Radical Perineal Prostatectomy

This is the alternate surgical management option for a localized prostate cancer. Widely used in the USA in the early 2000’s prior to robotic assisted surgery.

• Still a great technique to avoid a frozen abdomen due to multiple previous surgeries
• Transplanted kidney.
• Obesity
• Smaller than 50 cc prostates are better

Criteria include:

• PSA less than 10.
• Gleason 3,4 adenocarcinoma prostate.
• Higher grades with no extra-prostatic extension
• Staging negative, (bone scan negative, CT negative).
• 75 years and younger.

• It is the complete removal of the prostate, seminal vesicles and bladder neck.
• A nerve sparing procedure is attempted for those guys who have good erections and wish to maintain this.
• The procedure takes 2-3hours excluding the anesthetic time.

How is it done?

• • General anesthetic.
  • You will be placed in hyper-lithotomy.
  • Anus at eye-level.
  • The surgical filed is prepared.

• • A flexible cystoscopy is done to exclude any urethral strictures, bladder cancers and any other pathology.
  • An IDC is then placed.
  • A horseshoe incision is made around the anus.
  • The space in the front part of the rectum is entered and passed under the sphincteric muscle.
  • Dennon Villiers Fascia is cleared and opened in the midline, this brushing the erectile nerves laterally.
  • The urethra is encircled and cut just distal to the prostate sparing the sphincter.
  • The prostate is loosened anteriorly from the dorsal venous complex, thus sparing the complex and avoiding major blood loss (DVC).
  • The anterior bladder neck is opened.

• • The UO identified.
  • The posterior bladder neck cut.
  • The lateral pedicles are clipped.
  • The seminal vesicles and ampullae of the Vas Deferens, the SV are removed and the Vas clipped.
  • The prostate is loosened and removed.
  • The bladder mucosa is everted.
  • The bladder neck reconstructed.
  • The anastomosis with the urethra completed over an Indwelling Catheter.
  • A drain is left.

Complications

• Blood loss 200-400cc.
• Wound infections.
• Wound breakdown.
• Managed with Betadine sit baths.
• Stress incontinence which will improve over the next 12 months (12%).
• Complete incontinence at 12 months (2%).
• Erectile dysfunction (40-50%) where a nerve sparing procedure has been performed. It may take 12-18 months to recover.
• Anejaculation/ Infertility.
• Testicular pain similar to vasectomy for 2-3 day.

Post operative care:

• Sutures are dissolvable and will not be required to be removed.
• Normal diet.
• A salt water or Betadine Douche is required after every stool for the first week.
• Apical wound dehiscence can occur in 7% which requires extra care in the form of prolonged Salt water or Betadine Douches.
• Wounds generally heal in 7-10 days.

Post-operative review:

• Your catheter will remain for 10-14 days.
• Only after a cystogram (radiological investigations where radio-opaque contrast is placed in the bladder) confirms no leakages from the bladder-urethra-anastomosis, will the catheter be removed.
• Should there be any urine leakages on the cystogram, the catheter may remain another 7 days.
• Review PSA roughly 6 weeks after the surgery to assess post-operative Nadir.
• Review in rooms a week later.
• 3-6 monthly review depending on risk factors.
• If stable with good PSA outcomes, refer back to GP for 6 monthly PSA review.
• You will be referred to a Men’s Health Physician to assist with erectile function recovery – erections can take as long as 18 months to recover
• Continue your pelvic physiotherapy

PSA failure:

• PSA never dropping to undetectable with positive margins in histology.
• 3 consecutive PSA rises following RRP.

Download Information Sheet

Wes Prostatectomy Radical (Perineal)