Relative advantages and disadvantages of radical perineal prostatectomy versus radical retropubic prostatectomy

The evolution and resurgence of perineal prostatectomy in the robotic surgical era

PURPOSE

To review the recent advances in terms of surgical technique and new robotic platforms applied to radical perineal prostatectomy (RPP).

METHODS

A literature review was performed focusing on original articles on perineal prostatectomy searching via Medline/Pubmed and Embase. The entire spectrum was covered such as development of surgical technique including pelvic lymphadenectomy, adoption of novel surgical platforms, learning curve and future directions.

RESULTS

Surgical removal of the prostate plays a significant role on the treatment of localized prostate cancer (PCa). RPP was the first surgical approach described for radical prostatectomy. This technique declined in popularity secondary to the development of the retropubic approach. Recently, the appearance of novel robotic technology has generated renewed interest in the perineal approach.

CONCLUSION

There has been a recent resurgence on the interest of radical perineal prostatectomy for the treatment of localized PCa driven by the advent of new robotic surgical technologies into the field. Future studies are needed to better determine the learning curve of the perineal approach and its current role in the treatment of prostate cancer.

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.

Comparative analysis of radical prostatectomy techniques using perineal or suprapubic approach in the treatment of localized prostate cancer

OBJECTIVE

To compare the results of radical prostatectomy by perineal and suprapubic approaches as to operative time, procedure costs, and surgical site complications.

METHODS

The medical records of localized prostate cancer patients (PSA ≤ 10 ng/ml and Gleason score ≤ 6) were analyzed. Fifty-five patients were submitted to radical prostatectomy by perineal approach and 54 via suprapubic approach.

RESULTS

There were statistical differences between groups as to operative time (p < 0.05); for perineal approach it was in average 114 minutes (SD ± 0.03) and for suprapubic approach, an average of 167 minutes (SD ± 0.041). Prostatectomy via perineal approach resulted in 11 cases of surgical complications, and suprapubic approach, 3 cases.

CONCLUSIONS

Radical prostatectomy via perineal approach took less time at a lower cost as compared to the suprapubic approach. However, there were more complications in patients submitted to perineal approach, mainly rectal lesions.

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.

Radical perineal prostatectomy - the contemporary resurgence of a genuinely minimally invasive procedure: Procedure outline. Comparison of the advantages, disadvantages, and outcomes of different surgical techniques of treating organ-confined prostate cancer (PCa). A literature review with special focus on perineal prostatectomy

INTRODUCTION

Surgery plays a central role in the management of organ-confined prostate cancer (PCa). Four types of prostatectomy are currently practiced: perineal, retropubic, laparoscopic, and robot-assisted. The qualification criteria for all types are similar. Radical perineal prostatectomy (RPP) was the first method introduced into clinical practice, however, it has been neglected in favor of other procedures. Its resurgence has been facilitated by a multitude of advantages. Unfortunately, nowadays most urologists are not familiar with the perineal approach though many centers have begun to implement it.

MATERIALS AND METHODS

This manuscript presents the technique of RPP used in the author's institution. It also reviews a vast body of literature on the four techniques of prostatectomy including their advantages and outcomes. The data was collected from the literature and medical databases.

CONCLUSION

RPP proves to be a very efficacious, cost-effective treatment option for localized PCa. The outcomes of RPP, as defined by continence, potency, and complication rate, are equivalent to those accomplished by other methods.

A single-institution comparison between radical perineal and radical retropubic prostatectomy on perioperative and pathological outcomes for obese men: an analysis of the Duke Prostate Center database

OBJECTIVES

To examine the association between body mass index (BMI) and operative time, estimated blood loss (EBL), and adverse pathologic features in patients undergoing either radical perineal prostatectomy (RPP) or radical retropubic prostatectomy (RRP).

METHODS

We performed a retrospective analysis of 1006 patients treated with RPP or RRP at our institution from 1988 to 2005. Operative times and EBL were compared among BMI groups for both RPP and RRP. The odds ratio of positive surgical margins was estimated for the BMI categories using logistic regression after adjusting for preoperative and pathologic characteristics.

RESULTS

Increased BMI was significantly associated with increased operative time and EBL for men treated with either RPP or RRP (all P < or = 0.03), though the associations were weak (all Spearman r < or = 0.19). After adjusting for multiple clinical preoperative characteristics, higher BMI was associated with positive surgical margins among all patients (P trend <0.001). The association between obesity and surgical margins remained after adjusting for pathologic characteristics (P trend = 0.001) with similar patterns among RRP (P trend = 0.03) and RPP (P trend = 0.01) patients.

CONCLUSIONS

For mildly obese men, both RPP and RRP are associated with a similarly increased risk of higher EBL, longer operative time, and positive surgical margins. These data do not provide evidence to suggest that RPP should be preferred over RRP for mildly obese men. Further study is needed among men with a very high BMI.

Impact of nerve sparing technique on patient self-assessed outcomes after radical perineal prostatectomy

PURPOSE

We investigated the impact of nerve sparing technique on erectile function, urinary continence and health related quality of life after radical perineal prostatectomy using a validated self-assessment questionnaire.

MATERIALS AND METHODS

The Expanded Prostate Cancer Index Composite questionnaire was administered preoperatively and at defined intervals after surgery to 265 patients who underwent radical perineal prostatectomy at 2 institutions between January 2001 and December 2004. Of these patients 153 (57.7%) and 112 (42.3%) underwent nonnerve sparing and nerve sparing approaches, respectively. Kaplan-Meier analysis was used to determine time to recovery of erectile function (erections firm enough for intercourse) and urinary continence (0 pads per day).

RESULTS

Median patient age was 60.6 years. Median followup was 15 months. In multivariate analysis preoperative erectile function (p = 0.005) and preservation of the neurovascular bundle (p = 0.018) were independent predictors of earlier recovery of erectile function, with hazard ratios of 2.3 (95% CI 1.2-4.6) and 4.0 (95% CI 1.5-10.3), respectively. Median time to recovery of urinary continence was 4.8 months in the nerve sparing group and 6.1 months in the nonnerve sparing group (p = 0.001). In multivariate analysis nerve sparing technique (p = 0.001, HR 1.4, 95% CI 1.1-1.9) and age (p = 0.012, HR 1.7, 95% CI 1.3-2.2) were independent predictors of recovery of continence.

CONCLUSIONS

This analysis suggests that nerve sparing radical perineal prostatectomy is associated with improved recovery of urinary continence and favorable health related quality of life scores and, therefore, should be considered a viable alternative to other nerve sparing approaches.

Retropubic versus perineal radical prostatectomy in early prostate cancer: eight-year experience

BACKGROUND

Prostate cancer is the most common malignancy in men and the second leading cause of cancer death. A randomized study was performed on patients with localized prostate cancer and treated with radical prostatectomy using the perineal or the retropubic approach comparing oncological outcomes, cancer control, and functional results.

STUDY DESIGN

Between 1997 and 2004, in a randomized study 200 patients underwent a radical prostatectomy performed by retropubic (100 patients) or perineal (100 patients) approach.

RESULTS

Differences between hospital stay, duration of catheter drainage, intraoperative blood loss, and transfusion requirements were statistically significant in favor of perineal prostatectomy. Differences between positive surgical margins and urinary continence in the two groups were not statistically significant at 6 and 24 months. Differences between erectile function at 24 months were statistically significant in favor of retropubic prostatectomy.

CONCLUSIONS

Radical perineal prostatectomy is an excellent alternative approach for radical surgery in the treatment of early prostate cancer.

Radical perineal prostatectomy for treatment of localized prostate cancer in obese and nonobese patients: A matched control study

OBJECTIVES

To compare the perioperative outcomes of severely obese and nonobese patients undergoing radical perineal prostatectomy (RPP).

METHODS

A cohort of 71 severely obese patients, as defined by a body mass index of 35 kg/m2 or more, who underwent RPP between 1992 and 2003 was retrospectively identified. These patients were matched by age, American Society of Anesthesiologists class, and year of surgery to a cohort of 71 nonobese patients (body mass index less than 25 kg/m2). Statistical testing was performed to compare the estimated blood loss, transfusion requirements, and complication rates (primary endpoints), as well as the length of surgery, intraoperative anesthesia requirements, postoperative hematocrit level, length of stay, and surgical margin status (secondary endpoints).

RESULTS

The mean body mass index +/- standard deviation of patients in the obese and nonobese group was 38.9 +/- 4.7 and 22.9 +/- 1.6 kg/m2 (P = 0.001), respectively. Patients were similar with regard to baseline characteristics. Obese and nonobese patients did not demonstrate significant differences in mean estimated blood loss (571 +/- 391 and 494 +/- 317 mL, respectively; P = 0.06), transfusion rates (2.8% and 7.0%, respectively; P = 0.45), or positive surgical margin rates (14.1% and 9.9%, respectively; P = 0.22). The overall complication rates were significantly different at 16.9% and 7.0% (P = 0.03).

CONCLUSIONS

Severely obese patients undergoing RPP had blood transfusion rates similar to those of the nonobese patients. Obese RPP patients were at increased risk of surgical and anesthesia-related perioperative complications, many of which might be avoidable. Specifically, efforts should be directed toward preventing the development of lower extremity neurapraxia by minimizing the operative time and optimizing patient positioning.

Diagnostik und Therapie des Prostatakarzinoms nach Nierentransplantation

The number of patients with prostate cancer and end-stage renal disease or prostate cancer following kidney transplantation has continuously increased in industrialized countries. According to the data generated by Penn et al. a higher incidence of prostate cancer following kidney transplantation can be seen but is probably due to a more intense screening of the recipients. It is rather a common opinion that no elevated risk of prostate cancer following kidney transplantation exists. In patients with strictly localized prostate cancer curative treatment should be the aim also after kidney transplantation. Kidney transplantation does not interfere with surgical access to the prostate gland (retropubic or perineal). Nonlocal tumors of the prostate should also be treated following the general recommendations regarding prostate cancer. Looking at the current literature, a reduction or change of immunosuppression seems reasonable. It is necessary to establish a nationwide (or even European) cancer register, especially for patients before and after transplantation.

Impact of radical perineal prostatectomy on urinary continence and quality of life: A longitudinal study of Japanese patients

AIM

We used self-completed questionnaires to obtain a longitudinal assessment of urinary continence and urinary, bowel, and sexual domain-related quality of life (QOL) in Japanese patients undergoing radical perineal prostatectomy (RPP).

METHODS

A total of 41 Japanese patients with a median age of 69 years who underwent RPP between February 2002 and February 2004 were included in the study. We measured QOL by the University of California, Los Angeles, Prostate Cancer Index (UCLA-PCI) and assessed urinary continence on the basis of three different definitions of continence. The International Prostate Symptom Score (I-PSS) was also included to evaluate lower urinary tract symptoms (LUTS).

RESULTS

When urinary continence was de fi ned as none, one, or two protective pads per day, 100%, 73%, 94%, 97%, or 100% of the patients were continent before, and 1, 3, 6, and 12 months after, RPP, respectively. When it was de fi ned as total control or occasional dribbling, the corresponding values were 97%, 70%, 84%, 94%, and 97%. Urinary function returned to the preoperative baseline level by 6 months postoperatively and scores for urinary bother had significantly surpassed the baseline by 12 months (P = 0.043). The I-PSS was significantly improved (P = 0.014), with a mean 4.7-unit decrease. Sexual function worsened significantly after surgery, and its recovery was less favorable. No significant change was observed in scores for bowel function or bowel bother.

CONCLUSIONS

The majority of patients who undergo RPP rapidly regain urinary continence and QOL within 3-6 months. RPP has a favorable impact on LUTS.

RADICAL PERINEAL PROSTATECTOMY FOR THE TREATMENT OF LOCALIZED PROSTATE CANCER IN MORBIDLY OBESE PATIENTS

PURPOSE

We assessed the feasibility of radical perineal prostatectomy (RPP) in morbidly obese patients with clinically organ confined prostate cancer.

MATERIALS AND METHODS

Of 1,265 consecutive patients who underwent RPP at our institution from 1992 to 2003 we identified 18 with a body mass index (BMI) of 40 kg/m or greater. Demographic and clinical patient characteristics were obtained from the medical records, which were further reviewed to identify the perioperative incidence of surgical and anesthesia related complications.

RESULTS

Median BMI was 41.7 kg/m (range 40.2 to 62.6). Five patients had a BMI of 45.0 kg/m or greater. No intraoperative or anesthesia related complication occurred. Mean operative time +/- SD was 188 +/- 32 minutes and estimated blood loss was 573 +/- 285 ml. None of the 18 patients received blood transfusions. During the immediate postoperative period 4 complications occurred in the form of lower extremity neuropraxia in 2 patients, local skin bleeding in 1 and early sepsis in 1 requiring rehospitalization for intravenous antibiotics. Mean operative time and estimated blood loss were significantly lower when surgery was performed by a highly experienced surgeon compared with experienced surgeons (174 +/- 21 vs 235 +/- 10 minutes and 485 +/- 258 vs 838 +/- 197 ml, p = 0.001 and 0.027, respectively).

CONCLUSIONS

RPP in morbidly obese patients is feasible and it is associated with acceptable perioperative morbidity. The perineal approach should be considered in morbidly obese patients seeking surgical treatment for clinically localized prostate cancer.

Histotopographic study of the rectourethralis muscle

Radical perineal prostatectomy, relative to retropubic prostatectomy, has become an increasingly used surgical technique for prostate cancer, following advances in laparoscopic methods for pelvic lymph node dissection. Recent protocols of risk stratification may even obviate the need for lymph node dissection. Section of the rectourethralis muscle (RUM) is necessary for access to the retroprostatic space, however, during this procedure rectal injuries may be produced. In this work, we studied the topography and morphology of the RUM, which, despite its importance in perineal surgery, has not been univocally described in the literature. After in situ formalin fixation, the pelvic viscera were removed from 16 male cadavers (age: 54-72 years) and from 4 full-term infants (gestational age: 37-38 weeks). Serial macrosections of the bladder base, prostate gland, and lower rectum cut in horizontal (6 adults and 2 infants) and sagittal (6 adults and 2 infants) planes underwent histological (hematoxylin and eosin, azan-Mallory, and Weigert's staining) and immunohistochemical (anti-smooth muscle actin and anti-sarcomeric actin) study. The remaining 4 adult specimens were cut in horizontal and sagittal planes and plastinated using the epoxy resin E12 sheet procedure. RUM was identified in 10 of 12 (83%) adult specimens and in 4 of 4 (100%) infant specimens. In both sagittal and transverse sections, it showed a triangular-shaped configuration. In all cases, at the level of its posterior portion, fibers continuing with the longitudinal muscular layer of the rectum were visible. In the majority of adult and infant cases, attachment of muscle fibers into the anterior wall of the anal canal was also observed. Anteriorly, the mean (+/-SD) distance between the RUM and the membranous urethra was 5.3 (+/-1.25) mm in adults and 1.0 (+/-0.41) mm in infants. Location of RUM in the prerectal space and the absence of urethral attachment makes the original name of this muscle, "prerectal," by Henle, more correct. In 7 of 10 (70%) adult cases and in 1 of 4 (25%) infant cases, muscle fibers were densely packed along the lateral portions of the RUM, while in its central portion connective tissue was prevalent, with sparse numbers of smooth muscle fibers. Immunohistochemical staining showed that this muscle consists almost entirely of smooth fibers. In all the infant specimens, the RUM was clearly separated from the levator ani, while in 8 of 10 (80%) adult cases, striated fibers of the levator ani and smooth fibers of the RUM intermingled. These structural associations suggest a functional cooperation between the two muscles, particularly in determining the anorectal flexure.

PROSPECTIVE AND LONGITUDINAL PATIENT SELF-ASSESSMENT OF HEALTH-RELATED QUALITY OF LIFE FOLLOWING RADICAL PERINEAL PROSTATECTOMY

PURPOSE

We provide a comprehensive, longitudinal assessment of health related quality of life (HRQOL) following radical perineal prostatectomy (RPP).

MATERIALS AND METHODS

We report the results of a prospective cohort study of 109 patients with at least 3 months of followup who underwent RPP between January 2001 and July 2003. A validated patient self-assessment questionnaire, the Expanded Prostate Cancer Index Composite, was administered preoperatively, and 1, 3, 6, 9, 12 and 18 months postoperatively. Mean domain specific HRQOL scores were calculated as well as the proportion of patients achieving an individual baseline by each interval. The Cox proportional hazards model was used to identify predictors of a successful return to baseline of disease specific HRQOL scores.

RESULTS

HRQOL scores were lowest 1 month postoperatively and they increased with time. By 6 months a majority of patients had recovered baseline summary scores in urinary (65.1%), bowel (93.6%) and hormonal (91.7%) domains at a median of 5.8 (95% CI 3.6 to 6.2), 1.3 (95% CI 1.1 to 1.5) and 1.3 (95% CI 1.2 to 1.8) months, respectively. One in 4 patients recovered the sexual summary score by 18 months. Significant independent predictors for the recovery of domain summary scores were younger age in urinary (p = 0.001), individual surgeon in bowel (p = 0.022), and older age (p = 0.017) and absent medical comorbidities (p = 0.012) in hormonal domains.

CONCLUSIONS

A majority of patients undergoing RRP experience an early recovery of individual urinary, bowel and hormonal HRQOL. Future studies should establish the benefit of bilateral nerve sparing RPP on the recovery of sexual domain HRQOL.

Cost comparison of radical retropubic and radical perineal prostatectomy: single institution experience

OBJECTIVES

To perform a detailed comparison of the in-house hospital costs of patients undergoing radical perineal prostatectomy (RPP) and radical retropubic prostatectomy (RRP) performed with or without bilateral staging lymph node dissection (BPLND) for localized prostate cancer.

METHODS

A retrospective cost review was done of a cohort of 402 consecutive radical prostatectomies performed at our institution during a 21-month period. The procedure was performed as RPP in 279 (69.4%) and RRP in 123 (30.6%) patients, of whom 10.4% and 61.8%, respectively, underwent BPLND under the same anesthesia. The hospital costs were evaluated for each patient using the categories of surgical, nursing, laboratory/transfusion, and pharmacy. Surgical costs were further subdivided into operating room, anesthesia, and recovery room costs. Univariate and multivariate statistical analyses were applied to identify predictors of procedure-related costs.

RESULTS

The median hospital costs of patients undergoing RPP (7195 dollars, range 5052 dollars to 36,237 dollars) were substantially lower than those of patients undergoing RRP (9757 dollars, range 6935 dollars to 27,771 dollars; P = 0.001). The median costs for patients undergoing radical prostatectomy without BPLND were significantly lower in the RPP (7100 dollars, range 5052 dollars to 28,604 dollars) versus RRP (9169 dollars, range 6935 dollars to 16,705 dollars) patients (P = 0.001). The costs for RPP with BPLND (10,048 dollars, range 7529 dollars to 36,237 dollars) versus RRP with BPLND (9973 dollars, range 7658 dollars to 27,771 dollars) were not significantly different (P = 0.900). Patient age and nerve-preservation status did not significantly influence the procedure-related hospital costs.

CONCLUSIONS

RPP may result in lower in-house costs per patient than RRP in those patients who do not require BPLND. Total hospital costs depend largely on the factors of operating room time, length of stay, and laboratory and transfusion requirements, which may vary among institutions.

When to diagnose and how to treat prostate cancer in the ‘not too fit’ elderly

The appropriate management of elderly patients diagnosed with prostate cancer remains controversial. In order to provide guidelines as to when aggressive local treatment may be indicated, we provide estimates of the long-term probability of death from prostate cancer and other competing causes in patients of 70 years of age or older, who underwent radical surgery in the form of radical perineal prostatectomy for clinically non-metastatic disease. In this study, a total of 484 patients with an age of 70 or above who underwent radical perineal prostatectomy between 1970 and 2000 comprised a retrospective cohort of patients with clinically organ confined prostate cancer. Of these patients, 461 patients (95.3%) had a minimum follow-up of half a year and were included in the analysis. The median age was 73 years (range 70-81 years) and the median follow-up was 5.4 years. Overall 115 men died during the follow-up period with 49.6% of deaths attributable to prostate cancer. The median time to cancer-associated death was 17.5 years and the median time to death of any cause 11.6 years. When the likelihood of death from prostate cancer as a function of Gleason score was estimated, the 10-year cancer-associated death rates of patients with Gleason scores of 2-6, 7 and 8-10, were 15.2, 25.2 and 40.2%, respectively. In the subset of patient with margin positive disease the estimated likelihood of a cancer-associated death was 45.3% after 10 years. While the median time to cancer-associated death for margin positive patients with a Gleason score of 2-6 was not reached, patients with a Gleason score of 7 and 8-10 experienced median cancer-associated survival times of 9.6 and 7.6 years, respectively. In conclusion, Gleason score is a strong predictor of the likelihood of prostate cancer related death in elderly patients. Patients with a given Gleason score and a projected life expectancy of at least 10 years may be at similar risk of dying of prostate cancer as younger patients.