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Perineal Radical Prostatectomy: Back to the Future?
Sandip M. Prasad, MD, M. Phil.1, Xiangmei Gu, M.S.2, Rebecca S. Lavelle, M.D.1, Stuart R. Lipsitz, Sc.D.2, Jim C. Hu, M.D., M.P.H.3.
1Harvard-Longwood Program in Urology, Boston, MA, USA, 2Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA, 3Brigham and Women's Hospital, Boston, MA, USA.

Background: Throughout much of the 20th century perineal radical prostatectomy (PRP) was the preferred approach for prostate cancer surgery. However, due to the need for concomitant pelvic lymph node dissection (PLND), increased use of the retropubic approach for BPH and radical cystectomy, and loss of familiarity with the perineal approach, PRP was largely abandoned first for RRP and minimally invasive radical prostatectomy (MIRP) more recently. However, widespread PSA screening and expert guidelines have reduced the use of PLND, and MIRP anatomy is unfamiliar for most urologists. Our population-based study objective was to compare utilization and outcomes for PRP vs. RRP and MIRP.
Methods: We identified men who underwent PRP (n=452), MIRP (n=1,938), and RRP (n=6,899) from Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data during 2003 to 2007. We compared postoperative 30-day complications, anastomotic stricture, and use of adjuvant cancer therapy (hormonal therapy and/or radiotherapy). Additionally, we compared healthcare expenditures by surgical approach during the initial six month post-operative period.
Results: PRP comprised 4.9% of radical prostatectomies during our study period, with decreasing utilization over time. Patients undergoing MIRP were more likely to have fewer comorbidities than patients undergoing PRP (p=0.008). In addition, patients with higher education levels and median income were more likely to undergo MIRP compared to PRP (p=0.028 and p<0.001, respectively). Patients undergoing PRP vs. MIRP were more likely to reside in a non-metropolitan area (p<0.001). PRP was performed more commonly in the South and Midwest compared to MIRP and RRP, which were more commonly performed in the Northeast and West (p=0.014 and p=0.004, respectively). In propensity-score adjusted analyses, men undergoing PRP vs. RRP experienced shorter hospitalizations (median 2 vs. 3 days, p<0.001), fewer heterologous transfusions (7.2% vs. 20.8%, p<0.001), and required less additional cancer therapy (4.9% vs. 6.9%, p=0.020). When comparing PRP vs. MIRP, men undergoing PRP required more heterologous transfusions (7.2% vs. 2.7%, p=0.018), but experienced fewer miscellaneous medical complications (5.3% vs. 10.0%, p=0.045). PRP vs. RRP and MIRP had the lowest mean expenditures ($14,930 vs. $17,704 and $18,299, p<0.001).
Conclusions: Men undergoing PRP vs. RRP and MIRP experienced favorable outcomes with the exception of greater transfusion rates compared to MIRP. PRP was also associated with lower expenditures of almost $3,000 compared to competing approaches, suggesting that it may be more cost-effective. Urologists may be abandoning an under-utilized, more cost-effective surgical approach that compares favorably with its successors.
Propensity-model adjusted outcomes comparing PRP to RRP and MIRP, adjusting for surgeon volume

OutcomeRate (%)Odds and rate ratios*
RRP vs. PRPMIRP vs. PRP
PRPRRPMIRPRatiop-valueRatiop-value
Length of stay, median (days)2321.43<0.0011.120.165
Blood transfusion7.220.82.72.76<0.0010.350.018
30-day complications
Overall18.923.222.21.230.1011.170.199
Cardiac3.92.92.40.740.5040.620.372
Respiratory4.16.64.31.610.0651.050.340
Genitourinary52.14.70.420.3160.940.252
Wound2.51.920.760.6210.800.919
Vascular3.33.93.41.180.6581.030.628
Misc. medical5.38.5101.600.0551.890.045
Misc. surgical7.65.64.30.740.3440.570.211
Mortality0.40.20.10.500.4620.250.321
Stricture11.114.05.81.260.2610.480.054
Additional cancer therapy per 100 person-years
Overall4.96.98.21.410.0201.670.103
Radiation3.74.95.11.320.1241.380.301
Hormonal2.83.75.31.320.0921.890.113
*Median ratios for length of stay; Odds Ratios for blood transfusion, 30-day complications, and anastomotic stricture; and Rate Ratios for additional cancer therapy

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