Radical Prostatectomy

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Radical Prostatectomy

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.

FIGURE 54–1 Robot-assisted prostatectomy and surgical approaches to prostate.

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

Posterior Prostatic Dissection

Initial inspection of the pelvis is performed to identify the relevant landmarks: the medial umbilical ligaments and the vasa deferentia. The rectovesical cul-de-sac (pouch of Douglas) is approached, and the courses of the vasa are identified through the peritoneal layer (Fig. 54-2, A-D).

FIGURE 54–2 Posterior prostatic dissection.

The overlying peritoneum is incised, and the ampulla of the vas deferens is isolated and transected. Retraction on the vas deferens ventromedially allows for identification and dissection of the ipsilateral seminal vesicle. The artery to the seminal vesicle is either clipped or controlled with bipolar electrocautery. The contralateral vas deferens and seminal vesicle are then dissected in a similar manner.

The seminal vesicles and vasa are retracted ventrally, exposing Denonvilliers’ fascia (Fig. 54-2, E and F). This fascia is incised sharply just dorsal to the base of the prostate. This approach allows entry into a plane containing perirectal fat, and the surgeon can then carefully dissect the prostate off of the rectum in an antegrade direction to the prostatic apex.

Development of Space of Retzius

The urachus and medial umbilical ligaments are transected with electrocautery just inferior to the umbilicus (Fig. 54-3). The bladder is carefully dissected off of the anterior abdominal wall just deep to the posterior rectus sheath and transversalis fascia. The lateral limits of the dissection are the lateral borders of the medial umbilical ligaments.

FIGURE 54–3 Development of space of Retzius.

The bladder is then swept off of the iliac vessels and obturator muscles. The endopelvic fascia is exposed and sharply incised from the base of the prostate to the puboprostatic ligaments bilaterally. The superficial dorsal vein is coagulated with bipolar electrocautery and transected. Levator muscle fibers are then swept off of the lateral aspects of the prostate, exposing the prostate-urethral junction. The puboprostatic ligaments are sharply transected, allowing greater access to the prostatic apex. The deep dorsal venous complex (DVC) is then suture-ligated.

Bladder Neck Dissection

The contour of the prostate, the pliability of the tissues, and the balloon from the urethral catheter are used to identify the bladder neck just proximal to the base of the prostate. Electrocautery is then used to dissect the anterior, lateral, then posterior bladder neck off of the base of the prostate (Fig. 54-4, A).

FIGURE 54–4 Bladder neck dissection and neurovascular bundle.

An enlarged median lobe of the prostate, if present, is identified at this point in the procedure. The dissection is modified to ensure complete excision with the prostate specimen.

Care is taken by the surgeon during the posterior bladder neck dissection to avoid injuring the ureters by visually identifying and avoiding the ureteral orifices. Once through the posterior bladder neck, the surgeon can enter the posterior plane developed earlier in the procedure, and the transected vasa and seminal vesicles can be visualized and grasped for retraction.

Neurovascular Bundle Preservation

Release of the neurovascular bundles can be performed at this point in the procedure, or after control of the vascular pedicles to the prostate (Fig. 54-4, B). The levator fascia is sharply incised over the anterolateral prostate, preserving the underlying prostatic fascia. This incision is carried distal beyond the prostatic apex, and proximal to the vascular pedicles.

The dissection is then carried dorsally along the surface of the prostate until the posterior plane is entered, and the neurovascular bundles are completely released off of the prostatic surface. In many patients, venous or small arterial tributaries coursing between the neurovascular bundles and the prostate are encountered, and these must be ligated and transected.

Prostatic Pedicle Ligation and Division of Deep Dorsal Venous Plexus

The base of the prostate is left attached by the vascular pedicles (Fig. 54-5). The seminal vesicles and vasa are retracted anteriorly and contralaterally, defining the prostatic pedicles at the 5 and 7 o’clock positions. The pedicles are then clipped or suture-ligated and transected sharply.

FIGURE 54–5 Prostatic pedicle ligation and division of deep dorsal venous plexus.

The DVC is transected immediately proximal to the previously placed suture ligature. If bleeding from the DVC occurs, repeated suture ligation invariably results in adequate hemostasis. Once the DVC is completely divided, the prostate can be retracted farther out of the pelvis, and the junction between the prostatic apex and urethra can be seen.

Division of Urethra

The apex of the prostate is further defined with careful dissection around the urethra (Fig. 54-6, A). Inspection is done to confirm the neurovascular bundles are dissected off of the prostatic apex to ensure that the bundles will not be inadvertently transected during urethral division. The anterior urethra is then divided sharply just distal to the prostate apex.

FIGURE 54–6 Division of urethra and vesicourethral anastomosis.

Care is taken to inspect the contour of the posterior prostatic apex before dividing the posterior urethra. In some cases the posterior prostatic apex can protrude beyond the anterior apex, requiring a more distal dissection in this area. Once the urethra is divided, the prostate is free to be placed in a specimen bag for later extraction.

Vesicourethral Anastomosis

The vesicourethral anastomosis is created by running two sutures in opposite directions from the midposterior to the midanterior bladder neck (Fig. 54-6, B). Adequate apposition of the posterior bladder neck is needed to avoid postoperative urine leaks, because this is the area of greatest tension.

A urethral catheter is placed under vision at the completion of the anastomosis. A closed suction drain is then left in the prevesical space, adjacent to but not directly on the anastomosis.

Specimen Extraction

Incisions in the fascia and skin of the umbilical port are extended appropriately to allow safe extraction of the entrapped prostate specimen. Fascial and skin incisions are closed and dressings applied.

Suggested Readings

Bill-Axelson, A, Holmberg, L, Ruutu, M, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2011;364:1708.

Ficarra, V, Novara, G, Artibani, W, et al. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol. 2009;55:1037.

Hu, JC, Gu, X, Lipsitz, SR, et al. Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA. 2009;302:1557.

National Comprehensive Cancer Network. Clinical practice guidelines in oncology. www.nccn.org, 2010.

Young, HH. The early diagnosis and radical sure of carcinoma of the prostate. Johns Hopkins Hosp Bull. 1905;16:315.

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