Radical Retropubic Prostatectomy

Introduction

The concept of removal of the entire prostate to treat prostate cancer was first introduced by Irish urologist Dr Terence Millin in the late 1940s. The procedure did not develop widespread popularity until Dr Patrick Walsh performed detailed studies of the anatomy relating to the procedure and popularized the nerve-sparing open radical retropubic prostatectomy in the early 1980s. This dramatically improved outcomes with decreased blood loss and improved continence and erectile function. Traditionally considered the “gold standard,” the open radical prostatectomy (ORP) has been replaced by the robotic-assisted laparoscopic radical prostatectomy (RALP) as the most common surgical approach to treat localized prostate cancer based on 2008 data that began to specifically identify robotic assistance. Pure laparoscopic radical prostatectomy is still performed at a very limited number of centers. Open radical prostatectomy using the perineal approach is described in Chapter 37 and is less commonly used today.

RALP presents the major alternative approach to radical prostatectomy (RP) today and is discussed in Chapter 43 : “The technique of robotic nerve sparing prostatectomy.” In experienced hands the outcomes appear to be very similar between ORP and RALP with the exception of increased blood loss with the open technique and higher overall cost using the robot. Clinical pathways and improved perioperative management strategies guiding patient and spousal expectations have limited the previous significant differences in length of hospitalization, pain management, and recovery thus minimizing the initial marketing advantages of the RALP technique. The evidence surrounding RALP generally supports shorter hospitalization but lacks conclusive evidence that the robotic approach results in earlier return to physical activity or improved disease-specific outcomes. Schroeck et al. also found that patients who underwent RALP had higher expectations concerning erectile function return than did their radical retropubic prostatectomy counterparts. Furthermore, patients may decide on the experience of the surgeon over the technology in their decision to undergo open prostatectomy. For men 65 years of age and older, RALP and ORP had similar rates of complications based on a SEER data analysis. RALP and ORP have comparable rates of complications and additional cancer therapies, even in the RALP postdissemination era. Again in this study, RALP was associated with lower risk of blood transfusions and a slightly shorter length of stay, but the benefits did not translate to a decrease in cost.

There is ongoing conflict concerning outcome measures, such as potency and urinary continence, when comparing the RALP with ORP. Oncologic follow-up for robotically assisted laparoscopic radical prostatectomy and open radical prostatectomy appears to be similar. Variations in measurement and reporting of postoperative outcomes continue to make direct comparisons difficult. Clinical trials are unlikely to answer this question; a prospective randomized trial comparing RALP versus ORP at the Mayo Clinic was closed due to slow enrollment.

There is a wide spectrum of treatments for localized prostate cancer. The management decision takes into account tumor characteristics, patient characteristics and preferences of the patient and surgeon. It is essential that the patient be actively engaged in discussions of the risks and benefits of the various approaches that may include active treatment such as surgical removal of the prostate or some form of radiation therapy or less aggressive approaches such as active surveillance. At the Kimmel Cancer Center of Thomas Jefferson University we established a multidisciplinary clinic in 1996. This provides the opportunity for men and their families to be evaluated by all GU specialists including urology, radiation oncology, and medical oncology in one session, allowing a thorough discussion of all treatment options including active treatment with surgery or radiation, active surveillance, or investigational protocols. This clinic design is becoming commonplace in other centers.

Indications and contraindications

The traditional indications for RP have included men with organ-confined disease and a greater than 10 year life expectancy. There has been a shift toward lower-stage tumors and men are generally younger at the time of diagnosis and more interested in preserving sexual function. The European Association of Urology (EAU) has stated that radical prostatectomy is contraindicated with a high risk of extracapsular disease. The 2014 National Comprehensive Cancer Network (NCCN) guidelines state that RP is appropriate for any cancer that is clinically localized and can be completely excised, with a life expectancy of >10 years and no serious comorbid conditions that would contraindicate an elective surgical procedure.

However, the concept of cytoreductive radical prostatectomy in the setting of locally advanced or metastatic disease has recently gained interest. The majority of the data are retrospective in nature suggesting that patients with metastatic prostate cancer who had prior radical prostatectomy had a better survival and improved response to systemic therapy. The ECOG trial headed by Messing suggests excellent long-term (>10 years) survival in men undergoing ORP in the setting of positive nodes and immediate androgen deprivation. Cytoreductive RP is an evolving concept that is not yet supported by any guideline. Salvage RP is an option for highly selected men following local recurrence after radiation or cryotherapy; however, the morbidity can be significant.

There are some patients who are not ideal for RALP who may be better served with an open technique. Some relative contraindications and limitations of RALP described in the literature are noted here. While these may also present challenges to open surgery, these are generally considered more easily managed using open techniques.

• Obesity (BMI >30 kg/m ² ): may distort anatomy and may present difficulty tolerating the steep Trendelenburg position used in RALP.

• Prior abdominal surgery with extensive adhesions or history or ruptured viscera/peritonitis.

• Previous radiation or hormonal therapy.

• History of transurethral or suprapubic prostatectomy.

• Large-volume prostate (>60 g), large median or lateral lobes.

• Narrow pelvis.

Operative technique