The Common Vein Copyright 2010
Definition
The first radical prostatectomy was performed by Hugh Hampton Young in 1904, however due to the common complications of impotence and incontinence the procedure was not popular. As knowledge and technology improved so did the outcomes of surgery. This is the treatment of choice for removal of the prostate in men with organ confined disease and a life expectancy of more than 10 years.
There are four main ways to perform a radical prostatectomy:
1) Radical retropubic prostatectomy
2) Laparoscopic radical prostatectomy
3) Robotic assisted laparoscopic prostatectomy
4) Radical perineal prostatectomy
Indications
Radical prostatectomy is indicated in men who have disease that is confined to the prostate and with an estimatd life expectancy of greater than 10 years. Many surgeons will offer surgery to those 70 years old or younger. The most common approach is the retropubic approach, described below in detal. In recent years, Robotic-assisted laparoscopic techniques have come into favor. Perineal approach is often used in obese men.
Contraindications
Absolute contraindications include those for general anesthesia. Proven metastatic disease is a general contraindication as the surgery is unlikely to benefit.
Advantages
The major advantages of these procedures are prolonged life expectancy. Improvements in the understanding of pelvic surgical anatomy and of the relationship of the prostate to bladder sphincter anatomy have resulted in lower blood loss, decreased pain, and shorter hospital stays.
Disadvantages
Disadvantages of the surgery depend upon the technique and approach utilized. For example, the robotic approach makes the sampling of lymph nodes more difficult, and thus assessing the likelihood of distant metastases may be limited.
Aim
To remove the prostate and achieve local control of prostate cancer, including removal of fascia and at times the neurovascular bundle. Also important, is to complete a lymph node dissection to determine the likelihood of metastasis.
Preparation
Most surgeons wait 6 weeks after prostatic biopsy to perform a prostatectomy to allow for decrease in inflammation. Patient may be asked to be on a clear liquid diet prior to surgery and perform a bowel prep the day before.
Technique
Most surgeons prefer the retropubic approach to prostatectomy as it allows access to the pelvic lymph nodes for dissection. Also it allows for the prostate to be removed with the surrounding fascia. The procedure is performed through and infraumbilical incision. First the lymph node dissection takes place in the obturator space with the lateral margin of dissection being the pelvic wall and external iliac vein, the distal margin being the node of Cloquet and the proximal margin being the hypogastric vessels. The posterior margin is the obturator nerve within the pelvis. Next, the endopelvic fascia is defined by removing any fat from this structure, and a sharp incision is made in the endopelvic fascia just lateral to the capsular veins of the prostate. Now the prostate is able to be moved laterally. Next, attention is paid to the dorsal venous complex where sutures are placed to control bleeding. Next, the fascia covering the prostate is divided sharply, including division of the puboprostatic ligaments. The dorsal vein complex is then entered and oversewn. Next, the striated urethral sphincter and urethra are then divided just distal to the apex of the prostate. Care is taken to preserve urethral spinchter length. Next, the lateral prostatic fascia is divided just above the neurovascular bundle at the posterolateral level of the prostate, and the prostate is released from the neurovascular bundle starting at the apical level. The posterior prostate is then dissected from the rectum and Denonvilliers’ fascia is then incised just medial to the neurovascular bundle, freeing the bundle from the prostate. After the prostate is mobilized laterally, Denonvilliers’ fascia is incised over the level of the seminal vesicles allowing dissection along the seminal vesicles up laterally over the bladder. Next, the bladder is entered with care taken to avoid entry into the prostate. A midline dissection is then performed to isolate the vas deferens which are clipped and divided. The prostate can then be removed. Next the bladder is attached to the urethra with circumferential sutures in a tension free anastomosis.
Results
In general, with organ-confined disease, patients can expect to see a 10-year disease-free survival between 70-85%. Focal extension into the capsule correlates with 10-year disease free survival of 85%.
Complications
The major risk of the open prostatectomy are bleeding, incontinence, and impotence. Care with ligation of the dorsal venous complex will assist in decreasing blood loss. Incontinence and impotence rely heavily on preserving the neurovascular bundle. In some cases of impotence, recovery of secual function may occur in the 6-12 months following surgery. Bladder neck contracture occurs in between 2-6% of patients. Death is rare. Rectal is rare in the retropubic approach, but occurs more frequently in the perineal approach, and can usually be repared.