Commentary (Melman): Morbidity of Contemporary Radical Retropubic Prostatectomy for Localized Prostate Cancer

This article compares the results of radical retropubic prostatic surgery done by a group of urologists at the Mayo Clinic during a recent 3-year period with results obtained in a similar group of patients operated on prior to 1987. The authors show that when a surgical procedure is done often, with modern techniques and attention paid to surgical and anatomic detail, very good results can be achieved.

The most impressive aspects of the follow-up reported by Lerner et al are:

1) The absence of any surgical mortality.

2) The minimal loss of blood and low transfusion rate.

3) The very low complication rate.

The results in the more recent series compare very favorably to previously published results of radical perineal prostatectomy [1]. The presumed overall advantages of the latter procedure are reduced blood loss and improved bladder neck-to-urethra anastomosis because of the ease of visualization during surgery. The overall similarity of continence rates between the two approaches would seem to belie that concept. The cancer-free survival and potency rates were not assessed for this report.

Primary Considerations

At least two primary considerations can be gleaned from this study. One is directed to the practitioner who does radical retropubic surgery infrequently. That individual must decide whether his or her skills, as well as the institutional support, are sufficiently good to warrant performing the surgery. Clearly, the best opportunity to maximize operating room efficiency is accomplished at physician-run, private clinics such as the Mayo Clinic or at other high-volume academic centers. If both the surgeon's skill and operating room support are less than optimal, perhaps the patient should be referred to a center where the numbers and results of surgical cases equal those of the present series. In the current managed care revolution occurring in US medicine, those types of decisions may be dictated by market forces without our input.

A second consideration, which applies to those urologic surgeons who perform the operation very well, is that there should be little hesitancy to recommend a radical procedure as a potential curative approach to newly diagnosed cancer. Clearly, the low morbidity and mortality of these approaches afford the patient the best chance of permanent cure.

A final consideration reflects my own prejudice toward the perineal approach. Despite the overall mean efficacy reported in the paper by Lerner et al, I suspect that in obese patients, men who have had a prior renal transplant, and those who have undergone previous rectal or prostatic surgery, as well as after inflatable penile prosthetic placement or lower abdominal or vascular surgery, the perineal approach will yield a lower morbidity than the retropubic approach.

References:

1. Lerner SE, Fleischmann J, Melman A, et al: Combined laparoscopic pelvic lymph node dissection and modified belt radical perineal prostatectomy for localized prostatic adenocarcinoma. Urology 43:493-498, 1994.