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Radical Retropubic Vs. Radical Perineal Prostatectomy: a Comparison of Relative Benefits in Four Urban Hospitals

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Radical Retropubic Vs. Radical Perineal Prostatectomy: a Comparison of Relative Benefits in Four Urban Hospitals 519-UNJ December 2007.ps 11/28/07 3:24 AM Page 519 Radical Retropubic vs. Radical Perineal Prostatectomy: A Comparison of Relative Benefits In Four Urban Hospitals Matthias May Bernd Hoschke Michael Siegsmund Manuela Dorst Dirk Fahlenkamp Jana May Horst Vogler variety of surgical ap- This study used a retrospective chart review to compare outcomes from proaches exist for radi- 1,304 men who underwent a radical prostatectomy as treatment for cal prostatectomy. This localized prostate cancer.While differences between surgical approach- procedure, initially per- es were apparent, mortality and morbidity rates were similar. Aformed in 1867, was performed using a perineal approach (Billroth, 1869). Young (1905) Introduction Results advocated for this approach and defined the technique of radical The purpose of this study was to RRP had a longer operative evaluate the oncological and function- duration, higher EBL, higher BTR, and perineal prostatectomy (RPP) al outcome of retropubic and perineal longer hospital stay. The 5-year bio- almost a century ago. This approaches to radical prostatectomy. chemical-free survival rates were not approach remained the surgical significantly different between the two treatment of choice until the early Method techniques. 1980s when the nerve-sparing Data from 1,304 patients who radical retropubic prostatectomy underwent either radical retropubic Conclusions (RRP) was utilized by Walsh and (RRP) or radical perineal prostatectomy These results indicate there are no (RPP) over a 12-year period were com- significant differences in oncological pared. Variables included age, prostate- and functional outcomes between RRP specific antigen (PSA) level preopera- and RPP.However, RPP demonstrates tive, prostate volume, Gleason score, minimal EBL, low BTR, and shorter Matthias May, MD, is Chief Physician, estimated blood loss (EBL), blood trans- operative duration. Department of Urology, Carl-Thiem fusion rate (BTR), operative duration, Hospital, Cottbus (CTKC), Cottbus, surgical margin, pathological stage, Germany. short and long-term complication rates, impotence, and incontinence rates. Manuela Dorst, MD, is Assistant Doctor, Department of Urology, Vivantes-Clinic am Urban, Berlin (VCUB), Berlin, Germany. Donker (1982). Since then, the the procedure of choice. First, ini- RRP has become the standard sur- tial research results demonstrated Jana May, MD, is Assistant Doctor, gical approach utilized for clini- good results when a radical Department of Urology, Carl-Thiem cally localized prostate cancer laparoscopic prostatectomy was Hospital, Cottbus (CTKC), Cottbus, (Roehl, Han, Ramos, Antenor, & performed by an expert surgeon. Germany. Catalona, 2004). Advantages to this procedure included a lower complication Bernd Hoschke, MD, is Head Two developments altered Physician, Department of Urology, the perception that the RRP was rate and less blood loss while Carl-Thiem Hospital, Cottbus (CTKC), Cottbus, Germany. Horst Vogler, MD, PhD, is Head Physician, Department of Urology, Vivantes-Clinic Dirk Fahlenkamp, MD, PhD, is Head im Friedrichshain, Berlin (VCFB), Berlin, Germany. Physician, Department of Urology, Ruppiner Clinic, Neuruppin (RCN), Michael Siegsmund, MD, PhD, is Head Physician, Department of Urology, Neuruppin, Germany. Vivantes-Clinic am Urban, Berlin (VCUB), Berlin, Germany. UROLOGIC NURSING / December 2007 / Volume 27 Number 6 519 520-UNJ December 2007.ps 11/28/07 3:24 AM Page 520 achieving similar oncological and Figure 1. functional outcome (Guillonneau, Radical Prostatectomies from 1992 to 2003 Cathelineau, Doublet, & Vallancien, (Retropubic [RRP] vs. Perineal [RPP] Approach) 2001; Stolzenburg al., 2005). Dis- advantages associated with this 1992/93 1994/95 1996/97 1998/99 2000/01 2002/03 procedure included a lengthy sur- gical learning curve, a longer sur- gical time, and high initial capital expenses to purchase the neces- 300 sary equipment. These constraints limited the procedure to academ- ic training centers (Janoff & Parra, 2005). Second, the publication of 200 the Partin-tables in 1997 offered the opportunity to estimate the probability of pelvic lymph node metastases by patients with organ Frequency confined disease (Partin et al., 100 1997). This knowledge, together with the increased use of laparo- scopic pelvic lymph node dissec- tion (LPLND) in patients with high- 0 risk tumors, resulted in a renais- sance of RPP in the late 1990s RRR vs. RPP (Holzbeierlein, Langenstroer, Porter, & Thrasher, 2003; Matsubara et al., 2005). was performed by determining term complication(s), and bio- When comparing outcomes positive margins, biochemical chemical recurrence rates. of RRP, RPP results in a lower recurrence, and short and long- The EBL was defined as the estimated blood loss (EBL), term morbidity. The correlation volume of blood loss recorded by shorter operative time, nearly between these variables and the anaesthetist during surgery. immediate patient mobilization, treatment approach has not been The radical prostatectomy speci- and faster dismissal from hospi- verified in the literature. men was analyzed according to tal (Holzbeierlein et al., 2003; the Stanford protocol (Stamey, Matsubara et al., 2005). Al- Materials and Methods McNeal, Freiha, & Redwine, though the overall complication Data were collected using a 1988). The clinical and pathologi- rates between both appear to be retrospective chart review which cal staging was based on the 2002 quite similar, rectal injuries asso- included 1,304 men who under- TNM classification (Wittekind & ciated with RPP have been dis- went a radical prostatectomy for Wagner, 2002). Organ-confined cussed in the literature. This ten- localized prostate cancer at one tumor (OC) was defined as a dency, and the technical limits of four urban hospitals that pathological stage of pT2c N0; encountered in patients with served as study sites. Data non-organ-confined with capsular large prostate volume, represent included 1,184 men who under- penetration (NOC-CP) was defined the major disadvantages of RPP went RRP and 120 men who as a pathological stage of pT3a N0; (Holzbeierlein et al., 2003; underwent RPP from 1992 to non-organ-confined due to ad- Matsubara et al., 2005). 2003. Transrectal ultrasound- vanced disease (NOC-AD) was guided multi-core biopsies were defined as a pathological stage of Purpose performed to confirm the diagno- pT3b N0 or every pT and N+. Limited health care resources sis in each case. Pre-operative Incontinence after surgery and financial constraint of a pub- data included age, PSA level, the was defined as the involuntary lic health care system encouraged prostate volume (measured by loss of any urine and impotence us to compare the oncological and ultrasound), number of positive as the inability to gain an erec- functional results of RRP and RPP. biopsies, biopsy Gleason sum, tion (with or without pharmaceu- The purpose of this study was to and clinical stage. Intra-operative tical assistance) sufficient for sat- determine the most cost-effective data included the length of surgi- isfactory sexual intercourse. The therapy. Data were collected from cal time, EBL, incidence of blood use of auxiliary devices to attain four urban hospitals, using med- transfusions, organ-confined rate, or maintain an erection was ical records to obtain operative margin-positive rate, location of grouped as inability. time, blood transfusion rate, and margins, pathological stage, and A skewing of these data length of hospital stay. Assessing specimen Gleason sum. Post- occurred as a result of the retro- the oncological and functional operative data included the length pubic approach being used since equivalence for RRP and RPP of hospital stay, short and long- 1992 and the perineal approach 520 UROLOGIC NURSING / December 2007 / Volume 27 Number 6 521-UNJ December 2007.ps 11/28/07 3:24 AM Page 521 Table 1. Characteristics and Outcomes for 1.304 Patients Undergoing Radical Retropubic Prostatectomy (RRP) and Radical Perineal Prostatectomy (RPP) (p=Not Significant, *p<0.05, **p<0.01, ***p<0.001) Variable RRP (n = 1184) RPP (n =120) Mean age, years 63.6 Mean PSA level, ng/ml 13.6 Clinical stage, no. (%) 64.1 ÷ cT1c 432 (36.5) 10.3* cT2 691 (58.4) *** cT3 61 (5.1) 68 (56.7) Biopsy Gleason sum, no. (%) 52 (43.3) GS 2-4 204 (17.2) 0 GS 5-7 856 (72.3) ÷ GS >8 124 (10.5) 27 (22.5) Mean prostate volume, ml 32.4 87 (72.5) Mean PSA density, ng/ml2 0.49 6 (5.0) Mean percent positive cores 55.9 25.2*** Distance between diagnosis and prostatectomy, weeks 10.1 Operating time, min 150.3 Estimated blood loss, ml 1130.7 Mean blood transfusion, units 1.9 Hospital stay, days 15.4 Pathological stage, no. (%) 0.43 ÷ OC 739 (62.4) 41.9*** NOC-CP 188 (15.9) 10.5 ÷ NOC-AD 257 (21.7) 124.3*** Specimen Gleason sum, no. (%) 494.7*** GS 2-4 64 (5.4) 0.6*** GS 5-7 870 (73.5) 10.6*** GS >8 250 (21.1) *** Positive surgical margin, no. (%) 394 (33.3) 98 (81.7) Apical positive margins, no. (%) 204 (17.2) 11 (9.2) Mid lobar positive margins (anterior, posterior or lateral), no. (%) 86 (7.3) 11 (9.2) Bladder neck positive margins, no. (%) 20 (1.7) *** Multilocular positive margins, no. (%) 84 (7.1) 15 (12.5) Positive surgical margin rate for OC tumors, no. (%) 148 (20.0) 93 (77.5) Positive surgical margin rate for NOC-CP tumors, no. (%) 87 (46.3) 12 (10.0) Positive surgical margin rate for NOC-AD tumors, no. (%) 159 (61.9) 41 (34.2) ÷ Perioperative mortality, no. (%) 2 (0.17) 7 (5.8)** Procedure aborted, no. (%) 0 22 (18.3)*** Wound infection, no. (%) 94 (8.0) Postoperative bleeding/ reexploration, no. (%) 37 (3.1) Rectal injury, no. (%) 15 (1.3) Pneumonia, no. (%) 18 (1.5) Ureter traumation, no. (%) 14 (1.2) Anastomosis stricture, no. (%) 60 (5.1) Continence (>12 months after surgery), no. (%) 732 (62.0) 4 (3.3) ÷ Mild incontinence (1.°), no. (%) 436 (37.0) 8 (6.7) ÷ Severe incontinence (2.°-3.°), no. (%) 12 (1.0) 24 (24.5) ÷ Preservation of the neurovascular bundle, no.
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