Radical Perineal Prostatectomy

SAM D. GRAHAM JR.

THOMAS E. KEANE

Radical perineal prostatectomy, first performed in 1869 by Buchler and popularized in the United States by Young in 1903, remained the primary surgical approach to carcinoma of the prostate into the mid-1970s. With the recognition of the importance of assessing advanced (nodal) disease preoperatively, which if positive would halt the operative procedure, and the advantage that retropubic prostatectomy offered with the concomitant pelvic node dissection, perineal prostatectomy declined in popularity for the treatment of prostate cancer. The perineal approach, however, saw a resurgence in the 1990s for several reasons: (a) the trend toward minimally invasive surgery with a focus on reducing the morbidity and therefore hospital stay of patients, (b) the advent of laparoscopic surgery for lymph node assessment, (c) the introduction of prostate-specific antigen (PSA) for screening for prostate cancer with reduction in the numbers of patients with nodepositive disease, (d) algorithms that may predict patients at high risk for positive lymph nodes, and (e) increased recognition of similar results compared to all other methods of radical prostatectomy. The procedure is also associated with reduced blood loss and low morbidity, and it can be modified to incorporate the neurovascular-sparing techniques for preservation of potency.

DIAGNOSIS

All patients who are potential candidates for radical perineal prostatectomy should undergo appropriate preoperative staging to ensure that they are operable candidates; preoperative imaging is rarely required in low- to intermediate-risk patients. Methods of differentiating local versus advanced disease include digital rectal examination, transrectal ultrasonography, radionuclide bone scan, assessment of pelvic lymph nodes, and
pathologic indicators of progression such as Gleason sum and other markers.

PSA screening has made a significant impact on the preoperative stage of patients with prostate cancer. Patients presenting for surgery are generally younger, healthier, and more likely to have organ-confined prostate cancer than the population treated prior to PSA introduction, and in many ways, this attributes to the large increase in the number of radical prostatectomies done in the United States in the PSA era.

Digital rectal examination has a limited role in the clinical staging of prostate cancer. It is primarily used to crudely estimate the volume of the cancer. Transrectal ultrasonography is another modality that also has limitations in assessing local disease, but combined with digital rectal examination, it at least gives some gross assessment of the likelihood of extracapsular disease. Other modalities, such as fused-transrectal ultrasound and magnetic resonance imaging (MRI), computerized tomography (CT) scan, and pelvic MRI, have been shown to have limited usefulness. The new generation of MRI scanners and ProstaScint scanning using fusion technology with CT or MRI have the potential to improve prostate cancer staging. Radionuclide bone scans are useful in assessing advanced bone disease but generally are not positive in patients with PSAs below 20 and no other sign of advanced disease.

For the past 20 years, we have prospectively provided data that has been applied to an algorithm for the preoperative assessment of patients with prostate cancer developed through data on over 400 patients who had undergone pelvic node dissection. The current algorithm includes patients with a Gleason sum of 7, providing that the predominant pattern is 3, a low-volume cancer (T1b-c, T2a), and PSA of <10 ng per mL. Patients meeting all of these criteria have a <5% chance of positive lymph nodes, and therefore, we do not routinely perform pelvic lymph node dissections (1). Patients exceeding any one of the previously described criteria are considered to be in the high-risk group and have undergone pelvic lymph node dissections. Using this method of assessment, our overall PSA recurrence rate from 1986 to 1993 was 24%. This compares favorably to other series of retropubic prostatectomies from that time in which all patients had a node dissection; in those series, PSA recurrence rates were between 24% and 28% (2,3,4,5).

INDICATIONS FOR SURGERY

Patients who are candidates for radical prostatectomy must have clinically organ-confined prostate cancer (T1-2). Other factors that need to be taken into consideration are the patient’s life expectancy, other comorbidities, or any other factors that may affect the patient’s choice. We generally do not offer a radical prostatectomy to patients who have a <10-year expectancy. Over the age of 70, we offer a radical prostatectomy only in selected cases where we feel that the benefits that can be obtained from radical prostatectomy outweigh the potential risks, particularly when compared to alternative therapies.

ALTERNATIVE THERAPY

Alternatives to perineal prostatectomy include retropubic and laparoscopic or robot-assisted laparoscopic prostatectomies. The retropubic approach allows simultaneous node dissection and removal of prostate glands, although the length of hospitalization and immediate postoperative morbidity are higher in our institution. The robotically assisted laparoscopic approach allows some improvement in visualization compared to the retropubic or laparoscopic surgeries due to the magnification and three-dimensional visualization, but it has yet to show any significant advantages in terms of operative morbidity, length of stay, or reduction in long-term morbidity. There are few if any large comparisons with radical perineal prostatectomy, although results to date indicate that no significant differences exist.

Alternatives to radical prostatectomy include observation, active surveillance (AS), hormonal deprivation, and radiation therapy. Although we do not consider either observation or hormonal deprivation to be curative, these are good options only for patients with less than a 5-year life expectancy, patients who are >70 years old with a well-differentiated cancer, and patients who are at high risk for surgery and refuse radiation. Radiation therapy, however, may be definitive and has a 5- to 10-year survival rate equivalent to that of surgery. The recurrence rates with radiation therapy are bimodal, with initial recurrences within 1 to 2 years of treatment and a delayed peak at 5 to 7 years after treatment. The recognition that many low-risk cancers (low volume 3/3 Gleason grade) have a minimal risk of prostate cancer death or progression has led to the introduction of AS for many patients who would previously have chosen intervention. If the patient is young with a 15-year or longer outlook and has significant disease, we feel that our results would favor radical prostatectomy.

SURGICAL TECHNIQUE

The patient is placed in an exaggerated lithotomy position (Fig. 32.1). It is important that the patient’s perineum be parallel to the floor because this directly affects exposure. We use a
standard operating room table with seven folded sheets under the patient’s sacrum supporting the patient’s entire weight. Shoulder braces are not recommended, and if a patient tends to slide off the sheets, we will place the table in a slight reverse Trendelenburg position. The patient’s legs are stabilized using candy cane or Allen stirrups, again taking precautions to prevent stretching the hamstring or causing pressure on the legs. Prior to putting the patient in position, the legs are wrapped with ACE bandages.

FIGURE 32.1 Positioning of the patient requires the perineum to be parallel to the floor. The sacrum supports the patient’s weight, and the legs are positioned with no traction on the hamstrings. No shoulder braces are indicated.

Four instruments are significant in assisting the surgeon for this operation. These include the Lowsley curved tractor, the Young straight prostatic tractor, a Halogen head lamp, and an Omni-Tract Mini Wishbone retractor system. The curved Lowsley tractor is used to bring the prostate up into the perineum to allow dissection against the prostate while mobilizing the rectum from the prostate. The straight Young tractor is used to manipulate the prostate laterally as well as cephalad and caudad after the membranous urethra has been divided. The Halogen head lamp is important because it allows the surgeon to aim a strong light into the operative field, which may be too deep and narrow for standard operating lights to adequately illuminate the structures. The Omni-Tract Mini Wishbone allows virtually unlimited retraction in any direction. We have developed a posterior weighted speculum that is compatible with the Omni-Tract (Fig. 32.2). A further option is the harmonic scalpel, which allows coagulation and closure of vessels without transmission of electrical current, thereby reducing the risks to the neurovascular bundles.

It should be noted that in manipulating the prostate within the pelvis, the pelvis should be viewed as a cone with the apex of the cone being the incision (Fig. 32.3). To achieve better visualization, it is sometimes necessary to actually push the prostate further into the pelvis. Also note that traction is not placed directly on the bulb or membranous urethra, as this will decrease the likelihood of restoration of potency and potentially affect the patient’s continence postoperatively.

The incision is made from the ischial tuberosity crossing the midline at the juncture between the squamous epithelium and the mucocutaneous border of the rectum (Fig. 32.4). The incision extends posteriorly to a line equal to the posterior portion of the anus. Using sharp dissection and electrocautery, the ischiorectal fossae are entered, and using blunt dissection, the central perineal tendon is identified and transected with electrocautery. At this point, we employ the Belt approach, dissecting down to the white fascia of the rectum and proceeding subsphincterically (Fig. 32.5). A transsphincteric or suprasphincteric approach is also an option. Using predominantly careful dissection with an index finger in the rectum, the rectal sphincter and levator ani sling can be dissected free of the rectum with minimal bleeding (Fig. 32.6). The blades from the Mini Wishbone retractor are then used to retract these muscles anteriorly and laterally. With tension on these muscles and tension on the rectum, the rectourethralis is identified and divided, allowing the surgeon to dissect the rectum free of the apex of the prostate (Fig. 32.7). The assistant presses down on the handle of the Lowsley curved tractor, which elevates the prostate into the wound and facilitates mobilization of the rectum off the prostate.

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