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Radical Perineal Prostatectomy: Surgical Technique and Complications

Indications for Radical Prostatectomy

Radical prostatectomy (RPE) is the gold standard of curative therapy in patients with localized prostate cancer and a life expectancy of at least 10 years. For a detailed description of the surgical treatment indications and results, see:

• treatment options for localized prostate cancer
• prostatectomy for prostate cancer

A thorough pelvic lymphadenectomy cannot be performed via the perineal approach. Depending on the risk profile, pelvic lymphadenectomy is performed laparoscopically or omitted. Individual centers succeed in performing a limited staging lymphadenectomy via the perineal approach.

Contraindications to Retropubic Radical Prostatectomy

Absolute contraindications are uncorrected coagulation disorders and untreated urinary tract infections. Further contraindications depend on the surgical risk due to the comorbidity of the patient and the impact of prostatectomy on the life expectancy of the patient. Relative contraindications to perineal prostatectomy are a prostate size >100 ml, hip diseases, or spinal diseases that do not allow an exaggerated lithotomy position.

Surgical Technique of Perineal Radical Prostatectomy

Preoperative Patient Preparation

Timing of surgery:

A nerve-sparing prostatectomy should be performed no earlier than eight weeks after prostate biopsy and three months after TURP. The interval reduces adhesions between the prostate and neurovascular bundle.

Autologous blood donation:

There is no contraindication from an oncological point of view. Autologous blood donations are associated with substantial costs and, due to the low transfusion risk, are often unnecessary.

Bowel preparation:

The day before surgery, recommend a clear liquid diet and an enema before bedtime. Some authors recommend bowel preparation with, e.g., magnesium citrate.

Perioperative antibiotic prophylaxis:

Before skin incision, e.g., 2nd generation cephalosporin. See also section perioperative antibiotic prophylaxis.

Anesthesia:

General or spinal anesthesia.

Patient positioning:

Exaggerated lithotomy position, padding the pressure points is crucial. The perineum should be almost parallel to the floor. Proceed with skin disinfection and draping of the perineum, genitals, anus, thighs, and infraumbilical abdomen. A rectal shield allows access to the rectum during surgery.

Surgical Approach:

Use an arcuate skin incision from just right of the left ischial tuberosity to just left of the right ischial tuberosity (inverted horseshoe) with approximately 2 cm distance ventral to the anus. Clip the rectal shield to the dorsal wound margin. Insert a curved Lowsley retractor into the urinary bladder and open it. Use blunt finger dissection for the ischiorectal fossa on both sides. Undermine bluntly the superficial perineal muscles near the centrum tendineum until the index finger can pass under the midline ventral to the rectum. Transect the centrum tendineum.

Transsphincteric Hudson Approach:

The fibers of the sphincter ani externus muscle run in a horizontal direction. With blunt finger dissection, the transsphincteric approach finds the layer between the superficial and subcutaneous portions of the sphincter ani externus muscle. Sagittal fibers indicate the rectum. Alternatively, use the Young approach to the prostate and enter the layer between the prostate and the rectum ventrally to the sphincter fibers.

Dorsal Prostate Dissection:

Lower the Lowsley retractor to rotate the prostate, and the apex and urethra become readily palpable. Transect the rectourethral muscle at the apex of the prostate until the white surface of the Denonvilliers fascia appears. If the rectal anatomy is unclear, use rectal finger palpation for orientation. Blunt dissection separates the rectum from the Denonvilliers fascia. A sharp transection of the Denonvilliers fascia is necessary to expose the seminal vesicles at the base of the seminal vesicles. The neurovascular bundle is either transected or dissected laterally for a nerve-preserving approach. Use blunt dissection to separate the pelvic floor muscles from the lateral surface of the prostate.

Ventral Prostate Dissection:

Transect the urethra at the prostatic apex. Begin with the dorsal part of the membranous urethra, and take care to preserve the neurovascular bundle. Replace the curved Lowsley retractor with a straight one through the urethrotomy. Transect the ventral part of the urethra close to the apex. Use blunt dissection to separate the ventral/anterior surface of the prostate from the dorsal vein complex—control bleedings with suture ligatures in the direction of the symphysis. Transect the puboprostatic ligaments on both sides close to the prostate.

Dissection of the Bladder Neck:

A wide blunt dissection of the retropubic space is essential for sufficient mobilization of the bladder neck. Incise the ventral bladder neck and spread the incision with an overholt clamp. Exchange the Lowsley retractor for a bladder catheter, the catheter is passed out via the ventral cystotomy and clamped as a sling. Widen the bladder neck incision laterally with electrocoagulation or sharp dissection with scissors. Transect the dorsal bladder neck with right-angled scissors, this allows a dissection line perpendicular to the bladder trigone. After complete bladder neck dissection, the seminal vesicles and both vas are visible and mobilized. Transect the prostatic pedicles (lateral to the seminal vesicles) between ligatures or clips in several steps.

Vesicourethral Anastomosis:

Place ventral anastomotic sutures at the 10, 12, and 2 o'clock position. Close the bladder neck with a tennis racket suture. Complete the vesicourethral anastomosis with several dorsal anastomotic sutures.

Wound Closure:

• Irrigate the operative field and check for bleeding.
• Place two drains at the prostate pedicles on both sides.
• Re-approximate the perineal muscles and the subcutaneous perineal fascia with interrupted 2-0 sutures. Close the skin with interrupted sutures.

Technical Modifications:

Robot-assisted single-port endoscopic perineal prostatectomy has led to a resurgence of the perineal approach. This approach also allows diagnostic lymphadenectomy (Minafra et al., 2021).

Postoperative Care after Retropubic Radical Prostatectomy

• General measures: consider patient-controlled analgesia for pain management. Early mobilization, a ring cushion facilitates sitting. Thrombosis prophylaxis, laboratory tests (hemoglobin, creatinine), and regular physical examination of the incision wound.
• Diet advancement: a soft food diet is possible the day after surgery. Prescribe macrogol for stool softening.
• Drains and catheters: keep the drains for 1--2 days. In routine cases, the catheter stays for 7 days and cystography before removal is optional. Depending on the extent of bladder neck resection and reconstruction, extend the catheter stay to 10–14 days before the first cystography.

Complications of Perineal Radical Prostatectomy

Bleeding:

The possible complications are similar to radical retropubic prostatectomy. There is a trend toward fewer transfusions, faster convalescence, and less pain. Postoperative fecal incontinence is controversial in extent and comparison to radical prostatectomy. Fecal incontinence rates are surprisingly high in some series, 16% for perineal prostatectomy and 8% for retropubic prostatectomy (Bishoff et al., 1998); other studies did not find significant differences and lower figures.

References

Bishoff u.a. 1998 BISHOFF, J. T. ; MOTLEY, G. ; OPTENBERG, S. A.: Incidence of fecal and urinary incontinence following radical perineal and retropubic prostatectomy in a national population.
In: J Urol
160 (1998), S. 454458

Minafra P, Carbonara U, Vitarelli A, Lucarelli G, Battaglia M, Ditonno P. Robotic radical perineal prostatectomy: tradition and evolution in the robotic era. Curr Opin Urol. 2021 Jan;31(1):11-17. doi: 10.1097/MOU.0000000000000830. PMID: 33229862.

J. A. Smith, S. S. Howards, G. M. Preminger, and R. R. Dmochowski, Hinman’s Atlas of Urologic Surgery Revised Reprint. Elsevier, 2019.

  Deutsche Version: Technik und Komplikationen der perinealen radikalen Prostatektomie