What is Radical Prostatectomy (Surgery) for Prostate Cancer?

Before and after radical prostatectomy
Before and after radical prostatectomy
Cancer Research UK

Radical prostatectomy is surgically removing the prostate, seminal vesicles, nearest parts of the vas deferens, nearby tissue, and some nearby pelvic lymph nodes. Because cancer may be scattered in the prostate gland, the prostate must be removed. This makes sure cancer cells are not left behind to grow.

The pelvic lymph nodes are small oval or round bodies along blood vessels. They filter fluid from the lymph nodes. Prostate cancer usually spreads first to the soft tissues around the prostate. Then, it spreads to the seminal vesicles, lymph nodes, bones and other organs. There are many other lymph nodes. So the body will not be harmed by removing these few lymph nodes.

The surgery requires anesthetic. You will be in the hospital for one to three days.

There are four types of radical prostatectomy surgery:

Retropubic Open Radical Prostatectomy

Retropubic radical prostatectomy
Retropubic radical prostatectomy

This is the most common type of prostate surgery. Your surgeon will make a cut (incision) in your lower belly and remove the prostate through this opening. This type of surgery allows your physician to assess the prostate gland and surrounding tissue at the same time, while reducing injury to nearby organs. The prostate gland is removed with limited blood loss. The neurovascular bundles are preserved, and so is erectile function.

Perineal Open Radical Prostatectomy

Perineal radical prostatectomy
Perineal radical prostatectomy

The prostate is removed through a cut between the anus and scrotum. Because the complex pelvic veins are avoided, bleeding is rare. This type of surgery is not usually performed today.

Laparoscopic Radical Prostatectomy

Incisions (cuts) made for laparoscopic and robotic-assisted prostatectomy
Incisions (cuts) made for laparoscopic
and robotic-assisted prostatectomy

Your surgeon will make six 1-inch incisions in your belly. Small surgical tools and video camera fit through the incisions to remove the prostate. Small instruments including a camera are passed through ports in your belly. The prostate gland is removed. This surgery has been replaced with robotic assisted laparoscopic surgery.

Robotic Assisted Laparoscopic Radical Prostatectomy (RALP)

The prostate is removed through ports in your belly using a robotic system. The system holds and guides the laparoscopic surgical instruments and camera. RALP surgery is one of the most common types of prostate surgery today. In experienced hands, there are no major outcome differences between RALP and retropubic prostatectomy. However, the success of this surgery is dependent upon how experienced your surgeon is. The more surgeries your doctor has done, the better he/she will be at performing this procedure.

After the prostate has been removed, the urinary tract and the bladder are reconstructed. Then a catheter is passed through the urethra into the bladder. This is to drain the urine while the new connection between the bladder and urethra (the "anastomosis") heals. The catheter will stay in place one to two weeks after the surgery.

One or two suction drains are at times left beside the bladder, deep in the pelvic cavity. They are brought out through the lower belly to drain any fluid in the wound. They help lower the risk of infection and pressure from fluid. The drains are usually removed before you are discharged from the hospital.

Most people do not pass flatus (gas) for one to two days. Most do not have a bowel movement until the third day after surgery. This depends on the amount of narcotic pain medication. The goal of the first few days will be to prevent breathing and circulation problems. You will need to walk at least 100 yards three to four times a day.

The catheter is removed on a return visit to your surgeon. You should begin exercises to strengthen the urinary control valve (Kegel exercises) after the catheter is removed.

Once your surgeon has the final pathology report, he/she will make a plan. The surgeon reads the final pathology report. Based on this, the health care provider makes a plan. If the report is favorable, the plan includes regular health care provider's visits and a PSA test every 6-12 months. The post-operative PSA level should be in the "undetectable" ranger (less than 0.1 ng/mL).

If the pathology report shows cancer at the surgical margin or spread of cancer into surrounding tissues, seminal vesicles, or lymph nodes, more therapy may be needed. Therapy may include radiation therapy and/or hormone treatment. This would begin 2 to 4 months after surgery.

What Are The Benefits, Risks and Side Effects of Surgery?

The main benefit of a radical prostatectomy is that the cancer is removed with the prostate. This is true as long as cancer hasn't spread outside the prostate. Surgery also helps the health care provider find out whether the cancer has moved beyond the prostate.

If your prostate cancer is confined to the prostate, the cahcne of cure with surgery alone at 10 years (undetectable PSA) is more than 90 percent. If your cancer has gone beyond the prostate gland, surgery is also a good choice.

A study comparing radical prostatectomy to watchful waiting showed that prostate removal improved a man's chance of survival. In the study, men were randomly assigned to radical prostatectomy or watchful waiting. Men treated with surgery had a significant survival improvement.

But most men whose tumors were watched did not die from prostate cancer. And some men who had surgery did die from prostate cancer. About 20 operations were needed to save one life from prostate cancer. The likelihood of cure varies. It depends on the cancer removed. Usually one must have PSA test values of less than 0.1 ng/mL for 10 years before cure is certain.

The main risk of any surgery is complications that could happen from the operation. Some happen early and some later. Bleeding can happen in any major operation. About 1-2% of men develop deep venous thrombosis (DVT blood clots in the leg or pelvic veins) or pulmonary embolism (blood clot that goes to the lung).

With surgery, there are two big side effects, you may develop - erectile dysfunction and incontinence.

Nerves surround the prostate gland
Nerves surround the prostate gland
NIH Medical Arts, National Cancer Instutute (NCI)

Surgery may damage the nerve bundles that control blood flow to the penis; causing ED. Nerves involved in the erection process surround the prostate gland. While most surgeons try to perform a newve sparing procedure, it is not always possible. In addition, there could be a decreased amount of blood flowing to the penis after treatment. The chance of ED after treatment depends on many things. For more information on how prostate cancer surgery can affect your erections, read our After Treatment: Erectile Dysfunction Issues After Prostate Cancer Treatment section (This section is near the beginning of the After Treatment page.)

With surgery, there is also the risk for developing Peyronie's disease (a curve to the penis). This can be from scarring which comes from treating your ED with injections to the same spot. Or it could come from the penis kinking or buckling while having intercourse without a strong erection.

The ability to have an orgasm (climax) is not lost after radical prostatectomy. This is true even though there is no erection. There will be very little, if any, fluid with orgasm. Any fluid is usually mucus from the Cowper's gland. There is sometimes urine if urinary sphincter muscles have not fully recovered.

You can no longer cause a pregnancy during intercourse. This is because the prostate and seminal vesicles were removed and the cas deferens was divided. Artificial insemination can be used to cause a pregnancy.

Incontinence can sometimes occur as a result of treatment for prostate cancer. Incontinence is the inability to control your urine. After prostate cancer surgery, you may experience four different types of Incontinence.

  • Stress Incontinence - is the most common, is urine leakage when coughing, laughing, sneezing or exercising.
  • Overflow Incontinence - is the inability to empty the bladder completely, taking longer to urinate and when you do urinate, it is not a powerful stream.
  • Overactive Bladder (Urge Incontinence) - is the sudden need to go to the bathroom even when the bladder is not full because the bladder is overly sensitive.
  • Mixed Incontinence - is a combination of stress and urge incontinence with symptoms from both types.
  • Continuous Incontinence - is not common. It is the inability to control urine at any time.

Because incontinence may affect your physical and emotional recovery, it is important to understand what your options are for treatment. For more information on how prostate cancer surgery can affect your incontinence, read our After Treatment: Incontinence Issues After Prostate Cancer Treatment section (This section is near the end of the After Treatment page.)

Who Are Good Candidates for Surgery?

Prostate cancer surgery is best if your prostate cancer is in clinical stage T1 or T2. That means it is confined to the prostate gland. It is also used if your disease is clinical stage T3. There are no absolute cut-offs. But if you have a PSA level less than 20 ng/mL and a Gleason score of less than 8 you have a higher chance of cure.

Prostate cancer surgery is usually restricted to men who are healthy enough to tolerate a major operation. You should also have a 10-year or more life expectancy. Life expectancy is based on your age and health. Surgery may be offered to men with different circumstances.