Radical perineal prostatectomy shows lower blood loss but similar long-term outcomes to retropubic approach

BACKGROUND: Although radical perineal prostatectomy is performed less frequently, it represents a minimally invasive open approach that avoids the retropubic space and extensive pelvic dissection. Its longterm oncologic and functional equivalence to standard retropubic prostatectomy has not been adequately evaluated in randomized cohorts. OBJECTIVES: To compare perioperative outcomes, short and long-term oncologic, and patient-reported outcomes of RPP and RRP, with or without PLND. MATERIALS AND METHODS: Men with cT1-T2N0M0 prostate cancer and a predicted lymph-node invasion risk <5% were prospectively randomized to RPP, RRP, or RRP with PLND (40 patients per group). Data from 103 patients including 38 treated with RPP, 31 with RRP, and 34 with RRP with PLND were included in the analysis. Biochemical recurrence-free survival (BCRFS) was estimated using Kaplan-Meier analysis. Urinary, sexual, and satisfaction outcomes were assessed using selected items from the 'Expanded Prostate Cancer Index Composite' (EPIC) at baseline, 1 month, 1 year, and at long-term follow-up (10 years). RESULTS: Baseline characteristics were comparable across groups. Operative time was longest in the RRP+PLND group, while estimated blood loss was lowest with RPP (p=0.004). Early complications were mostly minor; prolonged drainage and wound infection were more frequent after RPP without long-term sequelae. At 1 and 10 years, BCRFS rates were 82% and 71.2% for RPP, 89% and 79.6% for RRP, and 87% and 79.8% for RRP+PLND (p=0.157 and p=0.679). ISUP grade >2, positive surgical margins, and pT3b stage independently predicted recurrence. Continence improved over time (p<0.001), reaching similar 10-year rates across groups (68-73%). Erectile function recovery remained limited (19-28%) and comparable. Patient satisfaction remained high. CONCLUSIONS: The perineal approach is associated with lower blood loss but may entail more wound-related complications. At both 1 and 10 years, RPP and RRP provide comparable oncologic, functional, and patient-reported outcomes.