CPT® Code 55815

1. Indications

The perineal radical prostatectomy with bilateral pelvic lymphadenectomy, as described by CPT® Code 55815, is indicated for the following conditions:

• Prostate Cancer Patients diagnosed with prostate cancer who require surgical intervention for tumor removal.
• Assessment of Lymph Node Involvement Situations where there is a need to evaluate the pelvic lymph nodes for potential metastasis.
• High-Risk Features Cases where the cancer exhibits high-risk features that necessitate a more extensive surgical approach, including lymphadenectomy.

2. Procedure

The procedure begins with the lymphadenectomy, which is performed first to assess the pelvic lymph nodes. An incision is made in the lower abdomen, and the pelvic lymph nodes on one side are explored without opening the peritoneum. Care is taken to preserve the genitofemoral nerve and psoas muscle during this exploration. Fatty tissue is carefully stripped from the mid-portion of the common iliac vessel and along the external iliac vessel. The iliac, hypogastric, and obturator nodes are biopsied and sent for separate reportable frozen section analysis. If malignancy is detected in these lymph nodes, they are excised. This process may be repeated on the opposite side if necessary.

Following the lymphadenectomy, the radical perineal prostatectomy is performed. An inverted-U incision is made in the perineum, positioned above the anal opening. The incision is deepened to reach the ischiorectal fossa, and the central tendon is divided on both sides. The fibrous confluence is exposed, and dissection is carried out posterior to the raphe of the bulbospongiosus muscle, which is also divided to reveal the rectourethralis and levator ani muscles. The rectourethralis muscle is then divided, allowing for the exposure of the rectum and urethra.

The rectum is mobilized posteriorly from the prostatic apex, and the Denonvilliers fascia is exposed. The prostate gland is mobilized toward the perineum while the rectum is moved away from the prostate. A transverse incision is made through the Denonvilliers fascia, located between the medial aspects of the vas deferens and seminal vesicles. Each vas deferens is freed from surrounding tissue, ligated, and divided. The seminal vesicles are retracted medially, and their lateral aspects are exposed, ligated, and divided. The base of the prostate is then exposed.

In a nerve-sparing approach, the Denonvilliers aponeurosis is incised, allowing for the separation of the cavernosal nerve bundles from the prostate. In contrast, a non-nerve-sparing approach involves dissecting the periprostatic tissue from the levator muscles and excising it along with the prostate. Regardless of the approach, the puboprostatic ligaments anterior to the prostate are divided, and the attachments of the prostate anterior to the bladder neck are exposed and divided.

A plane of dissection is created between the bladder neck and the base of the prostate, allowing for the exposure of the urethra at its junction with the prostate. The urethra is then dissected from the surrounding tissue and divided approximately 1 cm below the bladder neck. The prostate is subsequently removed, and the urethral ends are anastomosed. If preservation of the bladder neck is not possible, it is excised, and the bladder opening is reduced in size to facilitate the anastomosis of the urethra.

Finally, a catheter is placed transurethrally into the bladder, and the bladder is irrigated to remove any clots. The perineal incision is then closed, completing the procedure.

3. Post-Procedure

Post-procedure care following a perineal radical prostatectomy with bilateral pelvic lymphadenectomy includes monitoring for complications such as bleeding, infection, and urinary retention. Patients are typically advised to manage pain with prescribed medications and to follow specific instructions regarding activity restrictions to promote healing. The catheter placed during surgery is usually removed after a specified period, depending on the surgeon's assessment of recovery. Follow-up appointments are essential to monitor recovery, assess for any signs of complications, and evaluate the effectiveness of the procedure in managing prostate cancer.