Radical Prostatectomy

Radical prostatectomy (RP; RPE) represents a urologic surgical technique in which radical surgery (complete removal) of the prostate including the capsule, seminal vesicles (vesiculae seminales), and regional lymph nodes is performed in the presence of localized prostate cancer. Thus, the advantage of radical prostatectomy is that a complete tumor removal is performed and thus a cure can be achieved. Various established surgical procedures are available for performing radical prostatectomy, which differ in surgical technique and surgical access route, but all lead in principle to complete removal of the diseased prostate.

Indications (areas of application)

  • Prostate carcinoma (prostate cancer) – radical prostatectomy, primarily the retropubic form (RRP), is used as the curative therapy of choice in patients with localized prostate carcinoma with a concurrent life expectancy of at least ten years. The use of radical prostatectomy is considered the gold standard because it is the only curative procedure that has been shown to result in lower mortality compared to conservative therapy in several high-quality randomized trials. Based on this, new therapeutic procedures are compared with the functional and oncological outcomes of radical prostatectomy.
  • Note: In patients with “very low risk,” i.e., tumor is at stage T1c, PSA concentration is less than 10 ng/mL, Gleason score is 6 or less in up to four positive biopsies with a total tumor length of 8 mm or less, there is a strong rationale for active surveillance. The strategy of active surveillance is now also propagated in the German S3 guideline.

Contraindications

Contraindications vary depending on the procedure used. Laparoscopy must not be performed in the presence of severe chronic lung disease, severe heart failure (cardiac insufficiency), peritonitis (inflammation of the peritoneum), ileus (intestinal obstruction), active bleeding, or a large aortic aneurysm (bulging of the aorta), otherwise the risk of mortality (risk of death) would increase significantly. In cases of markedly impaired general health, surgery should be avoided, if appropriate, because the risk of surgery may exceed the benefit.

Before surgery

  • Discontinuation of anticoagulants (anticoagulants) – discontinuation of blood-thinning medications such as acetylsalicylic acid (ASA) or Marcumar should be done in consultation with the treating physician. Discontinuing medication for a short period of time significantly minimizes the risk of postoperative bleeding or intraoperative hemorrhage without a significant increase in risk to the patient. If there are diseases that can affect the blood clotting system and these are known to the patient, this must be communicated to the attending physician.
  • Discontinuation of antidiabetic medications (medications used to treat diabetes mellitus) – Medications such as metformin should usually be discontinued at least 24 to 48 hours prior to surgery, as there is an increased risk of lactic acidosis (form of metabolic acidosis (metabolic acidosis) in which a drop in blood pH is caused by the accumulation of acidic lactate/lactic acid) due to the use of the medication during anesthesia.

The surgical procedures

  • Retropubic radical prostatectomy (RRP) – the retropubic approach represents the original route by means of incision in the lower abdomen. It is considered an important advantage of this surgical technique that a clear lymphadenectomy (lymph node removal) is possible. However, an important disadvantage is the relatively high blood loss compared to other surgical techniques. The lower abdominal incision is made starting from the navel to the symphysis (cartilaginous bone connection between the two pubic bones, also called the pubic symphysis). First, the anterior leaf of the rectus sheath (sheath formed by the tendon plates of the muscles of the anterior abdominal wall around the rectus abdominis muscle) and the transverse fascia (innermost abdominal muscle layer) are cut.Then, the exposure of the vasa iliaca externae and internae (supplying and draining blood vessels), the ureters and the vasa testicularis (vessels supplying the testis and epididymis) is completed. In the specified area, the lymph nodes are removed and the prostate is exposed. In addition to the removal of the prostate, lymph nodes and seminal vesicles (vesiculae seminales), the optimal reconstruction of the urinary organs is an important part of the operation, which is crucial for the subsequent quality of life.
  • Radical perineal prostatectomy (RPP) – often the perianal access route (around the anus) is the Hudson approach. In this access route, the fibers of the external sphincter ani (external anal sphincter) are bluntly pushed forward and to the side with the finger, exposing the sagittal (anterior to posterior) fibers of the rectum. In addition to the Hudson approach, other access routes such as the Young approach can be used. Radical perianal prostatectomy cannot be used if hip disease or spinal disease is present that does not allow lithotomy. In addition, prostate weights greater than 100 g are not operable perianally.
  • Laparoscopic radical prostatectomy – to perform laparoscopic radical prostatectomy, five accesses are first created in the lower abdomen to expose and remove the seminal ducts, seminal vesicles, and subsequently the prostate. Electrical coagulation is performed to achieve adequate hemostasis. Usually, the intraperitoneal access route (inside the peritoneum) is used during surgery. Of particular advantage in laparoscopic prostatectomy is less blood loss.
  • Robotic-assisted radical prostatectomy (RARP) – the primary goal through the use of robots (e.g., Da Vinci robots) is to preserve potency while maintaining the chance of cure; see also “Additional Notes” below.

Note: If a long urethral stump is left above the prostate, this reduces the extent of urinary incontinence (involuntary, involuntary loss of urine) after radical prostatectomy.

After surgery

The outcome of surgery (surgical outcome) is directly dependent on the patient’s postoperative care. For example, to avoid deep vein thrombosis (occlusion of a blood vessel by a blood clot in the deep veins of the leg) and embolism, the patient should be mobilized very early after surgery. Depending on the flow rate, the wound drainage is removed after a few days. Furthermore, the urinary indwelling catheter is removed within one week after surgery. To check the postoperative urinary flow, a cystogram (synonyms: Cystography, urinary bladder x-ray; x-ray examination of the urinary bladder), contrast medium is given into the urinary bladder via the horizontal indwelling catheter and the tightness of the new bladder and urethra connection is assessed.

Potential complications

Early complications

  • Postoperative bleeding – postoperative bleeding can be observed as a relatively common complication, although it is usually self-limiting. If bleeding does not stop on its own, surgical recoagulation may be necessary as part of a second procedure.
  • Rectal (rectal) injuries – direct intraoperative treatment is usually performed for rectal injuries.

Late complications

  • Urinary incontinence (involuntary, involuntary leakage of urine) – due to scarring changes in the urethra or muscular lesions (muscle damage) can cause urinary incontinence.
  • Erectile dysfunction (ED; erectile dysfunction) – despite nerve-sparing surgical procedures, erectile dysfunction is a common complication of the surgical procedure. According to a Danish study, erections are only about 7% of men as strong as before surgery.
  • Abnormal sensations and gait disturbances – injury to nerves in the skin and muscles can cause permanent or temporary abnormal sensations, gait disturbances and numbness. However, permanent consequences of nerve lesions are relatively rare.

Further notes

  • In radical prostatectomy, inguinal hernia (inguinal hernia) is not an uncommon incidental finding: in 8.6% of patients, surgeons also found an inguinal hernia, and in a quarter of these patients, it was bilateral.Less than half of the hernias had been diagnosed before surgery. Patients with preoperative IPSS (International Prostate Symptom Score) of ≥ 15 (score of 1-35) had a particularly high risk of developing inguinal hernia. Among them, the risk of needing hernia surgery at the time of prostatectomy was 22.4%.
  • According to one study, recurrences (recurrence of disease) usually occur in the first two years. Five years after surgery, a total of 71.2% of patients were cancer-free (5-year DFS), and ten years later, 48.7% were cancer-free. The likelihood of remaining recurrence-free (relapse-free) increased with each year that passed: disease-free survival (CDFS; conditional disease-free survival) increased with each year:
    • Year 1 (no recurrence yet): 77.4% of patients still cancer-free after 5 years.
    • 2nd year: 82.1
    • 3rd year: 94.0

    Furthermore, of prognostic importance are the tumor stage and Gleason score. With the years showed the prognostic value of the PSA value and the factor cancer-free excision margins as lost.Conclusion: the recurrence-free time is thus the most important prognostic factor for long-term survival.

  • Robotic-assisted prostatectomy (RARP):
    • Little to no difference in operative complications (RR 0.41; 95% CI 0.16-1.04) or severe postoperative complications (RR 0.16; 95% CI 0.02-1.32).
    • Likely reduces length of hospital stay (MD -1.72; 95% CI -2.19 to -1.25).
    • Reduces the frequency of blood transfusions (RR 0.24; 95% CI 0.12 to 0.46).

    CONCLUSION: It is not the access route but the surgical experience of the surgeon that is most important.

  • Men with localized prostate cancer achieved a gain in life expectancy of an average of 2.9 years by radical prostatectomy: 8.4 men must undergo radical prostatecomy for this to avoid death from any cause. Observation duration was 23.6 years… Note: Because patients over 65 years of age with a low-risk constellation rarely die as a result of prostate cancer, the indication for radical prostatectomy in this patient group should be carefully considered.