RADICAL PERINEAL PROSTATECTOMY IN THE ERA OF LAPAROSCOPIC SURGERY

1. RADICAL PERINEAL PROSTATECTOMY IN THE ERA OF LAPAROSCOPIC SURGERY Moshe Shalev MD Meir Medical Center Kfar-Saba ISRAEL

2. INTRODUCTION • T. Billroth was the first to describe the technique of perineal prostatectomy for the treatment of prostate cancer in 1867. • At that time most of the procedure was performed blindly.

3. INTRODUCTION • Young performed the first radical perineal prostatectomy under direct visualization in 1904 after developing the Young retractor and the perineal table.

4. INTRODUCTION • In 1945 Millin popularized the technique of RRP but the significant blood loss associated with this approach discouraged many from its use. • RPP and RRP fell out of order with the advent of radiation therapy in the early 1960s • Walsh in 1979 described the modified RRP technique which includes early ligation of the dorsal vein to reduce blood loss and the preservation of the cavernosal nerves to preserve potency leading to wide acceptance of this procedure. • Weldon’s adaptation of the anatomical RRP to RPP in the late 1980s.

5. INTRODUCTION • In the recent years the concept of minimally invasive surgery with short hospitalization and less morbidity has been advanced with the introduction of laparoscopic radical prostatectomy.

6. Reassessment of modern radical perineal prostatectomy • The focus on minimally invasive approaches invites a reassessment of the perineal approach to radical prostatectomy, as it is: a) less invasive than the laparoscopic approach b) requires less operative time c) requires less disposable equipment d) has a significantly shorter learning curve e) as opposed to laparoscopy, long term data on outcomes are available.

7. ADVANTAGES OF RADICAL PERINEAL PROSTATECTOMY OVER RRP AND LAP. PROSTATECTOMY • In obese patients • In patients with previous pelvic surgery • In patients after meshed hernia repair • After renal transplantation • After pelvic/abdominal vascular bypass grafts. • In salvage prostatectomy after irradiation

8. CONSIDERATIONS IN PATIENT SELECTION • Morbid obese patients may not tolerate the exaggerated lithotomy position • Depth of patient’s perineum • Distance between the patient’s ischial tuberosities • Very large prostates • Hip ankylosis, severely limited hip mobility and lower extremity amputations • Severe hemorrhoids (?)

9. OPERATIVE TECHNIQUE • Patient is placed in an exaggerated lithotomy position

10. OPERATIVE TECHNIQUE • Lowsely prostatic retractor is placed into the bladder and the wings are opened.

11. OPERATIVE TECHNIQUE • A semilunar incision is made inside the ischial tuberosities with the apex located 1-3cm anterior to the anal verge.

12. OPERATIVE TECHNIQUE • Rectal mobilization • Division of the rectourethralis muscle

13. OPERATIVE TECHNIQUE • Thompson perineal retractor can be placed • Space is developed to the base of the prostate

14. OPERATIVE TECHNIQUE • At this point the decision to proceed with nerve sparing versus wide dissection must be made. BUT • THE DEVIL’S ADVOCATES SAY THAT IT IS IMPOSSIBLE TO SPARE THE CAVERNOSAL NERVES WITH THE PERINEAL APPROACH. • REALLY?!!!

15. תפסיקו לבלבל את ה...... !!!

16. NERVE SPARING • A vertical incision should be made to mobilize the neurovascular bundles within the Denonvillier fascia laterally.

17. NERVE SPARING • The neurovascular bundles must be mobilized at least 1cm over the membranous urethra and sufficiently proximal to the base of the prostate.

18. WIDE DISSECTION • The fascia is opened transversely at the level of the membranous urethra and the base of the prostate.

19. CLOSURE

20. COMPLICATIONS

21. RPP SPECIFIC COMPLICATION

22. INTRAOPERATIVE COMPLICATIONS *Zincke 2004

23. POSTOPERATIVE COMPLICATIONS

24. OVERALL COMPLICATIONS Catalona, J Urol 172; 2227-31, 2004 Holzbeierlein, Urol Clin Nor Am 31; 629-41, 2004 Zincke, Mayo Clin Proc 79; 1169-80, 2004

25. BLOOD LOSS

26. OPERATIVE TIME

27. HOSPITALIZATION DAYS

28. POSTOPERATIVE SOLID ORAL INTAKE

29. OUTCOMES

30. POSITIVE MARGINS

31. INCONTINENCE

32. POTENCY

33. ERECTILE FUNCTION

34. DISEASE CONTROL • When patients are matched for preoperative data including PSA level the biochemical recurrence rate for RRP and RPP are not significantly different.

35. 3-year recurrence free survival in Pts. with PSA less than 10 ng/ml

36. LEARNING CURVE RRP and RPP = 15- 20 LAP =80-90

37. SUMMARY • Modern radical perineal prostatectomy is a minimally invasive procedure that offers all of the advantages of surgical removal of the cancerous prostate with the least morbidity and the least cost. • RPP is the optimal approach for obese patients, pts. with prior pelvic surgery or pelvic radiation.

38. THANK YOU !!!