Open Radical Retropubic Prostatectomy

Open Radical Retropubic Prostatectomy



Until the last decade, open radical retropubic prostatectomy (RRP) had become the surgical procedure of choice to effect cure in men with clinically localized prostate cancer and a life expectancy that rendered them at risk of death from their cancer (1). In appropriately selected patients, total removal of the prostate gland with preservation of neurovascular bundles, where appropriate offers a high rate of cure of the cancer. In those men with risk factors suggesting a chance of microscopic breach of the prostatic capsule by the cancer, wider excision without neurovascular bundle (NVB) preservation is more appropriate. If other risk factors for disease progression are present, RRP should be combined with concomitant excision of pelvic lymph nodes.

Walsh and Donker (2) pioneered the anatomic understanding of the prostate and its surrounding structure, which allows us now to understand the nuances of a complex procedure where the surgeon is attempting to cure a cancer but retain both urinary and sexual function where possible. In order to perform this operation, the surgeon must have a mastery of this anatomy, including the periprostatic fascia, the position of the NVB, and the structure of the distal urethral sphincter mechanism. Subsequent modifications of the technique, which will be described in this chapter, have allowed improved visualization of the structures, improved hemostasis, and preservation of the anatomy while margin positivity rates have reduced (3).

The open retropubic approach for this procedure remains in common usage around the world, although in many Western countries, RRP is rapidly being superseded by laparoscopic or robot-assisted techniques. This chapter describes the open RRP operation and is based on our cumulative experience of >2,000 cases and the collective experience in the urologic literature.


Preoperative counseling for RRP is vitally important as men will have temporary and occasionally permanent effects on sexual and urinary function postoperatively. We recommend that this process occur over several visits to allow for an informed and participatory discussion between surgeon and the patient and his family. For men to be satisfied with their treatment decision, a thorough and informed consent is critical.

Given the low rate of rectal injury and lack of strong evidence favoring improved outcomes with mechanical bowel preparation, we do not routinely use bowel preparation except
for an enema in certain clinical scenarios, namely, salvage surgery following radiation, brachytherapy, and high-intensity focused ultrasound or after previous rectal surgery (6). In the preoperative holding area, prophylactic antibiotics are started prior to incision. For prophylaxis against thromboembolism, we use a regimen of elastic compression stockings, sequential pneumatic compression devices, and subcutaneous heparin (5,000 units) prior to induction of the anesthesia and throughout the postoperative period until patients are routinely ambulating (typically postoperative day 1).

FIGURE 31.1 A and B: Positioning of the patient. Legs are separated on spreader bars. The operating table is flexed with the break just above the patient’s anterosuperior iliac spine. (Adapted with permission from Han M, Catalona WJ. Ch. 29, Anatomic nerve-sparing radical retropubic prostatectomy. Urol Oncol 2005;514-527. Copyright © 2005 Elsevier Inc. All rights reserved.)

Patients are positioned supine on the operating room table with mild dorsiflexion with the break positioned just above the anterosuperior iliac spine to open the pelvis and improve access and visualization of the retropubic space. The patient’s legs may be positioned on spreader bars to facilitate a second surgical assistant (Fig. 31.1). Typically, RRP is performed with general anesthesia, but some advocate for the use of epidural or spinal anesthesia (7). With the increasing adoption of minimally invasive approaches to radical prostatectomy with their shorter lengths of stay and postoperative narcotic requirements, proponents of RRP have incorporated more aggressive use of non-narcotic anesthesia (standing Tylenol and Toradol) and local anesthetic techniques (e.g., transabdominal plane [TAP] block) to reduce postoperative opiate use and facilitate early mobilization and discharge.



Classically, an 8- to 10-cm lower midline incision is used. This allows access to the extraperitoneal retropubic space and the pelvic lymph nodes. The incision should commence over the superior aspect of the pubic bone and travel cranially. The skin and subcutaneous fat is incised and the rectus sheath opened along the linea alba. To facilitate identification of the linea alba, a retractor can be used at the apex of the incision with cranial retraction; the linea alba can then easily be palpated. The recti muscles can be parted in the midline with blunt dissection to create an extraperitoneal space which can give excellent access to the retropubic space of Retzius. Typically, the insertion of the recti abdominis muscles are divided with electrocautery to their attachment to the pubis. Blunt dissection is again performed to free the perivesical and periprostatic alveolar tissue from the pelvic side wall, and the external iliac artery and vein should be visualized bilaterally. A self-retaining retractor of appropriate size should be used; we prefer the Balfour or Bookwalter retractor for this incision.

It is possible to perform this operation through a standard Pfannenstiel incision although a randomized controlled trial did not demonstrate significant differences in need for postoperative analgesia and time to recovery compared with a standard vertical laparotomy (8). The Pfannenstiel incision may restrict access to the immediate retropubic space and make lymphadenectomy more difficult, although it allows for concomitant inguinal hernia repair.

Pelvic Lymphadenectomy (If Indicated)

Current National Comprehensive Cancer Network (NCCN) guidelines recommend the performance of pelvic lymph dissection in men with a predicted probability of lymph node metastasis greater than or equal to 2% (9).

The decision to perform standard versus extended pelvic lymph node dissection remains primarily driven by surgeon preference because the number of lymph nodes resected does not appear to affect disease-specific survival in men without positive nodes (10). In addition, a conversation should occur preoperatively with the patient with high-risk disease about his preferences regarding prostatectomy in the event that positive lymph nodes are found; if the patient would elect to forgo prostatectomy in the setting of metastatic disease, the pelvic lymph nodes should be sent for frozen section.

The surgical template for extended pelvic lymph node dissection extends from the bifurcation of the common iliac artery superiorly, the femoral canal inferiorly, and the obturator nerve and vessels and the hypogastric artery posteriorly. The standard template differs by exclusion of the lymphatic tissue overlying the hypogastric artery. Only those lymph nodes medial to the hypogastric vein should be removed and arterial branches from the external iliac, and obturator arteries should be preserved as these may supply the corpora cavernosa. Care should be taken to clearly identify, preserve, and avoid excessive traction to the obturator nerve.

Identification and Preparation of the Prostate

An often underrated step is the removal of fat and areolar tissue from the anterior surface and apex of the prostate in order to facilitate precise identification of relevant anatomy. This is best achieved by the use of a combination of blunt dissection with a peanut swab and limited use of electrocautery superficially when veins are encountered from prostatic apex to the bladder neck.

Incision of the Endopelvic Fascia

The endopelvic fascia is incised sharply or with electrocautery in the groove between the levator ani muscles and the lateral border of the prostate (Fig. 31.2). This groove can be clearly visualized with medial retraction of the prostate using a sponge stick. Inside the fascia, the lateral surface of the prostate is covered by a smooth membrane overlying the lateral portion of the Santorini plexus. Strands of the levator ani muscles are gently dissected off the prostate to the level of the urogenital diaphragm using a peanut swab. There is often a small vein just lateral to the puboprostatic ligaments, and this should be cauterized adjacent to the prostate. The endopelvic fascia should be opened from the apex to the base of the prostate, taking care to avoid the deeper veins of the DVC. There is often debate whether the puboprostatic ligaments should be divided or preserved at this point. If the decision is made to divide the puboprostatic ligaments, they should be divided close to the pubis to facilitate access to the dorsal vein complex (DVC) (Fig. 31.3).

Ligation of the Dorsal Vein Complex

The DVC and urethra can be gently retracted medially allowing access to the plane between DVC and urethra. If the DVC is difficult to access, an atraumatic clamp such as a Babcock or Allis may be used to grasp the DVC (but not the urethra). Lifting this clamp anteriorly will open the space between DVC and urethra, facilitating subsequent suture placement. The fibers of the striated distal urethral sphincter should be observed wrapping around the urethra as part of the complex. A 2-0 absorbable suture on a CT-1 needle is typically used to suture ligate the DVC (Fig. 31.4). The needle should be pushed straight through the notch between the DVC and urethra as distally as can be placed and rotated only after the needle tip emerges on the opposite side. A simple ligation will usually suffice, but some surgeons advocate a figure-of-eight suture for control of a broader DVC or improved hemostasis. Occasionally, it may be useful to pass the needle through the periosteum of the posterior pubis just anterior to the DVC. If the suture is then tied, it will both control the DVC and anchor it to the periosteum, facilitating underrunning of any bleeding points after transection. A 3-0 absorbable suture on a 5/8 or UR needle is an excellent tool for dealing with bleeding in this area.
A second caudal (Fig. 31.4) or “back-bleeding” suture on the anterior surface of the prostate (Fig. 31.5) may be used and is often best applied in a running inverted V over the anterior surface of the prostate for hemostasis. Once ligated, the DVC should be divided initially with a curved dissecting scissors, electrocautery, or scalpel (Fig. 31.6), allowing the curve to guide over the apex to the urethra just distal to the prostate. Lateral dissection around the urethra should be kept to a minimum to avoid the NVB at this point.

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Apr 24, 2020 | Posted by in UROLOGY | Comments Off on Open Radical Retropubic Prostatectomy
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