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Radical prostatectomy

Ideal candidates for radical prostatectomy

  • Life expectancy 10 years +
  • Intermediate risk or high risk disease (occasional high volume Gleason 6)
  • Resectable / able to achieve clear margins (no sphincteric invasion or adjacent organ invasion)
  • Understanding and accepting potential adverse outcomes

Factors which may make radical prostatectomy difficult or not ideal

  • Obesity
  • Previous surgery – laparoscopic hernia repair, TURP, pelvic radiation, pelvis surgery
  • Very large glands
  • Significant GA or bleeding risks
  • Urethral disease

 

Complications of radical prostatectomy

General complications:

  • Anaesthetic risks – MI, stroke, DVT/PE, anaphylaxis, chest infection, neuropraxia, air embolism
  • Bleeding – transfusion rare, especially if using cell saver
    • Specifically iliac injury if doing PLND, DVC bleeding
  • Infection – wound, urine, chest, IV access
  • Mortality – less than 0.5 %

Specific complications – early:

  • Injury to adjacent organs – rectum, bladder, ureter, obturator nerve, small bowel
  • Urine leak
  • Pelvic haematoma
  • Wound issues or dehiscence
  • Lymphocele
  • Conversion to open for either bleeding or other difficulty

Specific complications – late:

  • Incontinence – common at catheter removal, 25 % at 6 months, 5 – 10 % at 12 months
  • Impotence – at least 60 %, unlikely to achieve 100 % of pre-operative function
  • Anejaculation
  • Hernia
  • Anastomotic stenosis
  • Other sexual dysfunction – loss of length, climacturia, anejaculation, increased risk of curvature, psychosexual impairment including loss of libido

 

Pelvic lymph node dissection

Surgical lymph node dissection provides gold standard nodal staging, but at the cost of potential morbidity.

No trial has proven an oncological benefit to PLND during radical prostatectomy.

PSMA-PET is much more sensitive at picking up nodal metastases compared to CT and has demonstrated occasionally the initial nodal disease.

EAU – perform an extended LND based on nomogram prediction of lymph node invasion (> 7 %)

AUA – use nomograms to select patients for LND – balance potential benefit with risk – perform extended dissection if performing LND to improve staging accuracy.

I will only rarely perform extended LND if PSMA-PET suggests no nodal disease, in high risk cases.

No role for nodal frozen sections.

 

Boundaries of the obturator fossa:

  • Superiorly – bifurcation to external iliac artery
  • Inferiorly – node of Cloquet
  • Medially – bladder
  • Laterally – pelvic side wall / obturator internus

 

Open vs robotic

It has not been shown that robotic prostatectomy harbours any benefit on oncological outcomes, continence, or potency outcomes.

Patients undergoing RALP have shorter LOS, less blood loss and transfusions, and early return to function.

?Lower rates of vesico-urethral anastomotic stenosis (bladder neck stenosis) with robotic surgery.

Specific contra-indications to RALP may include inability to tolerate pneumoperitoneum / steep Trendelenburg positioning.

 

Management of urine leak

Urine leak after robotic prostatectomy will be intra-peritoneal, open retropubic should be all extraperitoneal.

Maximise drainage – IDC bag below bed, drain off suction. Drain out when dries up. Cystogram prior to TOV. If ongoing leak – wait longer – will settle. Consider imaging to exclude ureteric injury if prolonged leak. (Some place ureteric catheters via flexi (tunnelled to IDC) to maximise drainage?).

 

 

Technique for radical retropubic prostatectomy:

  • Cell saver, headlight.
  • Supine with break at pelvis
  • Lower midline incision
  • Through rectus sheath and divide transversalis fascia
  • Develop retropubic space of Retzius, omnitract retractors in
  • Remove pre-prostatic fat, controlling superficial dorsal vein
  • Open endopelvic fasciae bilaterally
  • Divide puboprostatic ligaments with scissors, taking care to avoid adjacent small vein
  • Bunch up EPF with Babcocks and suture ligate DVC with 0-vicryl proximally and distally
  • Divide DVC with cautery over McDougalls
  • Apical dissection with traction on prostate cranially
  • Sharp division of 60 % of urethra on to catheter
  • Place anastomotic sutures x 4 – 4/0 double armed monocryl
  • Divide urethra completely, cut catheter and bring through (swab on stick holding catheter to use as traction)
  • Posterior anastomotic sutures placed
  • Sharp release of posterolateral nerve bundles with right angles and scissors from cranial to apex
  • Retrograde dissection of prostate from apex to base above Denonvilliers with pedicles controlled with right angles and large angled Ligaclips
  • Dissection of SVs and vasa with right angles and diathermy, vasa divided with clips
  • Division of bladder neck aiming to spare bladder neck – feather diathermy with traction on prostate and using catheter balloon – specimen removed
  • Bladder neck reconstruction if required taking care to avoid UOs
  • Mucosal eversion of bladder neck with interrupted chromic sutures
  • Ensure haemostasis of pedicles
  • Place bladder anastomotic sutures, retractors off, tie down sutures ensuring IDC in bladder
  • Leak test and washout clot, drain and closure

RALP steps

  • Supraumbilical Hassan entry for camera, 3 other working ports 8 – 9 cm laterally, 5th assistant port left side cranially. Steep head down.
  • Drop the bladder – aiming for plane between peritoneum and transversalis
  • Remove periprostatic fat and control superficial DVC
  • Incise endopelvic fasciae
  • Divide bladder neck
  • Antegrade posterior dissection controlling pedicles with clips
  • Nerve sparing between fascial layers
  • Control DVC and divide puboprostatics
  • Apical dissection and division of urethra, aiming to maximise urethral length
  • Specimen bagged
  • Rocco suture with V-lock to bring together posterior tissue
  • Vesicourethral anastomosis with double armed V-lock
  • Washout and leak test, drain haemostasis agent such as Fibrillar along side prostate

Removed via small Pfannenstiel incision