The “open” radical perineal prostatectomy is the oldest “modern” surgical approach to removal of the prostate that is still in use today. It was first used in 1905 by a surgeon called Hugh Hampton Young (see right), who, like Patrick Walsh (the developer of the “anatomic” approach to radical retropubic prostatectomy) also taught and practiced medicine at Johns Hopkins Hospital in Baltimore, Maryland.
- The procedure is carried out in a hospital under general, spinal, or epidural anesthesia.
- Your surgeon will make the primary (curved) incision through your perineum (the area between your scrotum and your anus). He (or she) will carry out the operation through this incision.
- The operation will include the removal of the entire prostate and the associated seminal vesicles, but the perineal approach makes it impossible to remove any of the lymph nodes as an integral part of this procedure.
- After removal of the relevant organs, the surgeon will reconnect your urethra to your bladder so that urinary function is restored post-surgery.
- All patients will initially require a urinary catheter (a tube that runs up through your penis into your bladder).The primary reason for catheterization is not to manage continence; rather, it is to ensure healing of the connection between the bladder and the urethra in the proper anatomical position.
It should be made clear that the modern radical perineal prostatectomy (like the modern radical retropubic prostatectomy) allows for “nerve sparing” (preservation of the neurovascular bundles on both sides of the prostate) in order to permit recovery of erectile function post-surgery.
This operation tends to be slightly easier to perform than the radical retropublic procedure and may take between 60 minutes and 2 hours depending on things like prostate shape and size and other factors such as previous surgery (e.g., a transurethral resection of the prostate or TURP), as well as the skill of the surgeon.
There is normally a relatively brief period for recovery and observation in hospital (1-2 days) and then an extended recovery period of a week to 10 days at home.
For a detailed description of the modern radical perineal procedure, we refer the interested reader to the following source:
- A detailed description of this procedure by Korman and Harris is available on the eMedicine web site, complete with surgical imagery. This description was prepared for the education of other physicians and surgeons.
The procedure described by Korman and Harris includes the perineal version of “anatomic” nerve sparing. From the patient’s point of view, these technical details of the surgery are not of great significance. It is the outcome that is of importance.
Any patient who is believed to have early stage (localized) prostate cancer, i.e., prostate cancer that is confined within the prostate, is theoretically an appropriate candidate for open radical perineal prostatectomy. Such patients would normally have clinical stage T1N0M0 or T2N0M0 prostate cancer.
The Results You Can Reasonably Expect
Based on his series of 508 patients published in 2007, Harris has reported the following outcomes:
- Among patients with pathological stage T2N0M0 (comprising 64.2 percent of all prostate cancers shown to organ-confined post surgery), 96.3 percent had no indication of disease recurrence (PSA levels < 0.2 ng/mL) at follow-up ranging from 3 months to 8.5 years (mean 4 years).
- Among patients with pathological stage T3N0M0 with positive or negative surgical margins (comprising 30.1 percent of all prostate cancers believed to have extracapsular disease that did not extend to the seminal vesicles at the time of surgery), 69 percent had no indication of disease recurrence within the same time frame.
- Among patients with pathological stage T3N0M0 with positive seminal vesicles (comprising 4.9 percent of all prostate cancers at the time of surgery), only 24 percent had no indication of disease recurrence within the 3-month to 8.5-year follow up timeframe.
As in the case of radical retropubic prostatectomy, the message to the patient is that truly localized disease can be treated by open radical perineal prostatectomy with a high degree of confidence that all cancer will be removed if the cancer really is organ-confined at the start of surgery. However, again, until the operation is completed, the surgeon simply has no way to tell whether the tumor really is organ-confined.
A variety of tools, including the Partin tables, the Han tables, and the Kattan nomograms are available to help doctors and their patients project the likelihood of particular outcomes after radical perineal prostatectomy, based on pre-surgical data (the patient’s PSA, clinical stage, and biopsy-based Gleason score), post-surgical data (the patient’s pathological stage and pathology-based Gleason score), and other factors. These “prognostic tools” are discussed in detail elsewhere. (The fact that these tools were developed based on data from radical retropubic procedures as compared to radical perineal procedures appears to be unimportant.)
The Adverse Effects of Treatment
Like radical retropubic prostatectomy, radical perineal prostatectomy comes with a series of common (but usually manageable) short-term side effects, a risk for some significant and problematic long-term side effects, and some serious short-term risks, as follows:
The common, short-term side effects — Immediately following surgery almost every patient has two short-term problems. He has little to no control over his bladder, and he will have lost the ability to have an erection (even if he has the nerve-sparing procedure).
Assuming that the operation has been successfully carried out, and there are no unexpected complications, a high level of urinary control will start to return within weeks or a couple of months. (It is true that some men are continent immediately but they compose a decidedly small proportion of patients.)
Harris’s patients reported the following rates of return of continence (i.e., the patients stated that they no longer needed to use pads and were “dry”):
- 38 percent at 1 month
- 65 percent at 3 months
- 88 percent at 6 months
- 96 percent at 1 year.
However, nearly all men will find that they don’t have quite the same degree of urinary control as they may have had prior to their surgery. Even 5 or 10 years after surgery, some men may worry about minor leakage on sudden movement or when lifting a heavy weight. For most men this is a minor irritation as opposed to a serious problem.
Recovery of erectile function normally takes longer. The neurovascular bundles (even when preserved) are always affected to some degree by the surgical procedure. (You can think of this in terms of them being badly bruised by the procedure.) Some men find that they recover a degree of erectile function within a few weeks. For others it may take 18 months to 2 years. The overall likelihood of recovery of erectile function is dependent on many factors, not just on anatomical preservation of the neurovascular bundles. These factors including age, baseline function, obesity, smoking history, other illnesses (e.g., diabetes, depression, and fatigue), and more. Radical prostatectomy is not an operation designed to improve erectile performance for men! The use of products like sildenafil (Viagra/Pfizer) or taldalifil (Cialis/Lilly) can assist with both the return of erectile function and the quality of performance once function has returned.
Problems with bowel movements appear to be minor in men undergoing the perineal procedure.
Significant, longer-term problems — For a relatively small percentage of men (particularly in the hands of the most skilled and experienced surgical teams), long-term incontinence and perceived failure to achieve the return of erectile function may become major issues. And if both neurovascular bundles have to be removed, then normal erectile function is very rarely going to return (although it is known to happen). There are ways to address both of these problems, but they require the understanding and the cooperation of both partners. For many men, loss of erectile function can be emotionally and psychologically disturbing and, in combination with the diagnosis of cancer and other life stressors, can lead to clinical depression.
Similarly, some men may never regain a normal level of urinary continence; and we do not understand why this happens. Again, there are ways to manage such problems, sometimes requiring additional surgery or other interventions. However, as with loss of erectile function, loss of bladder control can lead to depression as a consequence of the loss of control over an important, normal function.
The third longer term issue that occurs with some frequency is a slowly (or sometimes rapidly) increasing difficulty with urination. Most commonly this is a result of what is known as a “bladder neck contracture.” When your urethra is reconnected to your bladder, there may be regrowth of tissue as the surgical join recovers. This may result in the new tissue gradually blocking the urethral passage, and making it difficult or impossible to urinate. Various surgical means are available to resolve this problem in the short term and the longer term. For the vast majority of men who experience this problem, it may be temporarily worrisome but is relatively easily solved.
The serious short-term risks — An open radical retropubic prostatectomy is a serious and invasive surgical procedure. As with all such procedures, there are risks related to anesthesia and the normal complications of surgery. In the past, death was considered to be a significant risk associated with this type of surgery. However, today, the number of deaths associated with radical prostatectomy has become vanishingly small except in the most unusual circumstances. (Please understand that it is never zero for any invasive surgical procedure.)
The risk of serious blood loss is much less of a problem with the perineal procedure than it is with the retropubic procedure. In his series of 508 patients, Harris reports transfusion in only 5 cases (1 percent), all occurring in the first 140 patients.
Patients should appreciate that this is not, nor is it intended to be, a complete list of every possible risk associated with open radical perineal prostatectomy. If you decide to work with a surgeon who intends to use this procedure, you should be sure to review these and other risks — infertility, infection, injury to other organs, pain, recurrence — with that surgeon prior to your operation, and you will certainly be asked to sign a relevant consent form prior to surgery.