prostate cancer ( pca ) patients can be stratified into different risk groups in terms of predicting prognosis and determining treatment strategy ( 1 ) . although the early detection rate of pca has recently increased due to prostate - specific antigen ( psa)-based screening ( 2 ) , the number of intermediate - risk ( ir ) and high - risk ( hr ) cases at an elevated risk of biochemical recurrence ( bcr ) and disease progression compared to those with low - risk ( lr ) still make up more than half of newly diagnosed cases ( 2 ) . the benefits of radical prostatectomy ( rp ) as first - line treatment for ir and hr pca as monotherapy or part of a multimodal plan are achievement of excellent local control , accurate pathological staging and guiding additional therapy based on better prediction of prognosis ( 34 ) . radical perineal prostatectomy ( rpp ) has been used for much of the 20th century as the oldest radical procedure for treatment of pca ( 5 ) . although rpp use decreased after nerve - sparing radical retropubic prostatectomy ( rrp ) was first described in the 1980s , there has recently been a renewed interest in rpp ( 6 ) , which is an effective minimally invasive technique with rapid recovery ( 67 ) , minimal cost ( 8) and the ability to be quickly mastered due to relatively easy dissection and anastomosis of the urethra ( 67 ) . the surgical outcomes of rpp with nerve - sparing and extended radical modifications are very similar to those of other rp series ( 678910 ) . however , as pelvic lymph node dissection ( plnd ) is conventionally recommended in patients with ir or hr pca ( 11 ) , rpp is typically offered only to patients with lr pca , in whom the risk of lymph node involvement ( lni ) is < 1% ( 12 ) due to a separate skin incision for plnd . however , the indications for plnd and the effects of plnd on oncological outcomes of pca remain unclear . there has been a significant decline in the use of plnd following the introduction of minimally invasive rp ( mirp ) ( 13 ) . additionally , in the era of psa testing , plnd is less often indicated during rp due to the significantly decreased incidence of lnis , thereby making avoidance of rpp no longer valid ( 14 ) . stage migration in the recent psa era has dramatically reduced the incidence of lni to 1% ( 14 ) . up to date , no consistent conclusions have been reached regarding the role of plnd in improving oncologic outcomes for ir and hr patients ( 15 ) . with a resurgence of interest in the perineal approach , it is critical to determine whether rpp is effective for cancer control in patients with ir or hr disease who would be most likely to benefit from rp , but in whom plnd is generally recommended . the goal of the present study was to investigate the oncologic efficiency of rpp as a first - line treatment in patients with ir or hr pca by making a direct comparison of pathological and oncologic outcomes among ir and hr pca treated either by rpp , rrp , and mirp in a single institution . clinico - pathological characteristics and onco - surgical outcomes were retrospectively reviewed in ir and hr pca patients . from 1995 through 2013 , we identified 2,581 consecutive patients undergoing rp for ir ( ct2b - t2c , bgs=7 , or psa 10 - 20 ng / ml , n=1,377 , 53% ) and hr ( ct3 , bgs 8 - 10 , or psa > 20 ng / ml , n=1,204 , 47% ) pca at samsung medical center ( 16 ) . of these , 689 ( 26.7% ) , 402 ( 15.6% ) and 1,490 ( 57.7% ) underwent rpp , rrp and mirp ( laparoscopic radical prostatectomy [ lrp ] , n=206 ; robot - assisted laparoscopic radical prostatectomy [ ralrp ] , n=1,284 ) , respectively . patients who received neoadjuvant treatment ( i.e. , hormonal therapy or radiation therapy ) were excluded from this study . the number of surgeons performing rrp , lrp and ralrp was 4 , 1 , and 4 , respectively , while rpp was performed by only one surgeon . all patients were preoperatively staged for metastases with a bone scan , magnetic resonance imaging ( mri ) , and pelvic computed tomography ( ct ) . in rpp cases , plnd was performed for accurate diagnosis of lni via mini - laparotomy ( 17 ) or a laparoscopic approach ( 18 ) in patients with radiographic findings suspicious for pelvic lni . prostatectomy specimens were reviewed with respect to pathologic gs ( pgs ) , pathologic t ( pt ) stage , and surgical margin ( sm ) status . additionally , we deemed men with a pgs of < 8 or pt3a pca to have favorable disease , and those with pgs 8 - 10 and pt3b or n1 disease to have unfavorable pathologic findings ( 19 ) . if the patient had no urinary leakage or required only a security pad , this was defined as being continent . in general , patients were followed for recurrence postoperatively using psa levels and clinical assessment at 3 - 6-month intervals for the first 3 - 5 yr , and then annually thereafter . when clinically indicated after surgery , further diagnostic testing was used , including ct , mri , chest radiography , and/or bone scans . bcr was defined as the first occurrence of two consecutive psa level rises of > 0.2 ng / ml at least 3 months after rp , and distant metastases was defined as a demonstrable metastatic deposit on imaging . pca - specific survival ( css ) refers to the time from rp to death attributed to pca or complications related to this disease . adjuvant treatment was started within 6 months of the surgery , and salvage treatment was started in patients with bcr or clinical progression that were more than 6 months out from rp . differences in the clinico - pathologic features based upon surgical technique were assessed using the rank - sum test and chi - square or fisher 's exact test . to evaluate the impact of rp on bcr - free survival ( bfs ) , metastasis - free survival ( mfs ) , and css in ir and hr patients , kaplan - meier analysis was performed along with log - rank tests . a multivariate proportional hazard regression model was used to identify independent predictors of bcr and metastases . all p - values were two - sided and p<0.05 was considered to be statistically significant . the analyses were performed using spss commercial software , version 17.0 ( spss inc . , this retrospective study was approved by the institutional review board of samsung medical center ( irb no . this retrospective study was approved by the institutional review board of samsung medical center ( irb no . the hr feature was observed in 40.3% , 46.8% and 49.5% of men undergoing rpp , rrp and mirp , respectively ( for a pairwise comparison of rpp vs. rrp , p=0.04 ; rpp vs. mirp , p<0.001 ) . plnd was performed in 7.1% , 21.4% and 19.3% cases of rpp , rrp and mirp , respectively ( p<0.001 ) . the rate of neurovascular bundle preservation was significantly higher in mirp ( 67.3% ) than rpp ( 56.2% ) and rrp ( 29.9% ) ( p<0.001 ) . in addition , estimated blood loss was lower in rpp patients compared to rrp patients ( p<0.001 ) although higher compared to the mirp group ( p<0.001 ) . there were statistically significant differences between continence rate at 1 yr ( rpp , 85.8% ; rrp , 70.9% ; mirp , 76.6% , p<0.001 ) . rpp patients had significantly lower proportions of pt3 stage and higher proportions of pgs 8 compared to mirp patients ( p=0.002 and p=0.047 ) although there was no statistically significant difference between the three cohorts with respect to proportion of unfavorable disease ( rpp , 5.1% ; rrp , 5.7% ; mirp , 4.0% , p=0.21 ) ( table 1 ) . while there were significantly fewer positive sms with mirp for pt2 organ - confined disease ( rpp , 17.5% ; rrp , 17.8% ; mirp , 8.8% , p<0.001 ) , we found no significant difference in the incidence of positive sms among men with extra - prostatic extension and seminal vesicle invasion irrespective of surgical approach ( rpp , 41.9% ; rrp , 44.4% ; mirp , 40.0% , p=0.55 ) . there was a significant difference in median follow - up duration between the rpp , rrp and mirp groups ( rpp , 68 ; rrp , 42 ; and mirp , 33 months ; rpp vs. rrp , p<0.001 ; rpp vs. mirp , p<0.001 ) ( table 1 ) . during the follow - up period , a total of 443 patients experienced bcr , 156 ( 24.7% ) in the rpp group , 90 ( 24.7% ) in the rrp group , and 197 ( 14.1% ) in the mirp group ( table 1 ) . distant metastasis was detected after rp in 5.1% of rpp , 1.7% of rrp and 2.4% of mirp . in terms of the bfs rate bfs rate at 5 yr was 73.0% , 70.1% and 76.8% for rpp , rrp and mirp , respectively ( rpp vs. rrp , p=0.02 ; rpp vs. mirp , p=0.23 ) ( table 2 ) . importantly , in hr pca , rpp was associated with higher bfs rates compared to rpp ( p=0.04 ) , but comparable bfs rates were demonstrated between rpp and mirp ( p=0.55 ) . similarly , there were no significant differences in bcr between rpp and mirp when stratified by pgs , pt stage and sm positivity ( table 2 ) . the comparison of mfs rates according to surgical approach also demonstrated no meaningful difference in overall cohorts and in subgroup analysis stratified by pre - operative risk ( fig . the independent prognostic factors associated with bcr and metastases were statistically analyzed using the multivariate cox proportional hazards regression method ( table 3 ) . after adjusting for age , psa density , pgs , pt stage , and sm status , the stratified preoperative risk were shown to be significantly associated with oncologic outcomes ( bcr , hazard ratio=1.54 , p<0.001 ; metastases , hazard ratio=2.76 , p=0.002 ) . while psa density , pgs , pt stage , and sm status ( all p<0.001 ) were significant predictors of bfs , independent factors of mfs included pt stage ( p<0.001 ) and pgs ( p<0.001 ) , suggesting that the presence of unfavorable pathology defined by high pgs ( 8 ) and advanced t stage ( pt3b ) was significantly associated with increased risk of bcr and distant metastasis from pca . surgical modality did not predict mfs in multivariate regression models controlling for these cofactors while rrp was associated with increased bcr ( hr 1.44 , p=0.01 ) compared to rpp . in landmark survival analyses in rpp ( table 4 ) , the 10-yr mfs and css rates for the entire cohort in patients who underwent rpp were 87.1% ( ir , 93.2 ; hr , 77.5% , p<0.001 ) and 92.8% ( ir , 94.0 ; hr , 89.3% , p=0.13 , fig . 10-yr mfs and css rates were also better for those with a pgs < 8 ( table 4 and fig . 2d ) , and these differences were also statistically significant ( all p<0.001 ) . finally , favorable rpp pathology was associated with improved oncologic outcomes in the overall cohort ( mfs , 93.3% and css , 94.4% at 10 yr , all p<0.001 ) ( table 4 ) . by far the most common argument put forward in favor of a retropubic approach as opposed to rpp is the issue of plnd , since lns can be dissected via the same skin incision or port sites . in this context , rpp has typically been offered to patients with lr pca in whom plnd is unnecessary ( 12 ) ; therefore , there is limited evidence in support of rpp in ir and hr patients in whom plnd is recommended . as for plnd , improved imaging techniques and accurate lni risk discrimination could help to better guide the clinician in deciding whether plnd is required , and as a result , unnecessary plnd can be avoided . because of limited comparing studies between rpp and other rp procedure regarding surgical outcomes , it is difficult to determine the best approach against ir and hr pca . since the opening of the samsung medical center in 1994 , this study reporting a large single institutional experience of surgical efficacy of rpp , rrp , and mirp in patients with ir and hr pca , we found no difference in disfavor of rpp regarding short - term oncologic outcomes in ir and hr patients , demonstrating comparable oncologic outcomes with previous reports ( 20212223 ) . furthermore , hr and the final pathologic characteristics rather than surgical approach were significant predictors of disease recurrence . finally , survival outcomes of rpp in clinically hr pca patients ( a 10-yr mfs , and css of 77.5% and 89.3% , respectively ) are comparable with those of other rrp and mirp reports , although published data for rp in hr pca patients are very heterogeneous in terms of risk criteria , final pathology , adjuvant / salvage treatments , and follow - up duration ( 2425 ) . the incidence of positive sms in this study was comparable to those found in recent studies ( 2627 ) . especially , the margin positivity rate was similar between rpp , rrp , and mipr in hr pca , and previous open and mirp series reported positive sm rate ranges from 21% to 47% ( 28 ) . the improved mirp sm status in lr disease may be attributed to better visualization of the prostate capsule and apex secondary to magnification , fiber - optic illumination , and co2 insufflation that tamponades venous bleeding ( 29 ) . lower estimated blood loss during mirp than other rp techniques could be due to high intra - abdominal pressure during pneumoperitoneum for mirp procedures ( 23 ) . we recognize that our study is limited by its retrospective design . as the application of additional therapies is not standardized , the exact effects of rp as a monotherapy for ir and hr pca could not be determined in our series . further long - term studies evaluating functional outcomes focusing on post - operative potency are required to better compare pros and cons of various rp approaches . to our knowledge , the present study is the largest single - institution series to investigate the impact of three different approaches on onco - surgical outcomes following rp for patients with ir and hr pca . taken together , our results support the use of rpp as an attractive alternative surgical approach in these patients , as it achieves equivalent favorable oncologic outcomes when applied alone or in combination with other therapies .
the aim of this study was to investigate a single - institution experience with radical perineal prostatectomy ( rpp ) , radical retropubic prostatectomy ( rrp ) and minimally invasive radical prostatectomy ( mirp ) with respect to onco - surgical outcomes in patients with intermediate - risk ( ir ; psa 10 - 20 ng / ml , biopsy gleason score bgs 7 or ct2b-2c ) and high - risk ( hr ; psa > 20 ng / ml , bgs 8 , or ct3 ) prostate cancer ( pca ) . 
 we retrospectively reviewed data from 2,581 men who underwent radical prostatectomy for ir and hr pca ( rpp , n = 689 ; rrp , n = 402 ; mirp , n = 1,490 [ laparoscopic , n = 206 ; robot - assisted laparoscopic , n = 1,284 ] ) . 
 the proportion of hr pca was 40.3% , 46.8% , and 49.5% in rpp , rrp , and mirp ( p < 0.001 ) , respectively . 
 the positive surgical margin rate was 23.8% , 26.1% , and 18.7% ( p = 0.002 ) overall , 17.5% , 17.8% , and 8.8% ( p < 
 0.001 ) for pt2 disease and 41.9% , 44.4% , and 40.0% ( p = 0.55 ) for pt3 disease in men undergoing rpp , rrp , and mirp , respectively . biochemical recurrence - free survival rates among rpp , rrp , and mirp were 73.0% , 70.1% , and 76.8% , respectively , at 5 yr ( rpp vs. rpp , p = 0.02 ; rpp vs. mirp , p = 0.23 ) . furthermore 
 , comparable 5-yr metastases - free survival rates were demonstrated for specific surgical approaches ( rpp vs. rpp , p = 0.26 ; rpp vs. mirp , p = 0.06 ) . 
 rpp achieved acceptable oncological control for ir and hr pca .