an anatomic dissection has been performed, bladder neck reconstruction is not required. Otherwise, 2-0 Vicryl sutures are placed in a posterior-to-anterior manner to close the bladder neck to the point where it just admits the tip of an index finger.

We have found a grooved urethral sound most useful for placement of the urethral anastomotic sutures. External perineal compression has been unnecessary, as the urethral stump generally is readily visible, and suture placement is not difficult. The operating surgeon uses the left hand to manipulate the urethral sound and the right hand to place the anastomotic sutures. We use five sutures spaced proportionately around the urethral circumference. The sutures on the patient’s left side are most easily placed outside to in and incorporate only the urethra. We use 2-0 Vicryl for the anastomosis and have a double-armed needle that allows inside-out placement of the sutures on the patient’s right. The sutures are then placed in a corresponding position in the bladder neck. We do not place mucosal eversion sutures before forming the anastomosis, but an Allis clamp placed anteriorly on the bladder neck can nicely evert the mucosa. A 20-Fr Foley catheter with a 5-cc balloon is passed through the anastomosis before placement of the most anterior sutures to prevent any tangling of the sutures that could result in catheter entrapment. The same style of clamps are always used to tag these sutures and avoid any confusion. For example, straight hemostats are used for the two most posterior sutures, curved hemostats for the two paired anterolateral sutures, and a Kocher clamp for the most anterior suture.

The Foley catheter balloon is inflated with 8 cc of water, and the table flexion is released. A sponge stick is used to displace the bladder medially so that the anastomotic sutures can be tied. After all of the sutures have been tied, the anastomosis is inspected both visually and manually to make certain that all of the ties have gone down completely and that there is no portion of the catheter either visible or palpable. Rarely, the anastomosis is not felt to be completely secure. Under these circumstances, we take down the anastomosis and redo it. Although this is painstaking, a secure anastomosis can help avoid long-term complications after the procedure.

We place a single Jackson–Pratt drain directly over the anastomosis and bring it out through a stab wound just lateral to the incision. The incision is closed with a running 1 Vicryl suture, and the skin is closed with a subcuticular 4-0 Vicryl suture.

OUTCOMES

Complications

When the aforementioned technique is used, intraoperative bleeding complications are unusual. Our median blood loss is less than 500 cc. We do not ask patients to donate autologous blood preoperatively, as our transfusion rate is less than 2%. Excessive drainage is extremely uncommon, and the Jackson–Pratt drain is removed on the second or third postoperative day.

Thromboembolic problems remain the most frequent cause of serious morbidity and occasional mortality after radical retropubic prostatectomy. Clinically recognized deep venous thrombosis occurs in 3% to 5%, and pulmonary embolus in 1% to 3% of patients. Routine use of anticoagulants in the perioperative period diminishes the rate of thromboembolic complications but does introduce a risk of wound or operative site bleeding or hematoma. We use heparin prophylaxis in patients at a high risk for thromboembolism such as those with obesity or a history of deep venous thrombosis.

The most concerning long-term complications of radical prostatectomy are the possibilities of impotence or incontinence. The risk of impotence is directly related to patient age, potency status before surgery, and whether a nerve-sparing approach is used unilaterally or bilaterally. Over half of younger men undergoing a bilateral nerve-sparing approach can anticipate the return of erections suitable for intercourse postoperatively. Incontinence requiring further treatment occurs in around 2% of patients, but up to 15% to 20% of patients have at least occasional episodes of stress incontinence.

Results

We have designed and implemented a collaborative care pathway for patients undergoing radical retropubic prostatectomy. The target date for hospital discharge is the second or third postoperative day. Ninety-four percent of our patients have accomplished this goal with no apparent adverse effect on morbidity. This is, however, but one factor in overall hospital charges. Operating room charges constitute the major component of overall costs in patients undergoing radical retropubic prostatectomy. By addressing all aspects of perioperative care, we have diminished hospital charges and costs by over 40% through a collaborative care pathway.

After surgical removal of the entire prostate, the serum prostate-specific antigen level should be undetectable. The success with which this occurs depends on pathologic tumor stage. If the tumor is completely confined within the prostatic capsule and of low to intermediate grade, nearly 90% of patients have an undetectable PSA, which apparently translates into long-term cure. As with any surgical procedure, the success of radical retropubic prostatectomy depends on appropriate patient selection and careful attention to anatomic detail and surgical technique.

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