Radical Prostatectomy

A radical prostatectomy is usually reserved for patients who:[20-22]

Open prostatectomy can be performed by the perineal or retropubic approach. The perineal approach requires a separate incision for lymph node dissection. Laparoscopic lymphadenectomy is technically possible.[23] Robot-assisted prostatectomy is an alternative to open prostatectomy and has become the most common technique in developed countries. In experienced hands, functional outcomes between open and robot-assisted prostatectomy appear very similar, at least in the short- to mid-term. In a randomized trial of 308 men suitable for prostatectomy, urinary, sexual, and bowel functional outcomes were similar between open retropubic and robotic surgeries at a median follow-up of 24 months.[24] The sample size and duration of follow-up were too small to detect meaningful differences in cancer outcomes.

For small, well-differentiated nodules, the incidence of positive pelvic nodes is less than 20%, and pelvic node dissection may be omitted.[25] With larger, less-differentiated tumors, a pelvic lymph node dissection is more important. In these cases, the value of open surgical or laparoscopic pelvic node dissection is not therapeutic, but it spares patients with positive nodes the morbidity of prostatectomy. Radical prostatectomy is usually not performed if a frozen-section evaluation of pelvic nodes reveals metastases; these patients should be considered for entry into existing clinical trials or receive radiation therapy to control local symptoms.

The role of preoperative (neoadjuvant) hormonal therapy is not established.[26,27]

After radical prostatectomy, pathological evaluation stratifies tumor extent into the following classes: