RADICAL PROSTATECTOMY

Radical (total) prostatectomy (RP) is excision of the entire prostate, including the prostatic urethra, with the seminal vesicles. It may be performed by open retropubic, perineal, or laparoscopic approaches. The perineal approach does not allow a simultaneous pelvic lymph node dissection. Following excision of the prostate, reconstruction of the bladder neck and vesico-urethral anastomosis completes the procedure.
RP is indicated for the treatment of fit men with localized prostate cancer whose life expectancy exceeds 10 years, with curative intent. It is not considered to be an appropriate treatment for locally advanced disease. Patients with Gleason score 2 - 4 disease appear to do as well with WW as with any other treatment. The patient should consider all available treatment options and the complications of RP prior to proceeding. The surgeon should take part in multidisciplinary team discussion of each case; there may be local guidelines on age and upper PSA cut-off for offering RP, perhaps 70 years and 20ng/ml respectively.

Stages in the open retropubic procedure
- The patient is under anaesthetic, catheterized, and positioned supine with the middle of the table broken to open up the entry to the pelvis.
- Through a lower midline incision, staying extraperitoneal, the retropubic space is opened.
- Obturator fossa lymphadenectomy is undertaken if the PSA >10 or the Gleason score ≥7.
- Incisions in the endopelvic fascia on either side allow access to the prostatic apex and membranous urethra.
- Division and haemostatic control of the dorsal vein complex passing under the pubic arch allows access to the membranous urethra, which is divided at the prostatic apex.
- The prostate is mobilized retrogradely from apex to base, taking Denonvilliers fascia on its posterior surface.
- If cavernous nerve sparing is undertaken, the apical and posterior dissection is modified.
- Denonvilliers fascia is incised at the prostatic base, allowing access to the vasa (divided) and seminal vesicles (excised).
- The bladder neck is divided, thereby freeing the prostate.
- The bladder neck is reconstructed to the approximate diameter of the membranous urethra.
- A sutured vesico-urethral anastomosis is stented by a urethral catheter, typically for 2 weeks.
- The wound is closed leaving pelvic drains, typically for 48h.

The nerve-sparing modification aims to reduce the risk of post-operative erectile dysfunction. The surgeon seeks to minimize injury to the cavernosal nerves passing from the autonomic pelvic plexus on either side in the groove between prostate and rectum, during mobilization of the prostate. This should not be attempted in the presence of palpable disease as it may compromise cancer control. The tips of the seminal vesicles may also be spared in cases with low risk of cancer involvement, potentially reducing bleeding and cavernosal nerve injury.

Post-operative course after radical prostatectomy: complications
- Day 1: mobilize; check FBC; C&E; transfuse if required; antimicrobials; physiotherapy if required.
- Day 2: free fluids and diet; remove drains if possible; teach catheter care; encourage bowel.
- Day 3 - 4: home with catheter and instructions.
Catheter time varies between 7 and 21 days; a cystogram is required only if there has been a documented urine leak or other catheter problem.

Complications of radical prostatectomy
General complications (rare)
Those of any major surgery: bleeding requiring re-operation and/or transfusion, infection, thromboembolism, and cardiac disturbance. These are minimized by attention to haemostasis, prophylactic antimicrobials, pneumatic calf compression, low-dose heparin post-operatively, and early mobilization. Chest infection may be prevented by physiotherapy and encouragement of deep breathing, especially in smokers. Post-operative death is estimated to occur in 1 in 500 cases.

Specific complications early
- Per-operative obturator nerve, ureteric, or rectal injury (all rare): these should be managed immediately if recognized end-to-end nerve anastomosis; ureteric re-implantation; primary rectal closure with or without a loop colostomy.
- Post-operative catheter displacement (rare): managed with careful replacement if within 48h, while later urethrography may reveal no anastomotic leak.
- Post-operative urine or lymphatic leak (distinguished by dipstick glycosuria or creatinine concentration) through drains (occasional): managed by prolonged catheter and wound drainage; lymphatic leaks may require sclerotherapy with tetracycline.

Specific complications late
- Erectile dysfunction (ED) affects 70 - 90% of patients; spontaneous erections may return up to 3 years post-operatively. Men >65 years or with pre-existing ED are more likely to suffer long term. 40 - 70% respond to oral PDE5 inhibitors at 6 months, while others require intraurethral or intracavernosal prostaglandin E1 treatments, a vacuum device, or (rarely) a prosthesis.
- Incontinence (stress-type) requiring >1 pad/day affects 5% of patients beyond 6 months; this is due to injury of the external urethral sphincter during division and haemostatic control of the dorsal vein complex. Predisposing factors include age >65 years and excessive bleeding. Pre-operative teaching of pelvic floor exercises helps to regain continence; periurethral bulking injections or implantation of an artificial urinary sphincter are occasionally necessary. Incontinence may also develop secondary to bladder neck stenosis or detrusor instability; flow rates, post-void residual measurement, urodynamics, and cystoscopy may help.
- Bladder neck stenosis affects 5 - 8% of patients; typically occurs 2 - 6 months post-operatively, rarely becoming a recurrent problem. Predisposing factors include heavy bleeding, post-operative urinary leak, and previous TURP. Patients complain of new voiding difficulties and treatment is by endoscopic bladder neck incision.

Prostate cancer control with radical prostatectomy
While no randomized studies exist comparing RP outcomes to those of radiotherapy, a randomized study comparing RP to WW has demonstrated a 50% reduction in death due to prostate cancer and a 66% reduction in metastatic progression in the RP group with a mean follow-up of only 6 years.3 High-grade cancers were excluded from this trial, though non-randomized data suggest more patients with Gleason 7 - 10 localized disease survive 10 years following RP than with WW or radiotherapy.
Excellent long-term results are seen in well-selected patients following RP, particularly those with organ-confined disease and prior lower urinary tract symptoms due to bladder outflow obstruction. Serum PSA is measured a few days after RP, then 6-monthly; it should fall to <0.1ng/ml. The 10-year PSA progression rate following RP (usually defined as a serum PSA >0.2 ng/ml) is about 30%. Of these, 80% will fail within 3 years of RP. Without additional treatment, the time to development of clinical disease after PSA progression averages 8 years.4 A 20-year clinical disease-free survival of 60% is reported.5 Outcome correlates with: Gleason score; pre-operative PSA; pathological T stage; and surgical margin status. Various tissue markers, none yet used routinely, may also predict PSA progression, including aberrant immunohistochemical expression of the p53 tumour suppressor gene in the biopsy or RP specimen.
Neoadjuvant hormone therapy (hormone therapy given 3 months prior to RP) does not alter the PSA progression rate, despite apparently reducing the incidence of positive surgical margins.

Management of biochemical relapse post-RP
The definition of rising PSA is controversial, though most agree >0.2ng/ml.
DRE should be performed in case there is a nodule. Biopsy of the vesicourethral anastomosis is not widely practised unless there is a palpable abnormality. Studies have shown that MRI and bone scans are rarely helpful in searching for metastatic disease unless the PSA is >7ng/ml.
Current management options include observation, pelvic radiotherapy, or hormone therapy. A good response to pelvic radiotherapy is likely if:
- the PSA rise is delayed >1 year
- the PSA doubles in >10 months
- the PSA is <1ng/ml
- the disease was low-grade and low-stage
- the radiation dose exceeds 64Gy

If the PSA never falls below 0.2, or it rises in the first year with a doubling time of less than 10 months, the response to pelvic radiotherapy is disappointing. It is likely in these circumstances that metastatic disease is present, and some form of hormone therapy is usually recommended. The choice is between non-steroidal anti-androgen monotherapy
(e.g. bicalutamide 150mg daily) or androgen deprivation by bilateral orchidectomy or LH-RH analogues. There are no comparative outcomes data, so discussion focuses on the side-effects. Most patients choose the anti-androgen, wishing to preserve physical and sexual capabilities.