Radical prostatectomy

Radical prostatectomy (RPE) - removal of the prostate gland and seminal vesicles behind pubic or perineal access. Laparoscopic and robot-assisted laparoscopic prostatectomy is becoming more common. The use of minimally invasive prostatectomy techniques allows earlier to activate the patient and shorten the period of hospitalization.

Radical prostatectomy was first performed in 1866, and at the beginning of the 20th century. When it was performed, crotch access was applied. Later, a retrospective access was offered. In 1982, the anatomy of the venous plexus and the neurovascular bundles of the prostate gland was described, which significantly reduced blood loss, the risk of impotence and incontinence.

Prostateectomy is the only treatment that has shown in a randomized trial to reduce the risk of death from a tumor compared to a dynamic observation. Its main advantage is the possibility of a complete cure of the underlying disease. When performed by an experienced physician, the operation involves a minimal risk of complications and gives a high chance of recovery. However, it should be borne in mind that radical prostatectomy is a complex operation with a very long "learning curve".

Posteroblock access is used in the bowl, as it allows removal of the pelvic lymph nodes. Given the anatomical features of the fascial cover of the gland (thinning in the fore sections), with crotch access, the possibility of preserving tumor cells in the area of resection is great. Probably, with perineal prostatectomy and laparoscopic lymphadenectomy, complications occur less often than in operations with post-retinal access. In recent years, some European centers have mastered laparoscopic prostatectomy. Despite the fact that data on long-term results have not yet been obtained, this method is gaining popularity.

Advantages and disadvantages of retropubic radical prostatectomy

Benefits	Missing
Excellent long-term survival	Risk of postoperative mortality and complications
Accuracy of stage and forecast determination	Risk of incomplete organ removal (positive surgical edge)
The possibility of simultaneous lymphadenectomy	Risk of persistent urinary incontinence or erectile dysfunction
Coping with complications	Visible cutaneous scar, possibility of postoperative hernia development
Early detection of relapse in the level of PSA and the possibility of carrying out other treatments (irradiation, HIFU, hormone therapy)	Hospitalization, temporary disability

With a localized tumor and an expected life expectancy of about 10 years or more, the goal of the operation (regardless of access) should be a cure. In case of refusal of treatment, the risk of dying from the underlying disease within 10 years is 85%. Age of the patient can not be an absolute contraindication to the operation, but with increasing age, the number of concomitant diseases increases, so after 70 years the risk of death directly from localized PCa is markedly reduced.

An important problem is the preservation of potency after surgery. The task of the urologist is to assess the degree of risk and the need to preserve the vascular-neural bundles responsible for the erectile function. A nerve-bending operation is shown to a limited number of patients who meet the following requirements before surgery: initially retained potency and libido, low cancer risk (PSA level less than 10 ng / ml, Gleason score - more than 6). Otherwise, the risk of local recurrence is high. With a high cancer risk, such patients are shown postoperative remote radiation therapy, so the preservation of vascular-neural bundles is inappropriate. To resume sexual activity after surgery, it is possible to use inhibitors of phospholiesterase type 5 (sildenafil, tadalafil), the use of intracavernous injections (alprostadil), vacuum eliminators. If the function is completely lost, it is possible to prosthetically replace the penis. If the patient insists on maintaining the neurovascular bundles, it is necessary to inform him about the recovery period of the potency (6-36 months), the risk of developing Peyronie's disease with incomplete stiffness of the penis and the possibility of complete loss of erectile function.

[1], [2], [3], [4], [5], [6], [7],

Preoperative preparation for radical prostatectomy

On the eve of the operation, the intake of fluid is limited, in the morning, a cleansing enema is performed before the operation. One hour before the operation, a single administration of antibiotics (fluoroquinolones or cephalosporins of III-IV generation) is indicated. The operation can be performed under epidural anesthesia or endotracheal anesthesia. A mandatory condition is compression of the lower extremities for the prevention of thromboembolic complications.

The main stages of the trailing RP:

• Tazoizaya lymphadenectomy.
• Dissection of the intraluminal fascia.
• Intersection of the laparoscopic ligaments (it is possible after the dorsal venous system is stitching - DVK).
• Stitching, ligation and crossing of DVK.
• Intersection of the urethra.
• Isolation of the prostate gland, seminal vesicles and vas deferens.
• Detachment of the prostate gland from the bladder.
• Reconstruction of the neck of the bladder.
• Imposition of anastomosis between the bladder and urethra.
• Drainage of the caucasus space.

The duration of the operation is 2-3 hours. Patients are activated the next day after the operation. Drainage is removed as the wound detachable decreases (less than 10 ml). The urethral catheter is removed on the 8th-12th day. To restore full retention of urine, recommend gymnastics Kegel. In the early postoperative period, in case of digging in urine, absorbent pads are used. Control of PSA level is carried out every 3 months after the operation.

Morphological study of macro preparation

A full study of the organ removed from the RPE requires a large number of blocks, which leads to significant economic costs. However, non-observance of the study protocol makes it difficult to clarify the stage of the disease and decide on the tactics of further treatment. The description of the macro preparation should contain the following information: description of the removed organ or tissue, mass (g), dimensions (cm) and number of samples, description of the tumor node (localization, size, appearance, margin). In histological conclusion, it is necessary to indicate: the histological type, the degree of Gleason differentiation, the degree of tumor spread, lymphatic and venous invasion, the damage of seminal vesicles and lymph nodes.

Extraprostatic spread is the germination of a tumor into adjacent non-iron tissues. The criteria for the spread of prostate cancer over the glandular capsule are based on the detection of components forming an off-pathogenic tumor site: tumor cells in adipose tissue, anterior muscle group, carcinoma in the perineural spaces of the neurovascular bundles. The extent of the lesion (has an important prognostic value) can be focal (several foci of the tumor outside the prostate gland) and diffuse (all other cases). The removal of seminal vesicles, in spite of preoperative examination, is carried out in full volume, which is connected with the mechanism of tumor spreading. It can occur by directly sprouting upwards, into a complex of seminal vesicles, by spreading from the base of the gland or surrounding fatty tissue, isolated in the form of a single metastasis without connection to the primary focus.

Tumors T _1a-2c (localized prostate cancer)

With a tumor of T _1a with a Gleason index of 2-4, the risk of progression without treatment is 5% when observed for 5 years, but after 10-13 years it reaches 50%. Thus, in patients with an expected life expectancy of 15 years or more, this risk is quite large. At the same time, most tumors T _1a and T _1b progress for 5 years and require radical treatment. That's why for diagnosis of tumors T _1a and T _1b recommended prostate biopsy after 3 months. For T _1b tumors and an expected life expectancy of more than 10 years, prostatectomy is indicated. After extensive transurethral resection, performing radical prostatectomy is technically more difficult.

The most common tumor is T _1c. In each case, it is difficult to predict the clinical significance of a tumor. According to most studies, T _1c tumors usually require treatment, since about a third of them have a localized nature. The proportion of clinically insignificant tumors is 11-16%. With an increase in the number of biopsies, this indicator may increase, although taking 12 biopsies usually does not increase it.

Dysplasia of the prostate is not considered an indication for treatment, but after 5 years, cancer is detected in 30% of patients with severe dysplasia, and after 10 years - in 80%. An easy degree of dysplasia is also dangerous: the risk of cancer in subsequent biopsies is comparable to that of severe dysplasia. Nevertheless, in the absence of cancer, radical prosthetectomy is not recommended, since dysplasia can be reversible.

It is important to determine for which T _1c tumors prostatectomy can be avoided. Predict nomographs can help to predict the significance of the tumor by biopsy data and the level of free PSA. Some doctors prefer to focus on biopsy results if the cancer is found in only one or a single biopsy and occupies a small part of the biopsy, the tumor is most likely not clinically significant (especially with a low Gleason index). In some such cases, dynamic observation is justified. However, usually for T _1c tumors , prostatectomy should be recommended, since most of these tumors are clinically significant.

Radical prostatectomy is one of the standard methods of treating T2 tumors with an expected lifespan of more than 10 years. If the morphological study of the tumor is limited to the prostate gland, the prognosis is favorable even at a low degree of differentiation (although usually such tumors go beyond the gland). With a high degree of differentiation, dynamic observation is possible, but it must be remembered that a biopsy often underestimates the Gleason index.

Tumors T ₂ is generally progressive. Without treatment, the median time to progression is 6-10 years. Even for tumors of T _2a risk of progression within 5 years of 35-55%, so when life expectancy of about 10 years or more is a prostatectomy. In T _2b tumors, the risk of progression is greater than 70%. The need for surgery confirms the comparison of prostatectomy with dynamic observation (most patients in this study had tumors T ₂ ). In relatively young patients, prostatectomy is the optimal method of treatment, but in elderly patients with severe concomitant diseases it is better to use radiation therapy.

The surgeon's experience and observance of surgery techniques can improve the results of surgical treatment of prostate cancer.

Tumors T ₃ (mestnorasprostranoeny prostate cancer)

The share of locally advanced tumors is gradually decreasing (before they were at least 50%), but the optimal tactics for their detection still causes discussion. Prostatectomy often does not allow to completely remove the tumor, which dramatically increases the risk of local recurrence. In addition, surgical complications in prostatectomy occur more often than with localized tumors. Most patients develop metastases to the lymph nodes and distant metastases. Thus, surgery for T ₃ tumors is usually not recommended.

Increasingly, a combination of hormone therapy and radiation is used, although it has not been proven that such a tactic is better than performing a prostatectomy. A randomized trial showed the advantage of combined treatment before the isolated use of radiation therapy, but there was no surgical control group in this study. Evaluation of the results of prostatectomy is also hampered by the frequent administration of concomitant adjuvant radiotherapy and immediate or delayed hormone therapy.

About 15% of tumors clinically assessed as T ₃ were localized (pT ₂ ), and only 8% were widespread (pT ₄ ). In the first case, the prognosis is favorable, but in the majority of patients with tumors of pT _3b, early relapses were noted.

Disease-free survival at 5 years (zero PSA) in tumors of T ₃ is about 20%. The prognosis depends on the Gleason index. Histologically examining the removed prostate, moderately- and low-differentiated cells are more often found. In addition to the degree of differentiation of cells to other independent adverse factors of the prognosis include invasion of seminal vesicles, metastasis to the lymph nodes, detection of tumor cells at the margin of resection and a high level of PSA (more than 25 ng / ml).

For tumors T _3a and a PSA content of less than 10 ng / ml, 5-year disease-free survival usually exceeds 60%. Thus, the operation can help not only those patients in whom the clinical stage was overstated, but also with a true T _3a. Ineffective surgery for patients with lymph node metastases and seminal vesicle invasion. Partian nomograms are used to detect this data. In addition, to evaluate the condition of lymph nodes and seminal vesicles, MRI helps.

Surgery for T ₃ tumors requires a high qualification of the surgeon, which helps to reduce the risk of complications and improve the functional results.

Metastasis to the lymph nodes

Lymphadenectomy can not be performed with low cancer risk, but its implementation allows more accurate establishment of the stage of the disease and detect micrometastasis. Metastases in the lymph nodes are harbingers of distant metastases. After surgery, such patients usually have a relapse. The importance of examining fresh-frozen sections of the lymph nodes during the operation is not clearly defined, but most urologists tend to perform advanced lymphadenectomy, refuse prostatectomy with a marked increase in lymph nodes (usually disseminated tumors that are subject only to hormone therapy) and stop the operation if Urgent histological examination revealed metastasis. It is noted that a planned study of the removed lymph nodes can help detect micrometastases. With single metastases to lymph nodes or micrometastases, the risk of recurrence is lower. In the case of metastases to the removed lymph nodes, adjuvant hormone therapy is possible, but since it is associated with side effects, it can sometimes be limited to observation, postponing hormone therapy until the PSA level increases.

Some surgeons always perform extensive pelvic lymphadenectomy (including, but not limited to, occlusal, external and internal iliac and sacral lymph nodes), but this approach requires randomized studies. In recent years, lymphadenectomy is increasingly being given not only diagnostic, but also therapeutic value.

Long-term results

In the further observation of cancer patients, the pathological stage (pT) with indication of the purity of the surgical margin, postoperative PSA level (biochemical relapse), local recurrence, metastasis, cancer-specific survival, overall survival are of great importance. The recurrence of the disease depends on clinical and pathomorphological data. The independent prognostic factors include clinical stage, Gleason grading and PSA level. Additional factors: capsule germination (extracapsular extention), perineural and / or lymphovascular invasion, lesion of lymph nodes and seminal vesicles.

Complications of radical prostatectomy

The overall complication rate after retropubic radical prostatectomy (with sufficient experience of the surgeon) is less than 10%. Among the early complications there may be bleeding, damage to the rectum, ureters, blocking nerves, anastomosis failure, vesical-rectum fistula, thromboembolic complications, cardiovascular pathology, ascending urinary infection, lymphocele, incapacity of postoperative wound. Among the late complications are erectile dysfunction, urinary incontinence, urethral stricture or anastomosis, inguinal hernia.

Complications of radical progatectomy

Complications	Risk, %
Mortality	0-2.1
Severe bleeding	1-11
Damage to the rectum	0-5,4
Deep Vein Thrombosis	0-8.3
Pulmonary embolism	0.8-7.7
Lymphocele	1-3
Bladder and rectum fistula	0.3-15.4
Stress incontinence	4-50
Total incontinence of urine	0-15.4
Erectile disfunction	29-100
Strain of an anastomosis	0.5-14.6
Urethral stricture	0-0.7
Inguinal hernia	0-2.5

Careful observation of indications for surgical intervention reduces the risk of postoperative lethality to 0.5%.

Usually the volume of blood loss does not exceed 1 liter. Infection of the ureter is considered infrequent, but a serious complication. If the defect is insignificant, it is possible to suture the wound and drain the catheter (stent). With more extensive lesions or the crossing of the ureter, ureterocystoneostomy is indicated. A slight defect in the rectum can also be sewn with a double seam after the anus vulgaris. Anus preater naturalis is applied with a pronounced defect or with previous radiotherapy.

The function of urine retention is restored more quickly than erectile. About half of the patients immediately after the operation retain urine, the rest of the recovery occurs within a year. The duration and severity of urinary incontinence depends on the patient's age. 95% of patients under 50 years old are almost immediately able to retain urine, and 85% of patients over the age of 75 suffer from incontinence of varying degrees. With total incontinence, the establishment of an artificial sphincter is shown. Erectile dysfunction (impotence) previously occurred in almost all patients. In the early stages of the operation, it is possible to perform an operation to preserve the cavernous nerves, but it contributes to an increased risk of local recurrence and is not recommended for low-grade tumors, invasion of the apex of the prostate gland and for palpable tumors. Good results are also due to unilateral preservation of the cavernous nerve. To reduce the risk of impotence, injections of alprostadil into the cavernous bodies help in the early postoperative period.

[8], [9], [10], [11], [12], [13], [14], [15],

Clinical recommendations for the implementation of radical prostatectomy

Indications: 

• stage T _1b 2Nx-0, M0 with an expected lifespan of more than 10 years; 
• tumors T _1a at very high (more than 15 years) expected life expectancy; 
• tumor T _3a with Gleason index more than 8 and PSA level more than 20 ng / ml.

In stage T _1-2, the appointment of a 3-month course of neoadjuvant therapy is not recommended.

Preservation of cavernous nerves is possible only at low oncological risk (T _1c, Gleason index less than 7, PSA level less than 10 ng / ml).

In stage T _2a, it is possible to perform a prostatectomy with unilateral preservation of the cavernous nerve.

Expediency of radical prostatectomy with a high risk of distant metastasis | with metastasis in the lymph nodes, as well as in combination with long-term hormone therapy and adjuvant radiation therapy has not been studied enough.

[16], [17], [18], [19], [20], [21]