Radical Prostatectomy

Radical prostatectomy is an established option to treat localized prostate cancer, based upon rates of long-term cancer control, perioperative morbidity and mortality, and side effect profile. The potential for cure with radical prostatectomy is highest when the cancer is confined to the prostate gland. RP is also an appropriate option for some men with locally advanced (T3) prostate cancer

RP is used as a potentially curative salvage procedure to treat carefully selected men with a local recurrence after RT for localized prostate cancer. Surgical techniques include open retropubic RP, laparoscopic RP, and robotic RP.

Open retropubic RP — An open retropubic RP is a widely used surgical approach for treating localized prostate cancer.

The most widely used clinical end point to measure the efficacy of RP is the absence of detectable PSA in the serum after treatment. The likelihood of recurrence depends upon the grade, volume, and pathologic extent of disease. Patients with organ-confined disease have long-term biochemical relapse-free survival rates of 80 to 90 percent, while those with locally advanced disease (extraprostatic extension, positive surgical margins, seminal vesicle invasion, regional lymph node involvement) have an increased risk of recurrence.

Disease-free and overall survival rates are even higher since many men with a biochemical recurrence do not have a clinical recurrence of their prostate cancer.

Minimally invasive RP — RP performed by a minimally invasive approach (robotic or laparoscopic) is an alternative to open radical retropubic RP. Because of the small incisions and magnification during surgery, minimally invasive RP appears to offer shorter hospital stays, more rapid recovery, and fewer acute complications. However, the impact of the approach on urinary incontinence and erectile dysfunction are unclear.

The rates of cure and functional recovery are related to the experience of the surgeon.

Perineal RP — A perineal RP is an alternative for some men with localized (T1-2) prostate cancer and a relatively small prostate gland.

Perineal RP is associated with less blood loss than open retropubic RP and is associated with a similar frequency of positive margins and biochemical relapse. However, recovery of potency is delayed and less frequent with the perineal approach, even with a nerve-sparing procedure. There is also a small, but increased risk of rectal injury and fecal incontinence.

There are no good randomized controlled trials in the literature comparing efficacy and complication outcomes between the different modalities of RP.

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