Radical prostatectomy removes the entire prostate and seminal vesicles with a vesicourethral anastomosis, and is a curative option for localized prostate cancer. It can be performed open (retropubic or perineal), laparoscopically, or robot-assisted (now the most common); functional and oncologic outcomes are broadly comparable across approaches, so the benefit of a robotic approach is chiefly its minimally invasive nature.
Surgical Anatomy
- Dorsal venous complex (DVC): the retropubic approach lies outside the endopelvic/anterior pelvic fascia, so the DVC (Santorini plexus) must be ligated and the lateral pelvic fascia divided; the perineal approach stays beneath these fasciae and does not divide the DVC.
- Neurovascular bundles (NVB): the cavernous nerves join the capsular vessels ~20–30 mm distal to the bladder–prostate junction, lying between the prostatic fascia and the endopelvic/levator fascia. Correct nerve-sparing is an interfascial dissection that leaves the prostatic fascia on the prostate. Divide the lateral pedicles near the bladder to avoid nerve injury.
- Accessory pudendal arteries (often from the obturator) run along the anteromedial prostate and may be the dominant corporal supply — preserve when possible.
- Striated sphincter: horseshoe-shaped fatigue-resistant slow-twitch fibers at the apex, innervated by the pudendal nerve, responsible for passive urinary control. The pelvic plexus lies on the lateral surface of the seminal vesicles.
Approaches
| Approach | Notes |
|---|---|
| Open retropubic | Allows pelvic lymph node dissection; the standard open route |
| Open perineal | Less blood loss and shorter operative time (DVC not divided), but no access for lymphadenectomy, higher rectal-injury risk, and ~2% lower-extremity sensory neurapraxia from positioning. Good for prior renal transplant or morbid obesity; contraindicated with hip/spine ankylosis |
| Laparoscopic / robot-assisted | Robot-assisted is now most common; comparable functional/oncologic outcomes (Coughlin 2018 RCT) |
Preoperative Preparation
Defer surgery 6–8 weeks after needle biopsy and 12 weeks after TURP. Hold anticoagulation (aspirin 7 days, clopidogrel 5 days, apixaban 2 days). Antibiotic prophylaxis: a single dose of cefazolin or TMP-SMX (2019 AUA). Use VTE prophylaxis (stockings + heparin) and encourage preoperative Kegel exercises.
Open Radical Retropubic Prostatectomy
Through an extraperitoneal lower-midline incision, with relative hypotension and limited crystalloid until the prostate is out:
- Pelvic lymph node dissection first — limits: inferiorly the femoral canal/circumflex vein, superiorly the ureter/common iliac bifurcation, medially the bladder, laterally the pelvic sidewall, posteriorly the obturator nerve. The internal iliac (hypogastric) nodes have the highest positive rate; preserve the lymphatics over the external iliac artery to avoid lymphocele/leg edema.
- Incise the endopelvic fascia laterally (a medial incision risks the Santorini plexus); divide the puboprostatic ligaments, sparing the pubourethral component to preserve anterior sphincter fixation.
- Ligate and divide the DVC. The apical dissection is the most important step — the apex is the most common site of positive margins.
- Divide the urethra and place ~6 anastomotic sutures (1, 3, 5, 7, 9, 11 o'clock) incorporating mucosa/submucosa.
- Nerve-sparing (when appropriate): release the NVB off the posterolateral prostate without upward traction (roll the prostate side-to-side), controlling vessels with clips — never thermal energy. The final decision to preserve or widely excise can be deferred until the prostate is removed.
- Divide the lateral pedicles near the bladder, the bladder neck, and dissect the seminal vesicles (the pelvic plexus lies on their lateral surface). Bladder-neck and seminal-vesicle sparing have not been shown to improve continence, potency, or margins.
- Vesicourethral anastomosis (± tennis-racquet bladder-neck reconstruction).
Robot-Assisted Laparoscopic Prostatectomy
Setup: supine (or lithotomy) with steep (25–28°) Trendelenburg; typically 6 ports placed >8 cm apart and, if off-midline, ≥6 cm lateral to avoid the inferior epigastric vessels. A transverse camera-port incision markedly lowers incisional-hernia risk (0.6% vs 5.3% for a vertical incision). Antibiotics, VTE prophylaxis, and equipment (monopolar scissors, bipolar Maryland, Prograsp 4th arm) as above.
Key operative sequence (posterior or anterior approach; condensed):
- Drop the bladder — develop the space of Retzius, always staying lateral to the medial umbilical ligament (the ureter runs medial/deep to it) and not too lateral (external iliac vessels). Divide the urachus.
- Defat the anterior prostate and send the fat for pathology (~15% contain nodes; in 2–3% the only metastatic site). Coagulate superficial DVC branches; preserve accessory pudendal arteries.
- Incise the endopelvic fascia (more medially if nerve-sparing) and oversew the DVC.
- Bladder-neck dissection — identify the bladder neck, incise anteriorly (not too far laterally — pedicle branches bleed), inspect the interior, identify the ureteric orifices (indigo carmine if needed; closer to the neck after prior TURP), and complete the posterior bladder-neck incision (keeping it thick for the posterior reconstruction).
- Posterior dissection — develop the seminal vesicles/vasa, incise Denonvilliers' fascia (above it for aggressive nerve-sparing, below it for aggressive cancer), and develop the prostate–rectum plane (caution: rectal injury).
- Pedicles and nerve-sparing — clip and divide the posterolateral pedicles; perform antegrade interfascial nerve-sparing, releasing the NVB sharply without traction.
- Apical dissection — release Myer's muscle to expose and protect the apex, NVBs, and urethra; divide the DVC and then the urethra (withdraw the catheter to its tip), and divide the rectourethralis (rectal-injury caution).
- Specimen retrieval, posterior reconstruction (Rocco stitch), and vesicourethral anastomosis (running barbed sutures); irrigate, place the final catheter, confirm hemostasis, and leave a drain.
Special scenarios:
- Median lobe — increases risk of ureteral injury, bladder buttonholing, positive margins, incontinence, and the need for bladder-neck reconstruction; manage with a traction stitch or grasper to elevate the lobe, dissecting in the plane between bladder mucosa and the lobe.
- Bladder-neck reconstruction — for a large defect, use a tennis-racquet (anterior or posterior) or fish-mouth closure; the inverting (posterior tennis-racquet) approach moves the ureteric orifices away from the anastomosis.
- Previous TURP — distorted anatomy and a wide bladder neck usually need reconstruction; plicate at 3 and 9 o'clock (avoid 6 o'clock — highest tension/leak risk).
Postoperative Care
Clear liquids the evening of surgery; early ambulation; remove the drain when output is low. The catheter stays ~7 days for robotic (3–21 days open; removal before 7 days carries a 15–20% retention risk). Restart Kegels after catheter removal; sexual-function recovery occurs over 1–2 years.
Complications
- Intraoperative: hemorrhage (DVC — best controlled by completely dividing it over the urethra and oversewing; <1% intraoperative transfusion open); obturator-nerve injury during PLND (attempt fine non-absorbable reanastomosis); rectal injury (<0.3% open, more common in salvage; repair with copious irrigation, multilayer closure, and omental interposition to prevent rectourethral fistula; consider a diverting colostomy for a large defect, prior radiation, or chronic steroids); ureteral injury (rare).
- Early: ileus, wound infection, UTI; venous thromboembolism (DVT/PE is a major cause of post-RP mortality, peaking 14–28 days); lymphocele (~3%; can masquerade as worsening incontinence after robotic RP); urine leak (~1.8%); reoperation (~1.6%); rare delayed hemorrhage (explore early for severe hypotension).
- Late: vesicourethral anastomotic stenosis / bladder-neck contracture (1.3–4.8%; less with robotic; up to 22–40% after salvage; manage with dilation or cold-knife incision ± triamcinolone); urinary incontinence; erectile dysfunction; incisional hernia; urethral stricture.
- Continence: ~95% of men <60 and ~85% of men >70 regain pad-free continence; nerve-sparing and posterior reconstruction (Rocco stitch) improve early continence (the long-term rate is less affected).
- Erectile function: recovery predicted by younger age (<65), good baseline potency, and extent of nerve-sparing; erections return as partial erections at 3–6 months and improve up to ~3 years — encourage early penile rehabilitation (PDE5 inhibitors, injections, vacuum devices).
Key Exam Points
- The NVB lies between the prostatic and endopelvic/levator fascia; interfascial dissection spares it (use clips, never thermal energy).
- The apical dissection is the most important step and the apex is the most common positive-margin site.
- Perineal prostatectomy has less blood loss but no access for lymphadenectomy and a higher rectal-injury rate.
- Repair rectal injury with multilayer closure and omental interposition; divert (colostomy) for a large defect, prior radiation, or steroid use.
- A transverse robotic camera-port incision reduces incisional hernia (0.6% vs 5.3% vertical).
- Posterior reconstruction (Rocco stitch) and nerve-sparing improve early continence recovery.
- Defer surgery 6–8 weeks after biopsy and 12 weeks after TURP; remove the catheter no earlier than ~7 days.