Radical retropubic prostatectomy
Encyclopedia
Radical retropubic prostatectomy is a surgical procedure
in which the prostate
gland is removed through an incision in the abdomen
. It is most often used to treat individuals who have early prostate cancer
. Radical retropubic prostatectomy can be performed under general, spinal, or epidural anesthesia and requires blood transfusion
less than one-fifth of the time. Radical retropubic prostatectomy is associated with complications such as urinary incontinence
and impotence, but these outcomes are related to a combination of individual patient anatomy, surgical technique, and the experience and skill of the surgeon.
and the top of the pubic bone. Since initial description by Walsh, technical advancements have been made, and incisional length has decreased to 8–10 cm (well below the belt-line). The pelvis is then explored and the important structures such as the urinary bladder
, prostate, urethra
, blood vessels, and nerve
s are identified.
The prostate is removed from the urethra below and the bladder above, and the bladder and urethra are reconnected. The blood vessels leading to and from the prostate are then divided and tied off. Recovery typically is rapid; individuals are usually able to walk and eat within 24 hours after surgery. A catheter
through the penis into the bladder is typically required for at least a week after surgery. A surgical drain is often left in the pelvis for several days to allow drainage of blood
and other fluid. Additional components of the operation may include:
An intraoperative electrical stimulation penile plethysmograph
may be applied to assist the surgeon in identifying the difficult to see nerves.
s such as bone scan
s, computed tomography
(CT), and magnetic resonance imaging
(MRI), to identify cancer outside of the prostate. Radical retropubic prostatectomy may also be used if prostate cancer has failed to respond to radiation therapy
, but the risk of urinary incontinence is substantial.
) but this is highly surgeon-dependent. Impotence is common when nerve-sparing techniques are not used. Although erection and ejaculation are affected, penile sensation and the ability to achieve orgasm
remain intact. Therefore, use of medications such as sildenafil
(Viagra), vardenafil
(Levitra), or tadalafil
(Cialis) may restore some degree of potency when the cavernous nerves remain functioning.
Continence and potency may improve depending on the amount of trauma and the patient's age at the time of the procedure, but progress is frequently slow. Potency is greatly affected by the psychological attitude of the patient. The sensation of orgasm may be altered and no semen is produced, but there may be a few drops of fluid from the bulbourethral glands. Marital counseling focusing on the changes may be effective in restoring potency or maintaining a satisfactory spousal relationship if impotence continues.
Erectile dysfunction
outcomes can be predicted by intraoperative cavernous nerve electrical stimulation with a penile plethysmograph
. The results aid in managing additional therapeutic options earlier.
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
in which the prostate
Prostate
The prostate is a compound tubuloalveolar exocrine gland of the male reproductive system in most mammals....
gland is removed through an incision in the abdomen
Abdomen
In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
. It is most often used to treat individuals who have early prostate cancer
Prostate cancer
Prostate cancer is a form of cancer that develops in the prostate, a gland in the male reproductive system. Most prostate cancers are slow growing; however, there are cases of aggressive prostate cancers. The cancer cells may metastasize from the prostate to other parts of the body, particularly...
. Radical retropubic prostatectomy can be performed under general, spinal, or epidural anesthesia and requires blood transfusion
Blood transfusion
Blood transfusion is the process of receiving blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood...
less than one-fifth of the time. Radical retropubic prostatectomy is associated with complications such as urinary incontinence
Urinary incontinence
Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners...
and impotence, but these outcomes are related to a combination of individual patient anatomy, surgical technique, and the experience and skill of the surgeon.
Description
Radical retropubic prostatectomy was developed in 1945 by Terence Millin at the All Saints Hospital in London. The procedure was brought to the United States by one of Millin's students, Samuel Kenneth Bacon, M.D., adjunct professor of surgery, University of Southern California, and was refined 1982 by Patrick C. Walsh at the James Buchanan Brady Urological Institute, Johns Hopkins Medicine. It can be performed in several different ways with several possible associated procedures. The most common approach is to make an incision in the skin between the umbilicusNavel
The navel is a scar on the abdomen caused when the umbilical cord is removed from a newborn baby...
and the top of the pubic bone. Since initial description by Walsh, technical advancements have been made, and incisional length has decreased to 8–10 cm (well below the belt-line). The pelvis is then explored and the important structures such as the urinary bladder
Urinary bladder
The urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow muscular, and distensible organ, the bladder sits on the pelvic floor...
, prostate, urethra
Urethra
In anatomy, the urethra is a tube that connects the urinary bladder to the genitals for the removal of fluids out of the body. In males, the urethra travels through the penis, and carries semen as well as urine...
, blood vessels, and nerve
Nerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...
s are identified.
The prostate is removed from the urethra below and the bladder above, and the bladder and urethra are reconnected. The blood vessels leading to and from the prostate are then divided and tied off. Recovery typically is rapid; individuals are usually able to walk and eat within 24 hours after surgery. A catheter
Foley catheter
A Foley catheter is a flexible tube that is often passed through the urethra and into the bladder. The tube has two separated channels, or lumens, running down its length. One lumen is open at both ends, and allows urine to drain out into a collection bag...
through the penis into the bladder is typically required for at least a week after surgery. A surgical drain is often left in the pelvis for several days to allow drainage of blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
and other fluid. Additional components of the operation may include:
- LymphadenectomyLymphadenectomyLymphadenectomy consists of the surgical removal of one or more groups of lymph nodes. It is almost always performed as part of the surgical management of cancer....
- Prostate cancer often spreads to nearby lymph nodes in the early stages. Removal of select lymph nodes in the pelvis allows microscopicMicroscopeA microscope is an instrument used to see objects that are too small for the naked eye. The science of investigating small objects using such an instrument is called microscopy...
evaluation for evidence of cancer within these nodes. If cancer is found in the lymph nodes, different therapies may be offered - Nerve-sparing surgeryNerve-sparing surgeryNerve-sparing surgery is a type of surgery that attempts to save the nerves near the tissues being removed.It is commonly applied in radical retropubic prostatectomy where surgeons may visually identify the cavernous nerves of penis or apply an electrical stimulation penile plethysmograph...
- Select individuals will be eligible for nerve-sparing surgery. Nerve-sparing surgery attempts to protect the Cavernous nerves of penisCavernous nerves of penisThe cavernous nerves are post-ganglionic parasympathetic nerves that facilitate penile erection. They arise from cell bodies in the inferior hypogastric plexus where they receive the pre-ganglionic pelvic splanchnic nerves ....
nerves which control erection. These nerves run next to the prostate and may be destroyed during surgery, leading to impotence. If the cancer is clinically unlikely to have spread beyond the prostate, nerve-sparing surgery should be offered to minimize impotency and to speed up urinary control.
An intraoperative electrical stimulation penile plethysmograph
Penile plethysmograph
Penile plethysmography , or "phallometry", refers to measurement of bloodflow to the male genital. The most commonly reported methods of conducting penile plethysmography involve the measurement of the circumference of the penis with a mercury-in-rubber strain gauge, or the volume of the penis with...
may be applied to assist the surgeon in identifying the difficult to see nerves.
Indications
Radical retropubic prostatectomy is typically performed in men who have early stage prostate cancer. Early stage prostate cancer is confined to the prostate gland and has not yet spread beyond the prostate or to other parts of the body. Attempts are made prior to surgery, through medical testMedical test
A diagnostic test is any kind of medical test performed to aid in the diagnosis or detection of disease. For example:* to diagnose diseases, and preferably sub-classify it regarding, for example, severity and treatability...
s such as bone scan
Bone scan
A bone scan or bone scintigraphy is a nuclear scanning test to find certain abnormalities in bone which are triggering the bone's attempts to heal. It is primarily used to help diagnose a number of conditions relating to bones, including: cancer of the bone or cancers that have spread to the bone,...
s, computed tomography
Computed tomography
X-ray computed tomography or Computer tomography , is a medical imaging method employing tomography created by computer processing...
(CT), and magnetic resonance imaging
Magnetic resonance imaging
Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...
(MRI), to identify cancer outside of the prostate. Radical retropubic prostatectomy may also be used if prostate cancer has failed to respond to radiation therapy
Radiation therapy
Radiation therapy , radiation oncology, or radiotherapy , sometimes abbreviated to XRT or DXT, is the medical use of ionizing radiation, generally as part of cancer treatment to control malignant cells.Radiation therapy is commonly applied to the cancerous tumor because of its ability to control...
, but the risk of urinary incontinence is substantial.
Complications
The most common serious complications of radical retropubic prostatectomy are loss of urinary control and impotence. As many as forty percent of men undergoing prostatectomy may be left with some degree of urinary incontinence, usually in the form of leakage with sneezing, etc. (stress incontinenceStress incontinence
Stress incontinence is a form of urinary incontinence.Stress urinary incontinence , also known as effort incontinence, is due essentially to insufficient strength of the pelvic floor muscles.-Pathophysiology:...
) but this is highly surgeon-dependent. Impotence is common when nerve-sparing techniques are not used. Although erection and ejaculation are affected, penile sensation and the ability to achieve orgasm
Orgasm
Orgasm is the peak of the plateau phase of the sexual response cycle, characterized by an intense sensation of pleasure...
remain intact. Therefore, use of medications such as sildenafil
Sildenafil
Sildenafil citrate, sold as Viagra, Revatio and under various other trade names, is a drug used to treat erectile dysfunction and pulmonary arterial hypertension . It was originally developed by British scientists and then brought to market by the US-based pharmaceutical company Pfizer...
(Viagra), vardenafil
Vardenafil
Vardenafil is a PDE5 inhibitor used for treating erectile dysfunction that is sold under the trade names Levitra and Staxyn.-History:...
(Levitra), or tadalafil
Tadalafil
Tadalafil is a PDE5 inhibitor, currently marketed in pill form for treating erectile dysfunction under the name Cialis; and under the name Adcirca for the treatment of pulmonary arterial hypertension...
(Cialis) may restore some degree of potency when the cavernous nerves remain functioning.
Continence and potency may improve depending on the amount of trauma and the patient's age at the time of the procedure, but progress is frequently slow. Potency is greatly affected by the psychological attitude of the patient. The sensation of orgasm may be altered and no semen is produced, but there may be a few drops of fluid from the bulbourethral glands. Marital counseling focusing on the changes may be effective in restoring potency or maintaining a satisfactory spousal relationship if impotence continues.
Erectile dysfunction
Erectile dysfunction
Erectile dysfunction is sexual dysfunction characterized by the inability to develop or maintain an erection of the penis during sexual performance....
outcomes can be predicted by intraoperative cavernous nerve electrical stimulation with a penile plethysmograph
Penile plethysmograph
Penile plethysmography , or "phallometry", refers to measurement of bloodflow to the male genital. The most commonly reported methods of conducting penile plethysmography involve the measurement of the circumference of the penis with a mercury-in-rubber strain gauge, or the volume of the penis with...
. The results aid in managing additional therapeutic options earlier.