RADICAL PERINEAL PROSTATECTOMY IN THE ERA OF LAPAROSCOPIC SURGERY

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RADICAL PERINEAL PROSTATECTOMY IN THE ERA OF
LAPAROSCOPIC SURGERY

• Moshe Shalev MD
• Meir Medical Center
• Kfar-Saba
• ISRAEL

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INTRODUCTION

• T. Billroth was the first to describe the
  technique of perineal prostatectomy for the
  treatment of prostate cancer in 1867.
• At that time most of the procedure was performed
  blindly.

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INTRODUCTION

• Young performed the first radical perineal
  prostatectomy under direct visualization in 1904
  after developing the Young retractor and the
  perineal table.

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INTRODUCTION

• In 1945 Millin popularized the technique of RRP
  but the significant blood loss associated with
  this approach discouraged many from its use.
• RPP and RRP fell out of order with the advent of
  radiation therapy in the early 1960s
• Walsh in 1979 described the modified RRP
  technique which includes early ligation of the
  dorsal vein to reduce blood loss and the
  preservation of the cavernosal nerves to preserve
  potency leading to wide acceptance of this
  procedure.
• Weldons adaptation of the anatomical RRP to RPP
  in the late 1980s.

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INTRODUCTION

• In the recent years the concept of minimally
  invasive surgery with short hospitalization and
  less morbidity has been advanced with the
  introduction of laparoscopic radical
  prostatectomy.

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Reassessment of modern radical perineal
prostatectomy

• The focus on minimally invasive approaches
  invites a reassessment of the perineal approach
  to radical prostatectomy, as it is
• a) less invasive than the laparoscopic
  approach b) requires less
  operative time
• c) requires less disposable equipment
• d) has a significantly shorter learning curve
• e) as opposed to laparoscopy, long term data
  on
• outcomes are available.

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ADVANTAGES OF RADICAL PERINEAL PROSTATECTOMY OVER
RRP AND LAP. PROSTATECTOMY

• In obese patients
• In patients with previous pelvic surgery
• In patients after meshed hernia repair
• After renal transplantation
• After pelvic/abdominal vascular bypass grafts.
• In salvage prostatectomy after irradiation

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CONSIDERATIONS IN PATIENT SELECTION

• Morbid obese patients may not tolerate the
  exaggerated lithotomy position
• Depth of patients perineum
• Distance between the patients ischial
  tuberosities
• Very large prostates
• Hip ankylosis, severely limited hip mobility and
  lower extremity amputations
• Severe hemorrhoids (?)

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OPERATIVE TECHNIQUE

• Patient is placed in an exaggerated lithotomy
  position

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OPERATIVE TECHNIQUE

• Lowsely prostatic retractor is placed into the
  bladder and the wings are opened.

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OPERATIVE TECHNIQUE

• A semilunar incision is made inside the ischial
  tuberosities with the apex located 1-3cm anterior
  to the anal verge.

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OPERATIVE TECHNIQUE

• Rectal mobilization
• Division of the rectourethralis muscle

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OPERATIVE TECHNIQUE

• Thompson perineal retractor can be placed
• Space is developed to the base of the prostate

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OPERATIVE TECHNIQUE

• At this point the decision to proceed with nerve
  sparing versus wide dissection must be made.
  
• BUT
• THE DEVILS ADVOCATES SAY THAT IT IS IMPOSSIBLE
  TO SPARE THE CAVERNOSAL NERVES WITH THE PERINEAL
  APPROACH.
• REALLY?!!!

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?????? ????? ?? ?...... !!!
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NERVE SPARING

• A vertical incision should be made to mobilize
  the neurovascular bundles within the Denonvillier
  fascia laterally.

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NERVE SPARING

• The neurovascular bundles must be mobilized at
  least 1cm over the membranous urethra and
  sufficiently proximal to the base of the
  prostate.

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WIDE DISSECTION

• The fascia is opened transversely at the level of
  the membranous urethra and the base of the
  prostate.

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CLOSURE
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COMPLICATIONS
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RPP SPECIFIC COMPLICATION
21- for 2-3 days 0- in modern series Lower extremity neuropraxia
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INTRAOPERATIVE COMPLICATIONS
ROBOTIC LAP. LAP RPP RRP Type
0.5 0 0 Bowel injury
- 1.4 1 1 Rectal injury
0.6 0 0 Ureteral injury
Zincke 2004
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POSTOPERATIVE COMPLICATIONS
ROBOTIC LAP LAP RPP RRP Type
- 2 0 0.2 Lymphorrhea
- 3.6 1 2.7 Anastomotic stricture
0.5 0.6 0 1.3 Thromboembolic events
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OVERALL COMPLICATIONS
ROBOTIC LAP. LAP. RPP RRP
5 15-10 2 9.1
Catalona, J Urol 172 2227-31, 2004 Holzbeierlein,
Urol Clin Nor Am 31 629-41, 2004 Zincke, Mayo
Clin Proc 79 1169-80, 2004
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BLOOD LOSS
Robotic Lap. LAP. RPP RRP Studies
- - 170-800 700-1400 Lance 2001, Boxer 1977, Frazier 1992, Haab 1994, Boccon-Gibod 1998
153 - - 910 Tewari 2003
326 TP 370 EP 438 - - Zincke 2004
lt100 380 500 900 Catalona 2004
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OPERATIVE TIME
Robotic lap. Lap. RPP RRP Study
140 min 248 min 150min 164 min Catalona 2004
332 min TP 257 min EP 204 min - - Zincke 2004
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HOSPITALIZATION DAYS
ROBOTIC LAP LAP. RPP RRP Study
1.2 1.3 1.5 3.5 Catalona 2004
- - 8 outpts.basis 84 - 1 d. - Davis 1998
- - 82 - 1 d. - Parra 2000
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POSTOPERATIVE SOLID ORAL INTAKE
ROBOTIC LAP. LAP. RPP RRP Study
- - Postop day 1 - Weizer 2003
- Postop day 2 - Postop day 2 Arai 2003
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OUTCOMES
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POSITIVE MARGINS
ROBOTIC LAP. LAP. RPP RRP STUDY
- - NO STATISTICALLY SIGNIFICANT DIFFERENCE NO STATISTICALLY SIGNIFICANT DIFFERENCE Frazier 1992 Haab 1994 Lance 2001
- 18,9 13,9 18,9 Salomon 2003
5 24 10 24 Catalona 2004
17.8 TP 21.6 EP 23.2 - - Zincke 2004
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INCONTINENCE
ROBOTIC LAP. LAP. RPP RRP STUDY
- - NO STATISTICALLY SIGNIFICANT DIFFERENCE (8-12) NO STATISTICALLY SIGNIFICANT DIFFERENCE (8-12) Lance 2001, Boxer 1977, Frazier 1992, Haab 1994,
- - 5 - Weldon 2003
- - - 7 Catalona 2004
32 TP 13.6 EP 23.6 - - Zincke 2004
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POTENCY
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ERECTILE FUNCTION
ROBOTIC LAP. LAP. RPP RRP STUDY
- - NO STATISTICALLY SIGNIFICANT DIFFERENCE NO STATISTICALLY SIGNIFICANT DIFFERENCE Lance 2001
- - - 77 Frazier 1992
- - 70 unilat. 68 - Weldon 1998
- - - 75 unilat. 53 Catalona 2004
NOT REPORTED TP 59 EP 49.3 - - Zincke 2004
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DISEASE CONTROL

• When patients are matched for preoperative data
  including PSA level the biochemical recurrence
  rate for RRP and RPP are not significantly
  different.

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3-year recurrence free survival in Pts. with PSA
less than 10 ng/ml
LAP RPP RRP STUDY
86.2 89.2 89.3 Salomon 2002
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LEARNING CURVE

• RRP and RPP 15- 20
• LAP 80-90

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SUMMARY

• Modern radical perineal prostatectomy is a
  minimally invasive procedure that offers all of
  the advantages of surgical removal of the
  cancerous prostate with the least morbidity and
  the least cost.
• RPP is the optimal approach for obese patients,
  pts. with prior pelvic surgery or pelvic
  radiation.

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THANK YOU !!!