Similar to the retropubic procedure in terms of before-surgery preparation and recovery, the radical perineal approach offers some advantages over that technique: There’s less bleeding, because the major vein system that overlies the prostate (the dorsal vein complex) is not removed with the prostate. However, this also means that surgeons aren’t able to cut out as much tissue as in the retropubic approach—so if the cancer has penetrated the prostate wall, “positive surgical margins” may be more likely here than in the retropubic approach. If the likelihood of cancer appearing in the pelvic lymph nodes is low (see table 3.3), there’s no need for an abdominal incision. Many men, however, do have a laparoscopic lymph node dissection before getting a perineal prostatectomy just to be sure cancer hasn’t reached the lymph nodes.

Another drawback to the perineal approach is that it’s more difficult for surgeons to see—and thus protect—the neurovascular bundles, the thin packets of nerves that sit on either side of the prostate and are essential for erections. Therefore, preserving potency is not as certain. Also, the operation is not ideal for heavyset men, particularly men with what one doctor describes as a “large-barrel abdomen.”

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