Radical Prostatectomy

The three aims of this operation are cancer control, preservation of urinary continence and of sexual function. Two approaches are available: the perineal approach was pioneered first and has the advantages of usually less blood loss and greater exposure of and access to the apex of the prostate, thus optimising removal of tumour from this critical margin and allowing precise transection of the urethra. However, its main disadvantage is that it does not allow access to perform a pelvic lymphadenectomy. Furthermore, a greater understanding of periprostatic anatomy and developments in surgical technique over the years have reduced blood loss and improved tumour clearance using the retropubic approach, to the extent that currently the perineal procedure is seldom performed. It may be indicated for small, low-grade tumours when pelvic lymphadenectomy can be safely omitted.

Surgery should be deferred for at least six weeks following needle biopsy and twelve weeks following TURP to allow any inflammatory adhesions or haematoma to resolve. In retropubic prostatectomy, a midline extraperitoneal lower abdominal incision is made from pubis to umbilicus and, after appropriate dissection, a bilateral pelvic lymphadenectomy is performed. This is a staging rather than a curative procedure and, in some centres, the surgeon may ask for a frozen section lymph node analysis, halting the operation should tumour be detected in the node. Prostatectomy proceeds with dissection of the periprostatic fascia, division of the pubo-prostatic ligaments, dorsal vein complex, urethra and bladder neck and excision of the seminal vesicles. Newer nerve-sparing surgical techniques are possible, with the aim of maintaining erectile function postoperatively. These involve preserving the neurovascular bundles, which run between two layers of periprostatic fascia (prostatic and levator). This is most successful in young patients with organ-confined disease but involves a higher risk of positive surgical margins. An option is to remove one neurovascular bundle, on the side of the palpable lesion or positive biopsy, leaving the other intact. Alternatively, if there is a high probability of capsular extension on preoperative assessment, or if the patient is impotent, the bundles should be widely excised.

This major operation has surprisingly low postoperative mortality (0.2%) or serious morbidity. Urinary incontinence, possibly due to distal urethral sphincter dysfunction or bladder neck contracture, is often the most troublesome side effect. Loss of erectile function is now less of a problem thanks to modern surgical alternatives.

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