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Northern Institute of Urology, PC

The Anatomic Radical Perineal Prostatectomy: Results

Dr. Harris has performed over 1000 radical perineal prostatectomies (RPP) for 'clinically localized' prostate cancer in the past 15 years. While about 250 cases were for locally advanced cancers, radiation resistant cancers or patients operated on as a visiting professor, 765 radical perineal prostatectomies were performed in Traverse City for 'clinically localized' prostate cancer. The outcomes database at Northern Institute of Urology is prospectively accumulated and updated daily. The following data are being published in various peer-reviewed urologic journals in the Unites States and Europe. These data represent Dr. Harris's personal surgical experience over the past 15 years.

Cancer control: Undetectable PSA is the ultimate goal of prostate cancer treatment. However, clean surgical margins are the cancer-specific goals of RPP, as some men present with more advanced disease than initially realized. The average tumor size is 7.3 grams. Positive margins are seen 16.4% of cases without seminal vesicle invasion (seminal vesical invasion (SVI) is associated with higher risk of recurrence than positive margins (18.9% if SVI included). Margins are considered 'focally positive' (less than 1 mm2) in 9.9% and 'non-focal' or multiple in 8.9.%. Follow up ranges from 3 months to 15 years. Data presented are 3, 5 & 7 - year minimal actual follow up. When comparing cancer results, it is important to understand the make up of the patient groups being compared.

PATHOLOGIC STAGE GRADE N PSA CAsize
grams
3YR, PSA=0 5YR, PA=0 7YR, PA=0
N % PSA=0 N % PSA=0 N % PSA=0
ORGAN
CONFINED
2-6 302 9.7 4.9 230 97.4% 184 97.3% 80 93.8%
7-10 241 5.6 7.4 155 96.1% 118 95.8% 43 88.4%
ALL 543 7.9 6.0 385 96.9% 302 96.7% 123 91.9%
SPECIMEN
CONFINED
2-6 28 7.4 10.6 27 85.2% 21 81.0% 15 73.3%
7-10 61 6.7 9.1 45 77.8% 34 67.6% 15 40.0%
ALL 89 6.9 9.6 72 80.6% 55 72.7% 30 56.7%
FOCAL
POSITIVE
MARGIN
2-6 26 6.0 5.7 23 91.3% 17 82.4% 9 77.8%
7-10 44 7.3 8.4 36 88.9% 25 80.0% 17 70.6%
ALL 70 6.8 7.4 59 89.8% 42 81.0% 26 73.1%
NON-FOCAL
POSITIVE
MARGIN
2-6 22 6.8 8.7 21 57.1% 18 44.4% 13 30.8%
7-10 42 7.7 8.8 30 53.3% 25 48.0% 15 46.7%
ALL 64 7.4 8.8 51 54.9% 43 46.5% 28 39.3%
SEMINAL
VESICLE
INVASION
2-6 3 7.1 24.1 3 66.7% 3 66.7% 1 100.0%
7-10 31 8.1 19.3 25 28.0% 21 19.0% 14 14.3%
ALL 34 8.0 19.7 28 32.1% 24 25.0% 15 20.0%
OCCULT
METASTATIC
CANCER
2-6 0 0 0 0 0.0% 0 0.0% 0 0.0%
7-10 5 14.3 11.3 5 0.0% 5 0.0% 5 0.0%
ALL 5 14.3 11.3 5 0.0% 5 0.0% 5 0.0%
TOTAL 2-6 381     304 92.8% 243 90.5% 118 83.1%
7-10 423     296 80.7% 228 75.4% 109 59.6%
ALL 805 6.0 7.3 600 86.8% 471 83.2% 227 71.4%

Urinary continence: The techniques used to reconstruct the urethra after the prostate is removed have evolved over the 15 years of this data. Since January 2002, a more advanced suture method is utilized resulting in dramatic improvement in urinary control. Today, the catheter is removed 8 days after surgery. 'Socially dry' refers to men who are essentially dry, but use no more than one pad in 24 hours for protection. 'Totally dry' refers to men who are confidently dry and do not wear pads. The graph shows the percent of men 'Socially dry' and 'Totally dry' in weeks after catheter removal.

The following graph compares the time to full urinary control (no pads) in weeks after catheter removal in men with or without erectile nerve preservation and bladder neck preservation (versus reconstruction). The men with at least one erectile nerve bundle spared and preservation of an intact bladder neck have the best results. Tumor characteristics and prostate anatomy influence whether nerves and/or bladder neck preservation is possible. (BNS: Bladder neck spared, BNR: Bladder neck reconstructed, NS: Nerves spared, WR: Wide resection (non-nerve spare).

Return of erectile function: Preservation of erectile nerves is considered in men with good erectile function and a very low risk of compromising cancer control by performing a 'less than radical' prostatectomy. In the summer of 2001, Dr. Harris significantly revised the technique of nerve preservation during radical perineal prostatectomy. This new technique has provided better results than those obtained in past years. The following results represent the past 5 years of unilateral (one nerve bundle) and bilateral (both nerve bundles) cavernosal erectile nerve preservation. 'Partial erections' refer to those erections that can be obtained by erotic stimulation but are not adequate for penetration. 'Adequate erections' are those capable of completing intercourse with or without the use of Viagra, Levitra or Cialis. While it is nice to preserve erectile function, the first consideration should focus on curing prostate cancer with an adequate resection of a sufficient margin around the prostate gland. The erectile nerves are right on the surface of the prostate, therefore, there is no margin for safety in cases of superficial tumors or cancers that have infiltrated just outside the confines of the prostate gland.

Complications: Strictures (scar tissue) develop at the bladder neck (1%) and in the urethra (<1%), requiring outpatient dilation. Blood transfusions are used <1% of the time (none in past 650 cases). As a result, blood banking in advance of surgery is not necessary. Most men are home on the day after their 60-90 minute surgery. Many patients do not feel it necessary to take pain medication following discharge home. The catheter is removed in 8 days and the patients are unrestricted in their activity (except bicycle riding for several months). One man has experienced anal incompetence, while 2-4% note mild fecal urgency or flatus with coughing. One person had a transient ischemic attack and another had a mild stroke on the day of after surgery, both have fully recovered. We have seen one heart attack in an uncomplicated recovery period that appears to have been coincidental to his prostatectomy. No deaths or lung problems have arisen.

Cost issues: With increased medical technology driving up the costs of care in medicine, the RPP remains far more affordable than any other management option, surgical or radiation. Short operating room time and an overnight stay keep total hospital charges under $9000, compared to $34,000 to $75,000 for laparoscopic, retropubic prostatectomies or radiation options at other centers of excellence. By avoiding the use of a robot and the associated loss of tactile sensation, the tremendous cost of this system is also avoided. Robotic prostatectomy outcomes have yet to consistently match the above outcomes, except for very few highly experienced surgeons. Time away from work varies from 1 to 3 weeks depending upon the type of work.

Comment: While radical prostatectomy is the most effective treatment of localized prostate cancer, the anatomical radical perineal prostatectomy is the most 'patient-friendly' method of curing prostate cancer.