The first modern radical perineal prostatectomy (RPP) for the treatment of prostate cancer was performed by Hugh Hampton Young in 1904. The technique was later modified in 1939 by Belt, who described an approach to the prostate posterior to the external anal sphincter. The technique was further modified by Hudson. Weldon and Tavel incorporated the nerve-sparing technique in 1988. The radical perineal prostatectomy in the modern day can serve as an important technique that continues to provide excellent long-term cancer control, low morbidity, short hospital stay, rapid convalescence, excellent cosmesis, and similar quality of life outcomes compared with radical retropubic prostatectomy and laparoscopic and robotic approaches. Pelvic lymphadenectomy can be performed immediately prior with little morbidity either retropubically or laparoscopically, if indicated.
Preoperative Preparation and Planning
Patients should undergo appropriate counseling regarding treatment of prostate cancer. Selection of surgical technique should be based on surgeon experience, disease and patient parameters, and shared decision making. Preoperative testing should at least include a urinalysis, complete blood count, and comprehensive metabolic panel. The rate of blood transfusion is very low, so a type and screen or type and cross is not necessary.
Although the likelihood of rectal injury is quite low in skilled hands, RPP requires extensive dissection in proximity to the rectal wall. Therefore, we recommend a mechanical bowel preparation and antibiotic prophylaxis. The patient administers a bowel preparation the day before the surgery and is placed on a clear liquid diet. The type of prep is per surgeon preference with magnesium citrate, polyethylene glycol, or phosphosoda. We use 10 oz of magnesium citrate on the day before surgery. Weight-appropriate cefazolin is administered intravenously on the day of surgery. In the setting of a cephalosporin allergy, intravenous gentamicin and vancomycin can be given.
In the preoperative suite, antithromboembolic surgical stockings (TED hose) and sequential compression devices are placed. Although regional or spinal anesthesia is an option, general anesthesia is optimal, preferred, and most commonly used.
Instruments and Equipment
The Yellofin stirrups (OR Direct, Acton, MA) are used for positioning on a standard operating room table, which allows for dorsal lithotomy positioning with rails for braces and securing self-retaining retractors. The following equipment and instruments should be included in the set: urology long and fine instruments, long Allis clamps, Young prostatic retractor and curved Lowsley retractor ( Fig. 77.1, A ), Thorek scissors and Hohenfellner clamp ( Fig. 77.1, B ), Young bifid retractor ( Fig. 77.1, C ), 20-Fr Silastic catheter, and 
Penrose drain. The authors use the Thompson retractor as seen in Fig. 77.9 (Thompson Surgical Instruments, Traverse City, MI). Others such as the Mini-Crescent (Omni-Tract Surgical, Minneapolis, MN) can also be used. 2-0 Monocryl double arm with UR-6 and SH is used for the anastomosis. Absorbable 2-0 sutures are used and described in more detail in the respective steps. The use of surgical magnification loupes and headlight is recommended.
Surgical Approach
Step 1: Positioning
After successful induction of anesthesia, the legs are secured in Yellofin stirrups, and the patient is placed into an exaggerated lithotomy position with the buttocks brought beyond the end of the table ( Fig. 77.2 ). The perineum is elevated using rolled blankets, essentially positioning the perineum parallel to the floor. All points of contact should be well padded. The arms should be abducted as little as possible to prevent nerve damage to the brachial plexus. Approximately 2 inches of the rail must be available at the end of the table for placement of a self-retaining retractor. Broad 3-in tape is attached to the stirrups and placed over the blankets to maintain the position. Furthermore, a loose belt can be placed across the abdomen to prevent patient migration.
The perineum and scrotum are shaved. The perineum, anus, thighs, penis, scrotum, and infraumbilical abdomen are scrubbed and painted with povidone–iodine paint. After sterile draping, the pole of the self-retaining retractor is secured to the rail at the end of the table. The bladder should be emptied with a catheter. A curved Lowsley tractor is inserted into the bladder, and the wings are opened, securing it in place.
Step 2: Incision
The ischial tuberosities are palpated and used as landmarks. Anterior to the anus, a curvilinear (inverted horseshoe) incision is made from a point medial to the right ischial tuberosity to a point medial to the left ischial tuberosity ( Fig. 77.3 ). The apex of the incision is located 2 cm from the anal verge; usually a color change in the skin denotes the proper location. The incision is extended posteriorly, staying lateral to the sphincter and continued to a point posterior to the anus. The incision should be kept medial to the tuberosities to keep the pressure off the incisions when the patient is sitting.
Step 3: Division of Central Tendon
The ischiorectal fossa is developed by making small bilateral incisions through the fascia at the superior aspect of each vertical arm of the incision. Each ischiorectal fossa is then further developed bluntly popping through the ischiorectal fascia with the index fingers directed inferiorly and perpendicular to the floor ( Fig. 77.4 ). The median raphe tissue is shown in a schematic form in Fig. 77.5, A , to help readers understand the central mechanism that has to be divided. Progressing the finger forward and cephalad along each side of the rectum, an index finger is passed through the median raphe beneath the central tendon ( Fig. 77.5, B ). If the fingers do not penetrate the tissue easily, adjusting posteriorly can help. The central tendon is then divided either sharply or with electrocautery. The rectum is then draped out of the surgical field by using four Allis clamps on the developed flap and attaching them to the surgical drape.
Step 4: Rectal Isolation and Mobilization
The Young approach enters anterior to the superficial and deep portions of the external anal sphincter. The Belt approach enters over the subcutaneous portion and then proceeds beneath the superficial and deep portions of the external anal sphincter. The Hudson approach stays anterior to the external anal sphincter and is a hybrid between the Belt and Young approaches. The approach of these techniques is shown in Fig. 77.6, A .
We prefer the Hudson technique as it allows us to dissect under the deep portions of the external anal sphincter and follow the longitudinal fibers of the rectum back to the prostate ( Fig. 77.6, B ). The rectal sphincter can be seen as an arch overlying the rectum. Dissection is performed between the longitudinal rectal fibers on the ventral aspect of the rectal wall and the external anal sphincter ( Fig. 77.7, A ). Bilateral spaces are created through the midportion of the sphincter with the remaining central tendon in the middle. This allows for the external anal sphincter to be elevated anteriorly using a Young bifid retractor ( Fig. 77.7, B ). Allis clamps are grasped in the palm of the nondominant hand with the index finger in the rectum allowing for posterior traction of the rectum. The remaining central tendon is then divided sharply using Metzenbaum scissors.
Step 5: Division of the Rectourethralis
The longitudinal fibers of the rectum are then followed to the rectourethralis muscle. The dissection is greatly facilitated by the index finger in the rectum to gauge the level of the dissection relative to the anterior rectal wall. The rectum is mobilized on both sides of the rectourethralis muscle bluntly to the level of the prostate apex. The rectourethralis can be variable ranging from few fibers to a well-developed fibromuscular structure. The rectourethralis muscle is exposed in the midline. The rectourethralis muscle tents the rectum anteriorly, and downward traction on the Lowsley further elevates the rectum and increases the chance of rectal injury during this step. Without any traction on the Lowsley tractor, the rectourethralis muscle is sharply divided with horizontally oriented scissors at its junction with the rectum ( Fig. 77.8 ). Blunt dissection of the rectourethralis will lead to rectal injury and therefore should not be performed. Care should be take not to divide this structure too far anteriorly because the bulbar urethra may be injured.
