Radical perineal prostatectomy: a novel approach for lymphadenectomy from perineal incision

A major disadvantage of radical perineal prostatectomy is that lymphadenectomy cannot be performed through the same incision. We developed a novel approach to access the obturator and internal iliac lymph nodes, partially the external iliac lymph nodes, via the perineal incision. We describe the method of lymphadenectomy.

After moving the rectum off of the prostate we separate the levator ani muscle and endopelvic fascia from the lateral prostate with finger dissection. A trocar mounted balloon distention device is inserted toward this space and distended with 200 cc air to create an intrapelvic space. Using several retractors or laparoscopy for viewing we first identify the obturator nerve and then the external iliac vessels next in order of depth. By retracting the obturator nerve with vessel tape we perform lymph node dissection between the obturator nerve and external iliac vessels under direct vision or laparoscopic guidance.

We have performed this technique in 20 consecutive patients because of prostate specific antigen greater than 10 ng/ml, Gleason score greater than 7 or bilateral disease. Bilateral lymph node dissection required 15 to 20 minutes. No major bleeding or complications occurred. The number of nodes was similar to that in our retropubic prostatectomy series because of the limited lymphadenectomy that we usually performed. Fecal incontinence and potency results were almost the same as in patients without lymphadenectomy. Although urinary continence was not good at catheter removal on day 7, patients became dry in 1 to 6 months.

This method resolves the major disadvantage of perineal prostatectomy. Radical perineal prostatectomy with lymphadenectomy via the same incision is feasible and reproducible.