Retropubic radical prostatectomy (RRP)
When is this procedure indicated?
The procedure is indicated in cases of clinically significant prostate cancer, i.e. in all cases that would expose the patient to a risk of developing distant metastases should the decision be made not to operate but to carefully observe the clinical course of the disease (active surveillance).
How is it performed?
Retropubic radical prostatectomy is a surgical procedure that involves removal of the prostate, seminal vesicles, and deferential ampullae with ligation of both deferent ducts.
The procedure is performed openly through an incision of the abdominal wall from the navel to the pubis. The fascial planes are opened and the pelvic cavity is accessed. If the risk of lymph node invasion calculated according to models based on the clinical variables available before surgery is greater than 5%, in accordance with the guidelines of the European Association of Urology, a pelvic lymphadenectomy (removal of lymph nodes) extended to the external, internal and obturator iliac stations bilaterally will be performed. In selected cases of high-risk disease, lymphadenectomy may be extended to the common iliac and presacral stations. Pelvic lymph nodes may also be removed in patients with less than 5% risk of lymph node invasion according to the above models if lymphadenopathy (increased lymph node size) is found on preoperative imaging or during surgery.
Once the eventual lymphadenectomy is completed, isolation, ligation, and section of the Santorini venous plexus is performed.
Then the removal of the prostate is done retrograde, starting from the prostate apex and reaching the seminal vesicles and the bladder neck that is separated from the base of the prostate taking care to preserve as much as possible the integrity of the muscular fibers of the bladder neck itself which participate in the mechanism of urinary continence. The technique of prostate removal provides the possibility to preserve bilaterally or on one side only the vascular-nervous bundles that are involved in the mechanism of erection. The possibility of preserving them depends on the oncological situation, i.e. on the preoperative characteristics of the disease (palpable disease at rectal examination, number of positive biopsies for cancer, aggressiveness of the tumor detected in the biopsies, PSA values) and on anatomo-surgical factors, i.e. on the technical possibility of carrying out such a type of intervention. In particular, it is possible to identify an intrafascial plane (extremely adherent to the prostate capsule) or an interfascial plane (slightly more distant from the prostate capsule but always paying the utmost attention to safeguard the nerves surrounding the prostate). Prostate isolation is performed with the utmost attention to limiting the use of thermal energy in order to avoid damage to periprostatic nerve tissue. Hemostasis is achieved with the application of titanium microclips (5 mm) or sutures placed at the end of the procedure. In some patients, in whom the prostate tumor proves to involve the rich network of nerves responsible for the recovery of erectile function that surrounds the prostate gland, this must be sacrificed in part or totally to allow the complete removal of the tumor (extrafascial technique). In these cases the recovery of penile erection can be very slowed down or a permanent erection damage can be created.
The last phase of the intervention is represented by the packaging of the vesicourethral anastomosis by means of detached sutures after the positioning of a bladder catheter. We then proceed to close the bands by layers and suture the skin, which is typically done with metal clips. At the end of the operation, in addition to the external bladder catheter for urine drainage (which is usually removed between the 7th and 14th post-operative day, once the anastomosis between the bladder and urethra has healed), one or two drainage tubes coming out from the abdominal wall are placed and removed during the post-operative course according to the clinical picture.
Recovery is usually rapid, generally as early as the first day after surgery the patient can resume walking and eating, thus promoting bowel movement and circulation.Discharge from the hospital occurs after about 4 days of hospitalization, the patient will return after about 7-10 days to the outpatient clinic for a check of the surgical wound and removal of the bladder catheter. Recovery of continence is variable, usually requiring the use of 1-2 diapers per day for the first 3-4 months, with progressive weaning.Recovery of erectile function is variable and has times between 3 months and a year. After about three weeks after surgery, it is necessary to repeat the PSA blood test, which is usually repeated every six months for the first years, then annually.
The percentage of patients who develop complications within the first 90 days after surgery reported in the literature varies from 5 to 30% and depends on individual characteristics (age, comorbidities, previous surgery), the aggressiveness of the tumor and therefore the need to be more radical surgically [6-8]. Post-operative complications are prospectively collected at our center, and listed below are the most frequent complications observed in the first 90 days after surgery in our case series:
- Sanguinamento con anemia comportante la necessità di eseguire trasfusioni di sangue (<10%).
- Fever requiring antibiotic treatment (8%).
- Pelvic lymphocele formation with possible need for percutaneous drainage vs. reintervention (7%).
- Lymphedema (accumulation of lymph and swelling in the tissues) in the lower limbs and pubic (3%). In some cases this condition may be permanent.
- Urinary fistulas with dehiscence of the vesicourethral anastomosis with need for prolonged maintenance of the bladder catheter (5%).
- Stenosis of the urethra (3%) or vesicourethral anastomosis that may require endoscopic treatment (<2%).
- Deep vein thrombosis (2%).
- Wound infection that may require reintervention (2%).
- Neuropraxia (altered sensation in the limbs) or nerve injury that may affect transient or, rarely, permanent sensory or motor changes (1.3%).
- Chronic transient or, rarely, permanent pelvic-perineal pain syndrome (1%).
- Clinically detectable pulmonary embolism (0.5%).
- Compression of ureters resulting in anuria and need for placement of percutaneous nephrostomies vs. urethral stents vs. surgical reintervention (0.5%).
- Lymphatic and intestinal fistulas (0.2%) with possible need for reintervention.
- Ureteral laceration (0.2%) with need for reintervention.
- Gutting - herniation at wound site requiring surgical treatment (0.1%).
- Rectal wall injury (0.2%) with possible temporary fecal diversion to the skin (colostomy).
- Inguinal hernia requiring surgical correction.
The need for reintervention occurs in about 1% of cases (generally needed in the immediate post-operative period) and is usually dictated by the need to control a bleeding or lymphocele. Finally, radical prostatectomy is characterized by a risk of mortality in the first 3 months after surgery of about 1 patient out of 1000, according to large multicenter case series. This value is in line with what has been observed in our case series.
The most typical sequelae after radical prostatectomy surgery are urinary incontinence and erectile deficit. In our experience, urinary continence is recovered by more than 85% of patients during the first 12 post-operative months. The patient may need to use protective diapers during this period. In our opinion, it is necessary to perform physiotherapy and/or a specific rehabilitation program to optimize the recovery of continence. In our experience, less than 2% of patients require additional surgical procedures to improve continence, such as placement of a urethral sling, small adjustable peri-urethral devices, or an artificial sphincter.
Reduction in erectile function is possible in patients who undergo radical prostatectomy surgery. If it is possible to perform the "nerve sparing" technique of preserving the nerves responsible for erection, about 65% of patients resume satisfactory sexual activity using specific medical therapy. The recovery of normal erectile function, however, depends on the general condition of the patient. We have shown that recovery of erectile function is influenced by the presence of pre-intervention impairment of erectile function, age, number of comorbidities, and body mass index (BMI). For this reason, the "nerve sparing" technique, although correctly performed, does not totally guarantee the complete recovery of erectile function. In our opinion, it is necessary that the patient follows pharmacological rehabilitation to facilitate the recovery of erections.
Following the surgery, ejaculation is completely and always lost (i.e., no more seminal fluid comes out at the moment of orgasm), while the perception of orgasm is almost always maintained. This loss of ejaculation actually determines a condition of male infertility following surgery. In this sense, seminal fluid can be collected and frozen before surgery, to be eventually used for a subsequent path of Medically Assisted Procreation (PMA).
In addition to erection and continence problems, other sexual disorders can sometimes occur. After surgery, in fact, once sexual activity is resumed, the patient may complain of the following problems:
- Reduced sexual desire (30%).
- Lengthening of the time of stimulation required to achieve orgasm (40%).
- Inability to reach orgasm (condition defined as anorgasmia) or decreased intensity of orgasm (30%); this condition is usually transient, rarely permanent.
- Pain at the moment of orgasm, typically localized in the penis, but also in other areas of the external genital district, pubic, pelvic and/or abdominal (7%); this condition is usually transient, rarely permanent.
- Climacturia, otherwise known as orgasm-associated urinary incontinence (consisting in the occasional loss of modest amounts of urine - usually drops - at the time of orgasm; 30%). This issue typically disappears in more than half of the cases in the months following surgery.
- Altered, more often decreased, penile sensitivity (25%).
- Retraction of the penile shaft, resulting in a shortening, usually greater than or equal to 1 cm (45%).
- Penile curvature during erection (35%).
A possible recovery problem that occurs infrequently is related to the occurrence of a subacute pelvic pain syndrome that may be related in some cases to a microscopic fistula at the level of the vesicourethral anastomosis that could cause osteitis or pubic osteomyelitis that is typically treated conservatively.
Finally, the most recent case reports show that 20-30% of patients treated with radical prostatectomy may have a tumor involving the surgical resection margins. Therefore, the presence of a positive surgical margin should not be excluded even in the presence of tumors with good preoperative characteristics and should be considered as an intrinsic risk of the procedure itself. The clinical relevance and prognostic implications of a positive margin seem to be limited, and often it is sufficient to follow the patient without doing any additional treatment because surgery alone is resolving anyway. However, when a positive surgical margin is associated with the presence of a very aggressive and extensive tumor, the administration of additional therapies may be indicated, such as radiotherapy and/or hormone therapy immediately or when PSA values rise to reduce the risk of distant recurrences.