William Tabayoyong and Robert Abouassaly

Introduction

Radical prostatectomy for the treatment of prostate cancer has been performed for more than 100 years. The location of the prostate deep in the pelvis challenged surgical extirpation and caused significant morbidity. Radical prostatectomy is a “gold standard” in the treatment of localized prostate cancer, and level 1 evidence confirms that it offers a survival advantage over the absence of treatment in men with this disease. With increased understanding of the anatomy of the prostate and surrounding structures, along with improvements in instrumentation, the morbidity associated with radical prostatectomy has decreased substantially. Currently, urinary continence is achieved in approximately 90% of patients, and erectile function is preserved in most men with good preoperative function.

Traditionally, radical prostatectomy has been performed in the open retropubic or perineal approach. In the last decade, however, use of minimally invasive approaches has dramatically increased, particularly laparoscopic robot-assisted radical prostatectomy (Fig. 54-1, A). This approach has gained popularity because of its greater technical ease for the surgeon, especially with laparoscopic suturing, which allows for more precise suture placement during the vesicourethral anastomosis.

Prostate Cancer: Therapeutic Principles

Once the diagnosis of prostate cancer is made on biopsy, staging is obtained depending on the patient’s Gleason score, prostate-specific antigen (PSA), clinical stage, and life expectancy. Staging can include a bone scan and pelvic CT or MRI scan. If the malignancy has a high probability of being localized to the prostate, treatment options are discussed with the patient, including active surveillance, radiation therapy, or surgery, depending on disease factors, life expectancy, and patient preference. Radical prostatectomy is considered in men with life expectancy greater than 10 years who have prostate cancer at significant risk of progression.

The variation in prostate size and shape, as well as its location deep in the pelvis between the bladder and urethra and adjacent to the rectum, make surgical extirpation challenging (Fig. 54-1, B). Additionally, the prostate is surrounded by a venous plexus, and the neurovascular bundles responsible for erection run alongside the prostate. Therefore the surgical dissection required during radical prostatectomy should be performed meticulously by a surgeon with detailed knowledge of the anatomic relationships of the prostate.

Surgical Approach