Radical Perineal Prostatectomy Made Easy:
A Step-by-Step Approach

Introduction:

• Prostate cancer is the most common malignancy in men in the United States with over 300,000 newly diagnosed cases being identified in 1996.

• Over 43,000 deaths in the coming year will be attributed directly to prostate cancer.

• Radical prostatectomy continues as definitive treatment for patients with localized adenocarcinoma of the prostate.

• Newer diagnostic modalities and greater awareness amongst both primary care physicians and patients, have provided greater opportunities for diagnosing prostate cancer.

• Though the original description for radical prostatectomy was transperineal, the need to evaluate pelvic lymph nodes for metastasis and the push to perform nerve-sparing prostatectomy has lead to radical retropubic prostatectomy as a preferred method for managing patients with localized prostate cancer.

• Moreover, many urologic surgeons who for decades have been proficient with the retropubic approach are not comfortable with the perineal approach for radical prostatectomy.

• Other transperineal procedures, such as urethroplasty, insertion of penile prostheses by the perineal route, and simple perineal prostatectomies, have been abandoned for alternative treatment modalities.

With the advent of laparoscopic pelvic lymphadenectomy (LPLND) radical perineal prostatectomy (RPP) is undergoing a resurgence. A better understanding of the perineal anatomy as it relates to the nerve-sparing approach and judicious use of catheters and drains to better define the anatomy have greatly enhanced the ease with which RPP can be performed. In addition, self-retaining retractors, such as the Omni perineal retractor, is a significant aid to retraction during perineal prostatectomy and directly improves visualization of the procedure.

Required Instrumentation:

• A routine laparotomy set

• A perineal prostatectomy drape set that includes a built-in rubber sheath for rectal examination (DRE) during the prostatectomy

• An appropriate operating table that will allow Trendelenburg and side-to-side positioning of the patient during the surgical procedure

• Stirrups that attach to the operating room table and are adequately padded to prevent any pressure points

• A pelvic roll or sandbag to help elevate the pelvis

• A radical perineal prostatectomy set that includes the curved Lowsley retractor, the straight prostatic retractor (Lowsley/Young), angled and bifid retractors to elevate or retract the various perineal and peri-prostatic structures (such as levator ani)

• Sharp, right angle forceps; one inch (in breadth) malleable retractor approximately 12 inches long

• A pair of fine tenotomy scissors for dissecting the neurovascular bundle

• Headlights for the operating surgeon, and possibly for the assistant

• Omni perineal retractor (or similar comparable self-retaining retractor set)

• 1/2 inch Penrose drain

• One 16 Fr. Foley catheter

• One 16 Fr. coud Foley catheter

• One 20 Fr. 30 cc Foley catheter

Patient Preparation:

• Discussion of the advantages and disadvantages of various surgical approaches for prostatectomy must precede the patient signing off on the consent form.

Bowel Preparation:

• The day prior to radical prostatectomy. The choice between using only a mechanical bowel prep and/or chemical bowel prep is at the discretion of the surgeon.

Exclusion Criteria:

• Prostate glands over 50 gms in size as measured by transrectal ultrasound (TRUS). Use of LH - RH analogs to achieve downsizing could be instituted in select patients if desired.

• Potentially difficult patients for perineal prostatectomy can be identified by using TRUS. With the patient in an exaggerated lithotomy position, the distance between the inner aspects of the ischial tuburosity is measured in centimeters. The transverse dimension of the prostate is then measured in centimeters using TRUS. Ideally there should be a one centimeter distance between the prostate and the ischial tuberosity on each side.

Anatomic Landmarks:

• With the patient in the exaggerated lithotomy position, with the hips rotated outward, the ischial tuberosities are initially identified.

• Following the skin incision, the central tendon is the first structure encountered in the perineum.

• The levator ani muscles are retracted laterally to gain access to the prostate.

• The transverse perineii muscles have to be retracted upward and laterally.

• The recto-urethralis, which anchors the rectum toward the apex of the prostate, is a key landmark that has to be carefully dissected.

• The neuro-vascular bundle, which runs on each side of the prostate (around 5 and 7 o'clock positions), has to be dissected off between the two layers of Denonvilliers' fascia.

• Identification and preservation of the bladder neck makes locating the ureteral orifices and reconstruction of the bladder neck unnecessary, and it greatly facilitates vesico-urethral anastomosis. However, the role of bladder neck preservation in maintaining urinary continence is still controversial.

• Ampullae of the vas deferens are posterior to the bladder neck and are identified on upward traction of the bladder with a malleable retractor.

• The seminal vesicles are lateral to the ampullae of the vas deferens.

• The prostatic pedicles are lateral to the seminal vesicles.

Positioning the Patient:

Goals:

• To gain optimum and comfortable exposure of the perineum.
• To avoid any pressure points on the patient.
• Stirrups are available that can comfortably position the patient.
• Optimally, mild hyperflexion of the lower spine and the pelvis, assisted by a sandbag or rolls to rotate the hip joints outwards.
• Extreme hyperflexion of the spine should be avoided.

Drape:

• A one-piece drape with the finger-cot built-in is preferred. DRE during the prostatectomy procedure is crucial.
• Other regular drapes could be used.

Technique:

Step 1. Incision.

• The curved Lowsley retractor is placed within the urethra and advanced into the bladder, then blades are opened within the bladder.

• The patient's ischial tuberosities are marked. The bulbo-cavernosus muscle is identified.

• A curved incision starting on one of the ischial tuberosities is curved around the anal opening half-way between the bulbo-cavernosous muscle and the anal verge. This incision is curved to the opposite ischial tuberosity.

• The central tendon is identifed and incised.

Step II. Developing the ischio-rectal fossa.

• A Metzenbaum scissors is inserted parallel to and hugging the medial aspect of the ischial tuberosity on each side and the blades are spread.

• Blunt dissection with a surgeon's fingers can adequately develop this space on each side of the prostate.

• Gentle movement of the curved Lowsley retractor can assist in this maneuver.

Step III. Exposing the prostate.

• Levator ani muscles are identified and retracted laterally. Preservation of the levator ani muscle, rather than transecting it, is strongly recommended.

• The rectum is anchored to the apex of the prostate by the recto-urethralis and needs careful dissection.

• Judicious use of the finger within the rectum can be a safeguard against entering the rectum.

Step IV. Identifying the Recto-Urethralis.

• One recommended maneuver is to approach the prostate on each side of the rectum and dissect the recto-urethralis towards the midline. This step, along with judicious DRE, can aid in incising the recto-urethralis and thus, dropping the rectum.

• During this maneuver, additional fibers of the levator ani muscles may be encountered. Retract these.

• The recto-urethralis is incised after the rectal extent is well defined.

Step V. Dissecting the rectum off the prostate.

• Use of a sponge on the surgeon's index finger can assist in further freeing the rectum from the prostate.

• Two sponges are left in place between the rectum and the ampullae. This dissection can usually expose the ampullae or the seminal vesicles, or both.

Step VI. Use of self-retaining perineal retractor

• Omni self-retaining retractor is placed after the rectum has been dissected off the prostate.

• This retractor is secured to the table and the various blades are then positioned so that the levator ani muscles are retracted laterally; the bulbo cavernosus muscle and the incision are retracted superiorly.

• Sometimes a weighted speculum can retract the rectum, but caution is advised to prevent trauma to the rectum.

• Such a self-retaining rectractor system prevents assistant fatigue during the radical prostatectomy procedure.

Step VII. Preservation of potency.

• If potency-sparing is being considered, the neuro-vascular bundle that runs alongside each lateral aspect of the prostate must be identified.

• A number 15 knife blade is used to incise the posterior leaf of Denonvilliers' fascia.

• This incision parallels the neurovascular bundle on each side. A pair of sharp tenotomy scissors can assist and accentuate this dissection, which can be carried between the two layers of Denonvilliers fascia.

• Peanut dissectors are used to further retract the neurovascular bundle laterally.

• At this point, often the plane between the rectum and the seminal vesicles can be enhanced and the neurovascular bundle can be further pushed from the prostate, the seminal vesicles, and the lateral prostatic pedicle.

• Prevent any grasping of the neurovascular bundle, but instead use counter-traction on the prostate by grasping across on the prostate rather than the neurovasuclar bundle. Use of the electrocautery in the proximity of the neurovascular bundle is not recommended because of potential conduction of electrocautery current.

Step VIII. Transecting the urethra.

• The junction of the urethra of the prostate is exposed leaving adequate surgical margins.

• A transverse incision is made on the posterior urethra leaving a 2 mm stump at the apex of the prostate.

• The curved Lowsley that is exposed is then closed and withdrawn. Through this incision the straight prostatic retractor is inserted into the bladder and its blades opened to maintain its position within the bladder.

• A 16 Fr. Foley catheter is then passed through the urethral meatus and brought out through the incision just made in the posterior urethra. This procedure helps to identify the anterior wall of the urethra for further incision.

• The anterior wall of the urethra is then identified and transected. Thus, the urethra is severed from the prostate.

Step IX. Dissecting the anterior surface of the prostate.

• Downward traction on the straight prostatic tractor identifies the anterior surface of the prostate.

• Anterior attachments on the prostate such as the pubo-prostatic ligaments are identified and can be transected, cauterized, or ligated.

• Stay close to the prostate during the maneuver to stay away from the dorsal venous complex.

• Dissection is carried anteriorly until the prostato-vesicle junction is reached.

• Continue blunt dissection with the peanut dissector around the anterior and lateral surface of the junction to delineate the limits of the prostate and the bladder neck.

Step X. Placing Penrose for retraction purposes.

• After the prostato-vesicle junction is identified, the prostatic retractor is rotated so that the blades can be palpated at the anterior bladder neck.

• A number 15 or 11 knife blade on a long handle is used to make a small incision in the anterior bladder neck over the blade of the straight prostatic tractor.

• The straight tractor is closed and removed.

• A regular right angle forceps is passed through the prostatic urethra and its tip is brought out through the small incision just made in the bladder neck.

• A small Penrose drain is passed through the jaws of this forceps and brought out through the prostatic urethra and out the apex of the prostate. (Thus the Penrose drain goes around the anterior surface of the prostate, entering through the small opening made at the bladder neck and travels through the prostatic urethra and exits at the apex of the prostate).

• A hemostat is used to secure the Penrose drain.

• A 16 Fr. coude' Foley catheter is then passed through this incision at the bladder neck. This foley passes into the bladder. Dissection is eventually carried around this coude' catheter and helps identify the bladder neck.

Step XI. Preservation of the integrity of the bladder neck.

• Every effort is made to preserve the bladder neck.

• Blunt and sharp dissection between the bladder neck and the prostate is begun, starting at the bladder neck and moving laterally.

• The lateral pedicles may be identifiable at this point and can be either tied or clipped. This maneuver further frees up the prostate from its attachment with the bladder.

• These maneuvers will better define the presence of the Foley catheter within the bladder neck.

• This dissection is then carried around the Foley catheter to expose the posterior bladder neck.

• Once dissection is carried around the posterior aspect of the bladder neck, the posterior bladder neck is incised. This frees up the prostate from the bladder.

Step XII. Dissecting posterior to the bladder neck.

• Once the posterior bladder is incised, a Metzenbaum scissors is used to dissect underneath the posterior bladder neck.

• The curve of the scissors is directed downwards (away from the bladder) and gentle dissection behind the isolated bladder neck should free up the space behind the bladder. A 1 inch wide malleable retractor is used to retract the bladder upwards to visualize the ampullae of the vas deferens.

Step XIII. Ligating ampullae of vas deferens.

• Blunt and sharp dissection around the ampullae is carried out.

• Each ampullae is individually ligated and transected.

• The malleable retractor is invaluable at this stage of the procedure

Step XIV. Repositioning the Penrose for enhanced retraction.

• After the ampullae have been ligated, a right angle forceps is passed around the entire prostate posteriorly just above the rectum and brought out at the site of the transected ampullae.

• The Penrose drain that was within the prostatic urethra is then removed and replaced around the entire prostate to assist in retraction.

• The Penrose drain now goes between the transected ampullae and around the entire prostate.

Step XV. Isolating the seminal vesicles

• The dissection is carried laterally (still posterior to the bladder). The seminal vesicles are identified.

• The Metzenbaum scissors is a useful tool to isolate the seminal vesicle. Use the curve of the scissors along the curves of the seminal vesicles.

• Identify the vasculature at the apex of the seminal vesicle. Ligate, clip, or cauterize these prior to transecting the apical region of the seminal vesicle.

Step XVI. Ligating posterior prostatic pedicles.

• Downward traction of the Penrose drain that is around the entire prostate will further isolate the posterior prostatic pedicles. These are the only structures at the present time holding the prostate in place.

• The prostatic pedicles can be taken in segments and either clipped or ligated.

• If a nerve-sparing prostatectomy is being performed, ensure that the nerves are away from this part of the dissection. Once the pedicles are ligated, the prostate is free and can be delivered.

Step XVII. Hemostasis.

• The specimen is examined to ensure that all of it has been completely removed. If the seminal vesicles have not been completely removed, every effort is made to remove the rest at this point.

• Hemostasis is ensured.

• Any bleeding is usually at the site of the apex of the seminal vesicles.

• The bladder neck is reconstructed to a 24 Fr. size in a standard fashion, if required.

• Everting the mucosa at the bladder neck using 4-0 chromic sutures is recommended.

Step XVIII. Vesico-urethral anastomosis.

• Vesico-ureteral anastomosis is one of the easier parts of RPP. The catheters, which are exiting through the urethral and the bladder neck areas, are invaluable in assisting with the anastomosis.

• The anterior anastomotic sutures are placed first using 2-0 polyglycolic acid sutures or chromic sutures.

• The sutures are initally taken through the bladder neck and then the urethral end so that the knots can be tied on the outside. Once the anterior sutures are taken the two catheters in place are removed sequentially and the final Foley catheter is passed through the urethral meatus and then into the bladder. Using a 20 Fr., 30 ccs catheter is recommended.

• Additional sutures in the posterior urethra are taken. Usually a total of five sutures are easily placed.

• The Omni retractor is then removed. The stirrups are brought forward to decrease any tension while these sutures are being tied.

Step XIX. Insertion of Penrose drain.

• The vesico-urethral anastomotic site is drained with a small Penrose drain that exits through another small incision, lateral to the skin incision.

• The wound is closed in multiple layers using absorbable sutures.

• The levator ani muscles and the rectum are repositioned as anatomically as possible. The skin is closed with subcuticular absorbable sutures.

• Adequate dressing is applied.

• The Foley catheter is securely taped and anchored to the thigh.

Step XX. Post operative care.

• Patients are usually sent back to a regular room following recovery.

• Patients are fed clear liquids as soon as they are awake and alert and able to tolerate this. The dressing is checked for urine drainage.

• Most Penrose drains are out within 24-48 hours. A majority of patients are discharged within 24 hours. The Penrose drain may be removed on an outpatient basis.

• The Foley catheter is usually left in place for approximately two weeks.

• Following removal of the Foley catheter, the patient is given routine instructions on Kegal exercises.

• The rest of the follow-up is routine.

References:

Thomas, R. Radical Perineal Prostatectomy Made Easy: A Step-by-Step Approach. Techniques in Urology, Vol. 1, No. 2, Pages 106-114, 1995. (Lippincott-Raven publishers).

Thomas, R., Steele, R., Smith, R. and Brannan, W. One-Stage Laparoscopic Pelvic Lymphadenectomy and Radical Perineal Prostatectomy. J. Urol. 152: 1174-7, 1994.

Paulson, D.F. : Perineal Prostatectomy In: Campbells Urology, Vol. 3, 6th ed. Philadelphia: W.B. Saunders , pp. 2887-99, 1992.

Walsh, P.C., Radical Prostatectomy: Preservation of sexual function, cancer control. The controversy. Urol. Clin. North Am. 14: 663, 1987.