Editing Open Radical Prostatectomy (section)

== Radical perineal prostatectomy ==

* '''Advantages compared to radical retropubic prostatectomy'''
*# '''Shorter hospital stays and lower costs'''
*# '''Blood loss is significantly lower than with the retropubic approach.'''
*** '''The dorsal venous complex is usually not encountered, resulting in relatively lower blood loss when compared with the retropubic approach.'''
*** Transfusion rates are generally around 5%.
*** A blood type and antibody screen are performed in the days or hours before surgery, but a crossmatch is generally unnecessary.
* '''Disadvantages'''
*# '''Inability to perform lymph node dissection'''
*#* In the 1970s, the procedure fell out of favor because the importance of pelvic lymphadenectomy was understood for the purposes of staging. However, with the advent of nomograms, surgeons could accurately predict the chances of lymph node involvement, obviating the need for staging lymphadenectomy.
*#* '''Concomitant radical perineal prostatectomy and laparoscopic lymph node dissection results in little increased morbidity and remains cost effective when compared with radical retropubic prostatectomy.'''
*# '''Potential post-operative sensory neurapraxia of the lower extremity due to positioning'''
*** '''Occur in approximately 2% of cases, significantly more often than with retropubic prostatectomy.'''
*** '''Transient in nature, true motor defecits are rare'''
* '''Similarities'''
** '''Pathologic outcomes are not significantly different for either procedure'''
** '''A nerve-sparing technique can be accomplished.'''
* '''Indications'''
** '''Patients with prior renal transplantation or morbid obesity are often better candidates for a perineal approach than for the retropubic approach.'''
* '''Contraindications'''
** '''Ankylosis of the hips or spine'''
*** '''Procedure necessitates either an exaggerated lithotomy or a modified exaggerated lithotomy position'''
*** '''A history of degenerative disk disease is not a contraindication to surgery.'''
* Procedure
** Exposure of the urethra is facilitated by the Lowsley retractor
*** Traction on the Lowsley tractor during division of the rectourethralis muscle tents the rectum upward and increases the likelihood of injury during radical perineal prostatectomy. Traction should not be placed until after the rectourethralis muscle is divided.
**** If a rectal injury occurs, a fistula may ensue.
***** Incidence of rectal injury: 1-5%.
***** When the injury is recognized and repaired at the time of occurrence, the operation can continue without a problem