The craft of urologic surgery: modern radical perineal prostatectomy

Gasless robotic perineal radical prostatectomy: An initial experience

Radical prostatectomy (RP) is the gold standard treatment method of localized prostate cancer. Today, this surgery is performed with open or minimally invasive methods. The history of open perineal RP (RPP) is very old, but it is not often preferred by urologists. The use of robot-assisted laparoscopic RP (RALP) is very frequently applied today. Robotic perineal RP (r-RPP) by using a Gel-Point and insufflating CO₂ into the perineal region was first described in 2014. In this case report, we report a 68-year-old patient with localized prostate cancer in whom we successfully performed gasless r-RPP, and according to our knowledge, this is the first case of gasless r-RPP to be reported.

Radical perineal prostatectomy: Our initial experience

OBJECTIVE

Radical prostatectomy is the standard treatment modality for localized prostate cancer. Minimally invasive surgery, especially robotic surgery, has attracted interest in the last 10 years, and open surgery has been less preferred. Among the open surgical procedures, the perineal approach is the least preferred by urologists, which may be related to their perception of its overall difficulty. In this study, we aimed to present our initial experience with learning and performing radical perineal prostatectomy (RPP) and to draw attention to this method.

MATERIAL AND METHODS

After a short training period between November 2011 and May 2013, RPP was performed on 9 patients with localized prostate cancer. The patients were evaluated as for medical, and perioperative and major postoperative complications.

RESULTS

The mean age of the patients was 60.4±5.3 (50-68) years, the mean preoperative prostate-specific antigen (PSA) value was 5.8±1.3 (4.0-7.6) ng/mL and the mean prostate volume was 38.8±7.7 (28-54) cc. The biopsy Gleason score ranged from 5 to 7. The median follow-up period was 14 (3-30) months. Anastomotic stricture did not occur in any of the patients. Of the 9 patients, 4 (44%) were immediately continent after catheter removal, while the remaining patients were continent at the end of three months. Of the 7 patients who underwent nerve-sparing surgery, 2 had postoperative spontaneous erections. Erectile function was maintained with phosphodiesterase 5 (PDE-5) inhibitor treatment in 3, and with intracavernosal injection in 1 patient. Penile prosthesis implantation was performed in 1 patient.

CONCLUSION

RPP has been a promising procedure at the start with its favorable oncologic and functional outcomes. This method should be considered by urologists, although it has been previously perceived as a challenging surgical procedure to perform.

Contemporary radical prostatectomy

Purpose. Patients diagnosed with clinically localized prostate cancer have more surgical treatment options than in the past. This paper focuses on the procedures' oncological or functional outcomes and perioperative morbidities of radical retropubic prostatectomy, radical perineal prostatectomy, and robotic-assisted laparoscopic radical prostatectomy. Materials and Methods. A MEDLINE/PubMed search of the literature on radical prostatectomy and other new management options was performed. Results. Compared to the open procedures, robotic-assisted radical prostatectomy has no confirmed significant difference in most literatures besides less blood loss and blood transfusion. Nerve sparing is a safe means of preserving potency on well-selected patients undergoing radical prostatectomy. Positive surgical margin rates of radical prostatectomy affect the recurrence and survival of prostate cancer. The urinary and sexual function outcomes have been vastly improved. Neoadjuvant treatment only affects the rate of positive surgical margin. Adjuvant therapy can delay and reduce the risk of recurrence and improve the survival of the high risk prostate cancer. Conclusions. For the majority of patients with organ-confined prostate cancer, radical prostatectomy remains a most effective approach. Radical perineal prostatectomy remains a viable approach for patients with morbid obesity, prior pelvic surgery, or prior pelvic radiation. Robot-assisted laparoscopic prostatectomy (RALP) has become popular among surgeons but has not yet become the firmly established standard of care. Long-term data have confirmed the efficacy of radical retropubic prostatectomy with disease control rates and cancer-specific survival rates.

Apical soft tissue biopsies predict biochemical failure in radical perineal prostatectomy patients with apical cancer involvement

The aim of the study was to prospectively assess the role of apical soft tissue biopsies in radical perineal prostatectomy (RPP) patients with documented apical prostate cancer (PCA) involvement. Between June 1998 and May 1999, 77 consecutive men with localized PCA and documented invasion of the prostatic apex underwent RPP by a single surgeon. Soft tissue biopsies were systematically obtained from the prostatic fossa overlying the apex at the time of surgery. Time to biochemical failure was calculated using the Kaplan-Meier method. The rates of positive apical margins and positive apical soft tissue biopsies were 23.4% (18/77) and 15.6% (12/77). The sensitivity, specificity and positive predictive value of positive apical margins for residual apical disease as determined by apical soft tissue biopsy were 41.7, 80, and 28%, respectively. The overall biochemical failure rate was 28.6% (22/77) with a median follow-up of 51 months (range 3-73 months). The 36-month biochemical recurrence-free survival rate was 55.9+/-14.9% for patients with positive apical biopsies and 78.7+/-5.3% for those with negative biopsies (P=0.023). In conclusion, positive apical soft tissue biopsy is an independent predictor of biochemical failure in patients with apical PCA who undergo RPP. Positive apical surgical margins poorly predict residual apical disease that is frequently identifiable by apical soft tissue biopsy. Apical soft tissue biopsies should therefore be obtained in patients with known extensive apical cancer involvement at the time of RPP.