The Martini-Clinic technique of open radical retropubic prostatectomy

Abstract

Despite the emergence of robotic approaches, the technique of open radical retropubic prostatectomy (RP) is still the predominant approach for surgical treatment of clinically localized prostate cancer in most clinics worldwide. The principles of this technique and its oncological efficacy were published decades ago; however, the surgery carried out today has undergone continuous refinements, reducing the morbidity rate and significantly improving postoperative functional outcomes such as urinary continence and erectile function. We report on the current technique of open nerve-sparing radical RP with data analysis to address the issues of urinary continence, potency, cancer control rates and perioperative morbidity. The analyses are based on 1875 patients who were treated with nerve-sparing RP in the Martini-Clinic. The key elements of open radical RP are a selective ligation of the dorsal vein complex and early release of the neurovascular bundles using a high anterior tension-free and energy-free intrafascial technique, intraoperative frozen section (NeuroSAFE technique) and full functional length urethral sphincter preparation (FFLU technique). During dissection of the urethra, the posterior insertion at Denonvilliers' fascia is preserved and remains in situ, and is selectively opened above the seminal vesicles. The later seminal vesicles are completely removed inside Denonvilliers' fascia and six muscle-sparing interrupted sutures are used for anastomosis. Functional and oncological outcome data were determined, which were prospectively collected using validated questionnaires and intraoperative and perioperative morbidity data were also evaluated. Patient age and the extent to which the nerve-sparing approach was influenced by urinary continence and potency. Overall, 97.4% of men less than 60 years of age, and 84.1% of men over 70 years, had complete urinary continence 1 year after nerve-sparing RP. In preoperative potent men, erections sufficient for intercourse were seen in 84–92% of patients who underwent bilateral nerve sparing and in 58.3–70% of men who underwent unilateral nerve sparing. Median blood loss was 590 ml (range 130–1800 ml) and the transfusion rate was 4.5%. Median operative time was 175 minutes (range 95–215 minutes). In organ-confined cancers, recurrence-free survival and cancer-specific survival at 10 years after RP were 87% and 98.3%, respectively. Open intrafascial nerve-sparing RP combines excellent long-term cancer control rates with superior functional outcome and a low morbidity.