Modified Pfannenstiel approach for radical retropubic prostatectomy: a 3-year experience

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Abstract

A modified Pfannenstiel approach for radical retropubic prostatectomy (RRP) has been described previously. We present our experience with this approach for performing a RRP over the past 3 years. Between January 2003 and July 2006, 544 consecutive RRPs by modified Pfannenstiel approach between January 2003 and July 2006 were performed. We analyzed blood loss, transfusions, use of drain, pain score, analgesia and hospital stay. Patients were followed up at 6 weeks, three monthly for a year and six monthly thereafter. All clinical and operative variables were entered into a database and analyzed. A total of 544 men underwent RRP with median follow-up of 11 (s.d.±10.5) months. The mean age was 60 (s.d.±7) years. About 83, 91 and 95% of patients had nerve sparing, bladder neck preservation and a lymph node dissection, respectively. Fifty-three patients had a concurrent inguinal hernia repair through the same incision. Mean estimated blood loss was 431(s.d.±267) ml. The pathological staging distribution was T2, 82%; T3a, 9%; and T3b, 9%. The mean pain score at days 1 and 7 were 3.7 (s.d.±2.5) and 3.3 (s.d.±3), respectively. The median hospital stay was 36 h (s.d.±24). About 5.5% have had biochemical recurrence. At 12 months 97% were continent and 46% potent. RRP using a modified Pfannenstiel approach offers safety and efficacy. It facilitates repair of associated inguinal hernia through the same incision.

Introduction

Prostate cancer (PC) is the most common cancer in men that accounts for 33% of new cancer cases diagnosed in the United States. In 2006, 234 000 new cases are expected to be diagnosed and 27 000 deaths among US men.1 Radical retropubic prostatectomy (RRP) is one of the common therapeutic choices in the treatment of localized PC. RRP is most commonly performed using a vertical midline incision.2 In the recent past, laparoscopic radical prostatectomy (LRP) and robotic-assisted prostatectomy (RAP) are being used.3, 4 We have previously described a modified Pfannenstiel approach for performing a RRP using a transverse incision. This approach combines the advantages of open technique while providing excellent cosmesis, pain control and wound healing.5 We present our experience with this approach for performing a RRP over the past 3 years.

Materials and methods

A total of 544 men with clinically localized PC, who underwent RRP though modified Pfannenstiel approach between January 2003 and July 2006 were included in this analysis. Institutional review board approval was obtained for this study. Patient demographics, relevant clinical and pathological data were collected. Tumor node metastsis (TNM) classification was used for pathological staging and the Gleason score system was used for grading.6 Data collected included age, body mass index (BMI), prostate-specific antigen (PSA), biopsy Gleason score, clinical stage, preoperative continence and potency. Operative parameters such as type of anesthesia, estimated blood loss, transfusions, use of a drain and length of the procedure were recorded. A standard RRP was performed.7 If a patient had an inguinal hernia, we repaired it through the same incision using Lichtenstein's mesh technique.8 We do not obtain self-donated autologous blood. Intraoperative cell salvage was used as needed. Discharge decision was based on patient well-being, ambulating without assistance, tolerating liquids and good pain control. Postoperative pain score levels were collected on days 1 and 7 using a visual analog scale of 0–10. The analgesic requirement was expressed in morphine equivalents. The urethral catheter was removed on the seventh postoperative day. Patients were followed up at 6 weeks, three monthly for 1 year and six monthly thereafter. Information on potency and continence were obtained from clinic records and was not assessed by validated questionnaire. Potency was defined as the ability to have penetrating sexual intercourse with or without phosphodiesterase inhibitor (PDE)-5 inhibitors. Men who were not using pads considered continent. All postoperative complications were collected. All clinical and operative variables were entered into a database and analyzed.

Surgical technique

The technique of modified Pfannenstiel approach RRP was described by authors previously.5 A brief description of the surgical technique is given below.

The patient is placed in supine position with the anterior superior iliac spines at the level of kidney rest. The bridge is raised and the table is flexed to have better access to the pelvis. A transverse curvilinear incision is placed along the pubic hairline centered over the symphysis pubis (Figure 1a). The length of the incision is about 8 cm, which can be extended laterally if necessary. On reaching the anterior rectus sheath, a V-shaped incision is made with the midpoint 2 cm above the symphysis pubis (Figure 1b). The limbs of the V are directed superiorly and laterally at a 30° angle to avoid entering the inguinal canal inadvertently. The rectus sheath is reflected of the rectus muscle (Figure 1c). Then the V incision is converted into Y incision by vertical incision on the inferior leaflet of rectus sheath towards pubic symphysis (Figure 1d). After the incision, the rectus and pyrimidalis muscles are exposed and separated along the midline. The fascia transversalis is incised close to the pubis, and the retropubic space of Retzius is entered. By blunt dissection, the peritoneum is mobilized away from the pelvis. A Buck–Walter self-retaining retractor is used. Two lateral blades are applied to retract the wound laterally. A small Richardson retractor is applied inferiorly to retract the skin and fatty tissue. A 16F Foley catheter is inserted in the bladder, and the balloon inflated with 30 ml of water. A Holtgrewe–Yu retractor is placed over the balloon and retracted superiorly. This provides excellent exposure of the prostate. The surgical procedure follows the steps of standard RRP thereafter. The anastomosis was performed with seven interrupted 2-0 chromic catgut or poliglecaprone 25 sutures. After the anastomosis was completed, approximately 100 ml of sterile saline was instilled through the urethral catheter without pressure, and the anastomosis was assessed. A 7-mm Jackson–Pratt closed suction drain was placed in the pelvis mainly on the surgeon's preference or if the anastomosis was not watertight or hemostasis was not adequate. A 20F urethral catheter was left in place postoperatively. The skin is approximated with a 4-0 monocryl subcuticular technique.

Figure 1
figure1

(a) Skin incision. (b) V-shaped incision on rectus sheath. (c) Dissection of superior leaflet of rectus sheath. (d) V to Y conversion of rectus sheath incision.

Results

A total of 544 consecutive RRPs by a modified Pfannenstiel approach were performed between January 2003 and July 2006. Table 1 shows the patient demographics and clinicopathological details. The mean follow-up was 11 (s.d.±10.5) months. Mean BMI of the patient was 26.8 (s.d.±3.2). Mean age was 60 (s.d.±7.5) years. The mean operative time was 160 (s.d.±26) min. The mean blood loss was 431 (s.d.±267) ml. Sixteen percent received intraoperative salvaged blood. No patients required an allogenic transfusion. Table 2 shows operative parameters and pathological details of study subjects. A total of 516 (95%) patients had pelvic lymph node dissection, 453 (83%) had a unilateral or bilateral nerve sparing procedure, 137 out of 544 (25%) patients had a pelvic drain inserted and 493 had (91%) the bladder neck preserved. The median hospital stay was 36 h (s.d.±24). The catheter was removed on the seventh oreighth postoperative day. Fifty-three (9.7%) patients had inguinal hernia repair through the same incision. The mean pain score at days 1 and 7 were 3.7 (s.d.±2.5) and 3.3 (s.d.±3), respectively, in a 10-point visual analog scorecard. During hospital stay, the mean analgesic use was 7.4 (s.d.±6) morphine equivalents.

Table 1 Demography and staging
Table 2 Operative parameters

Postoperative continence was assessed at 30 days, 6 months, 1 year and at 2 years. The continence details are given in Table 3a. At 6 months, 91% of patients were continent and not using pads. At 2-year follow-up, the continence rate was higher at 98%. Preoperatively 110 patients were identified to have significant erectile dysfunction. Review of potency in patients who had nerve sparing RRP and completed 1-year follow-up (n=162) demonstrated that 46% patients achieved good erection suitable for intercourse with or without PDE-5 inhibitors and 11% achieved partial erections, but not suitable for penetrating intercourse. Forty-three percent could not achieve satisfactory erections (Table 3b).

Table 3a Continence after RRP
Table 3b Potency rate at one year after RRP

Early and late complication details are shown in Table 4. One patient had postoperative bleeding which was treated conservatively with a blood transfusion. About 0.7% had urinary leak that was self-limiting and treated conservatively with placement of the urethral catheter for 2 weeks. None required return to the operating room. Five patients with an anastomotic stricture (0.9%) required bladder neck incision. One patient died during follow-up due to an unrelated cause. Biochemical recurrence was defined as a postoperative PSA 0.4 ng/ml.9 About 5.5% of the patients had a PSA recurrence. Seven patients (1.3%) have received adjuvant therapy (e.g. hormones and radiotherapy).

Table 4 Postoperative complications–RRP

Discussion

Radical prostatectomy is one of the most common urological procedure performed in the United States.10 This procedure has undergone several technical advances since Millin introduced this approach in 1947.11 The surgical aim is to achieve complete cancer eradication while preserving continence and erectile function. Surgeons constantly strive to improve the surgical technique to minimize morbidity yet maintaining cancer control.

The anatomical location of prostate facilitates various surgical approaches, including retropubic, transperineal and laparoscopic approaches. Traditionally, RRP is performed with a lower abdominal vertical midline incision. The vertical approach was modified to a ‘minilaparotomy’ approach, in an effort to reduce incisional pain and hasten recovery.12 The transperineal approach may be an alternative but has the limitation of access to pelvic lymph nodes.13

A transverse Pfannenstiel incision has been used to perform RRP.14 The original Pfannenstiel incision was described by a German gynecologist in 1900.15 This ‘Bikini’ incision is still effective and widely used among gynecologists and surgeons. This incision offers excellent accessibility to the pelvic organs. It has been used for various procedures such as cesarean section, hysterectomy, ovarian pathology, colorectal surgery16 and femoral hernia repair.17 In urology, ileal augmentation cystoplasty,18 specimen extraction after retroperitoneal renal surgery19 and prostatectomy5, 14 are performed through this approach. Interestingly a report described a splenectomy through a Pfannenstiel incision.20

The advantage of the midline incision is that it is vertically centered over the prostate and can be extended to the pubic bone. On the other hand, the transverse Pfannenstiel incision is centered on the prostate and minimizes exposure of the lower abdominal contents. This approach offers excellent cosmesis and wound healing and is not dependent on body habitus (Figure 2).5 We have previously reported that the postoperative pain and analgesic requirement are minimal when this approach is combined with long-acting spinal anesthesia.21 Soulie et al.14 and Kiyokawa et al.22 reported that the horizontal approach was associated with reduced analgesic consumption when compared with a vertical midline incision. Incisional hernia is rare with a Pfannenstiel incision (0–2%).23 Our modification of Pfannenstiel incision involves the V-Y-shaped rectus incision instead of transverse incision. This modification combines the advantages of both vertical and transverse incisions, resulting in better exposure, healing and good cosmesis. This Y approach prevents any inadvertent entry into inguinal canal and also facilitates concurrent inguinal hernia repair through the same incision.8, 24 This modification also reduces the chance of ilio inguinal and ilio hypogastric nerve entrapment, which is a known complication of classical Pfannenstiel approach.25 Salonia et al.,26 in a prospective randomized study, concluded that outcome after Pfannenstiel approach for a RRP was not significantly different from a vertical midline incision. However, the V-Y modifications of the rectus sheath incision was not utilized in his study. The pain score was measured during the immediate post period and day 1 only. Cosmesis and patient satisfaction was not assessed.

Figure 2
figure2

Healed modified Pfannenstiel incision.

The functional outcome of our modified Pfannenstiel approach is favorable. The exposure to the pelvis, blood loss, hospital stay, analgesic requirement and cosmesis are the advantages of this approach. Continence rates at 12 months (96%) and 24 months (98%) are excellent. Although it is early to comment on oncological outcome, the current results are equivalent to results reported by the authors using the midline incision. Overall, our results are comparable with other series.27, 28

About 5–10% of men undergoing RRP will have a detectable inguinal hernia. An asymptomatic inguinal hernia could be treated conservatively; however, it is reasonable to repair them after a RRP.29 The modified Pfannenstiel approach facilitates classic Lichtenstein's mesh repair of inguinal hernia through the same incision. Overall, 56 concurrent hernia repairs were performed in 44 patients who underwent a RRP. There were no major complications and only one patient had recurrence of a hernia.24 We also performed penile prosthesis insertion in two patients through the same incision.

Recently, LRP has been accepted as minimally invasive technique to reduce the surgical morbidity and accelerate recovery. LRP is reported to have reduced postoperative stay and discomfort. The oncological outcome and continence recovery are comparable to the open RRP.30 However, LRP is associated with significant learning curve. In contrast, most urologists are familiar with the Pfannenstiel approach, which is easy to learn and provides good cosmetic results. Most patients can be discharged within 36 h, which is comparable to the minimally invasive technique results. The development of robotic interface with three-dimensional vision facilitated minimally invasive radical prostatectomy by a surgeon who is skilled in conventional open surgery but with limited laparoscopic exposure. It is hoped to shorten the learning curve, although maintaining the cancer control.4 However, the financial constraints are a major concern and may not be affordable to all health-care providers. The RRP using modified Pfannenstiel approach is not associated with any additional cost and can be performed in all centers.

We recognize that there are few limitations to this study. This study is retrospective and is not randomized to compare with other approaches. The mean follow-up is short. Our intention is to assess the clinical and functional outcome of our approach to RRP. We are currently conducting a randomized study to compare the differential outcome between vertical and modified Pfannenstiel approach to RRP.

Conclusion

RRP by modified Pfannenstiel approach offers safety and efficacy. This approach is easy to perform, reproducible and is not associated with additional financial burden. It also facilitates concurrent repair of associated inguinal hernia through the same incision. We feel that modified Pfannenstiel approach offers an alternate to expensive laparoscopic and robotic RRP without compromising treatment goals.

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Acknowledgements

Financial support from Jackson Memorial Hospital Foundation and Mr Vincent Rodriguez.

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Correspondence to M Manoharan.

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Manoharan, M., Ayyathurai, R., Nieder, A. et al. Modified Pfannenstiel approach for radical retropubic prostatectomy: a 3-year experience. Prostate Cancer Prostatic Dis 11, 74–78 (2008) doi:10.1038/sj.pcan.4500969

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Keywords

  • prostate cancer
  • prostatectomy
  • Pfannenstiel incision

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