Blunt apical dissection during anatomic radical retropubic prostatectomy
© Rosser et al; licensee BioMed Central Ltd. 2009
Received: 31 December 2008
Accepted: 06 February 2009
Published: 06 February 2009
Meticulous apical dissection during a radical prostatectomy is imperative to achieve desirable pathologic and quality of life outcomes.
We describe a novel technique using careful blunt dissection to better delineate the apex of the prostate, providing a simple means to potentially lessen positive surgical margins at the apex and promote better continence and erectile function in men undergoing an anatomic radical prostatectomy.
Median operative time and blood loss were 190 minutes and 675 mL, respectively. Only 10 percent of the patients with positive surgical margins were found to have apical positive surgical margins. Ninety-three percent of patients reported no urinary leakage.
We believe our technique of isolating the DVC with blunt dissection and then ligating and transecting the DVC to be feasible approach that requires larger studies to truly confirm its utility.
In the US, radical prostatectomy (RP) is the most common treatment for localized prostate cancer  and results in durable, disease-free survival with few complications [2, 3]. The durable disease-free survival and low complication rates are in part due to the meticulous apical dissection of the prostate which translates into less blood loss and improved visualization of critical structures . Optimal visualization leads to reduction in positive apical surgical margin rates as well as improvement in the dissection of the urethra and caveronosal nerves which are critical when addressing post-prostatectomy continence and erectile dysfunction, respectively. This concept has been clearly illustrated previously by Walsh and Donker, who reported using sharp dissection to create a plane between the dorsal venous complex (DVC) and urethra [4, 5]. Inappropriate sharp dissection can cause bleeding and may inadvertently injure the rhabdosphincter. A natural plane exists between the DVC and urethra that can be identified through careful blunt dissection. Herein, we report an effective method to optimally dissect the apex of the prostate and to assist in identifying and ligating the DVC.
Key Surgical Technique Steps
Characteristics of patient (n = 54) undergoing radical prostatectomy.
No. of Patients
64 ± 7 years
Clinical tumor classification
Preoperative PSA level
Biopsy Gleason score
Prostatectomy Gleason Score
Pathologic tumor classification
N1 (lymph node pos.)
Pos. surgical margin
Radical retropubic prostatectomy is a challenging surgical procedure with a known, significant learning curve to achieve optimal outcomes. The ultimate effect of a careful dissection of the apex of the prostate is gauged by measuring surgical outcomes, specifically pathologic and quality-of-life outcomes. We believe that the surgical modifications described in this report should result in a lower incidence of positive apical surgical margin rate, even in patients with clinical Stage T2 disease. Several recent publications have also described modifications to reduce the incidence of positive apical surgical margins. Despite these modifications, apical positive margin rates could not be reduced to below 15% [6–8].
In this study, patients had pathologic outcomes – specifically positive surgical margin rates – that were comparable to those reported in the literature [8–10]. Although it is possible that our improved surgical margin rate was in part related to better patient selection and increased surgical experience, we do not believe that these factors alone account for the very low positive apical surgical margin rate in this study compared with those in other recent series. In fact, we believe the reduced apical surgical margin rates were due to the optimal visualization this technique provided.
The ultimate goal of radical retropubic prostatectomy is cancer control with little to no morbidity. We do not believe our established technique is associated with increased morbidity, seeing that in our patients less than 65 years reported excellent urinary continence rates and favorable potency rates as assessed by their 12 month EPIC questionnaire. Previously we have reported on the outcomes of subjects treated utilizing this technique [11, 12]. However, the outcomes from this reported technique should be corroborated by other surgeons.
Radical retropubic prostatectomy continues to be a challenging procedure. Careful apical dissection is needed for optimal results. We believe our technique of isolating the DVC with blunt dissection to be a feasible approach that requires larger studies to truly confirm these encouraging preliminary results.
dorsal venous complex
prostate specific antigen
Expanded Prostate Cancer Index Composite.
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