RADICAL PROSTATECTOMY
Category: Urology
Abstract : 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 anastomosi
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.
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