Surgery Overview

A radical prostatectomy is an operation to remove the prostate gland and some of the tissue around it. It is done to remove prostate cancer. This operation may be done by open surgery or by laparoscopic surgery through small incisions.

Laparoscopic surgery is most often done by hand. A few doctors now do it by guiding robotic arms that hold the surgery tools. This is called robot-assisted prostatectomy.

Open surgery

In open surgery, the surgeon makes an incision to reach the prostate gland. Depending on the case, the incision is made either in the lower belly or in the groin between the anus and the scrotum.

When the incision is made in the lower belly, it is called the retropubic approach. A radical prostatectomy using the retropubic approach is the most common treatment for prostate cancer. In this procedure, the surgeon may also remove lymph nodes in the area so that they can be tested for cancer.¹

When the incision is made in the groin, it is called the perineal approach. The recovery time after this surgery may be shorter than with the retropubic approach. If the surgeon wants to remove lymph nodes for testing, he or she must make a separate incision. If the lymph nodes are believed to be free of cancer based on the grade of the cancer and results of the PSA test, the surgeon may not remove lymph nodes.

Laparoscopic surgery

For laparoscopic surgery, the surgeon makes several small incisions in the belly. A lighted viewing instrument called a laparoscope is inserted into one of the incisions. The surgeon uses special instruments to reach and remove the prostate through the other incisions.

Men who have laparoscopic surgery tend to lose less blood during the operation and to recover faster than men who have open surgery.² Laparoscopic prostatectomy is not yet widely available, and because it is a relatively new technique, no results from long-term follow-up after treatment are available.

Robotic-assisted laparoscopic radical prostatectomy is surgery done through small incisions in the belly with robotic arms that translate the surgeon's hand motions into finer and more precise action. This surgery requires specially trained doctors.

The main goal of either open or laparoscopic surgery is to remove all the cancer. Sometimes that means removing the prostate as well as the tissues around it, including a set of nerves to the penis that affect the man's ability to have an erection. Some tumors can be removed using a nerve-sparing technique, which means carefully cutting around those nerves to leave them intact. Nerve-sparing surgery sometimes preserves the man's ability to have an erection.

What To Expect After Surgery

Prostatectomy usually requires general anesthesia and a hospital stay of 2 to 4 days. A thin, flexible tube called a catheter usually is left in your bladder to drain your urine for 1 to 3 weeks. Your doctor will give you instructions about how to care for your catheter at home. Bladder control can be poor for a few months after the catheter is removed.

Although prostatectomy often removes all cancer cells, it is important to receive follow-up care, which may lead to early detection and treatment if your cancer comes back. Your regular follow-up program may include:

• Physical exams.
• Prostate-specific antigen (PSA) tests, to monitor PSA levels and to measure the speed of any changes in those levels.
• Digital rectal exams.
• Biopsies as needed, to examine suspicious tissue.

Why It Is Done

Radical prostatectomy is most often used if testing shows that the cancer has not spread outside the prostate (stages I and II).

Radical prostatectomy is sometimes used to relieve urinary obstruction in men with more advanced (stage III) cancer, but a different operation, called a transurethral resection of the prostate (TURP), is most often used for that purpose. Surgery usually is not considered a cure for advanced cancer, but it can help relieve symptoms.

How Well It Works

Radical prostatectomy is generally effective in treating prostate cancer that has not spread. This is called early-stage cancer. Following surgery, the stage of the cancer can be determined based on how far it has spread. PSA levels will drop almost to zero if the surgery successfully removes the cancer and the cancer has not spread. If cancer has spread, advanced cancer may develop even after the prostate has been removed.

Compared with watchful waiting for early-stage cancer, radical prostatectomy lowers the risk that the cancer will grow or spread. And it lowers the long-term risks of death from cancer.³ This is important to know if you expect to live 10 or more years. (If you are already in poor health or are in your later years and you have an early-stage prostate cancer, it may not grow or spread during your lifetime.)

Robotic-assisted laparoscopic radical prostatectomy is only done in medical centers where doctors have special training. With an surgeon who does a large number of these procedures, men who have this procedure heal more quickly and report fewer problems with impotence and incontinence.⁴ But the benefits of this method are yet to be proven.

Risks

Erection problems

Up to 80% of men experience erection problems after a prostatectomy.⁵ The nerves that control a man's ability to have an erection lie next to the prostate gland. They often are damaged or removed during surgery. In the months and years after surgery, most men who had erection problems after prostatectomy are able to regain their ability to have erections:⁶

• 76% of men younger than 60
• 56% of men age 60 to 65
• 47% of men older than 65

Recovery depends on:⁶

• Whether the man was able to have an erection before surgery.
• How the surgery affected the nerves that control erections.
• How old the man was at the time of surgery.

Urinary incontinence

Up to half of all men who have a radical prostatectomy develop urinary incontinence, ranging from a need to wear urinary incontinence pads to occasional dribbling. Studies show that one year later, between 15% and 50% of men report urinary problems.⁵

The urethra—the tube that carries urine from your bladder—runs through the middle of the doughnut-shaped prostate gland. In order to remove the prostate, the surgeon must cut the urethra and later reconnect it to the bladder. Evidence shows that the greater the surgeon's experience and skill in making this reconnection, the lower the rate of incontinence.⁷

Some men may require treatment for incontinence after prostatectomy, if urinary leakage continues longer than 1 year.

Complications

Radical prostatectomy is major surgery, so it carries the same general risks as other major operations, including heart problems, blood clots, allergic reaction to anesthesia, blood loss, and infection of the wound.

These additional complications can be caused by radical prostatectomy:

• Erection problems
• Urinary incontinence
• Damage to the urethra
• Damage to the rectum

What To Think About

When considering prostatectomy, take into account your personal wishes, age, other medical conditions you may have, the stage and grade of your cancer, and your PSA level. Your age and overall health will make a difference in how treatment may affect your quality of life. Any health problems you have before treatment, especially urinary, bowel, or sexual function problems, will affect your recovery. Radiation treatment or watching and waiting may be reasonable alternatives.

If you decide to have surgery, find a surgeon who does at least 40 prostate surgeries a year. Studies show that men have fewer side effects from prostate surgery when they have a skilled and experienced surgeon.⁸

Robot-assisted prostatectomy may be best suited to a younger man in good health who has a small prostate and a small, lower-grade cancer. This technology is not yet widely used.

Both surgery and radiation can cause urinary incontinence (not being able to control urination) or impotence (not being able to have an erection). The level of urinary incontinence and how long it lasts and the quality of the erections a man has after treatment will depend on whether the cancer has spread. These also depend on what treatment is used.

Surgery may completely remove your prostate cancer. But it is not possible to know ahead of time whether the cancer has spread beyond the prostate and is not curable with surgery alone.

Complete the surgery information form (PDF)(What is a PDF document?) to help you prepare for this surgery.

References

Citations

1. Jani AB, Hellman S (2003). Early prostate cancer: Clinical decision-making. Lancet, 361(9362): 1045–1053.

2. Scher HI, et al. (2005). Cancer of the prostate. In VT DeVita Jr et al., eds., Cancer: Principles and Practice of Oncology, 7th ed., pp. 1192–1259. Philadelphia: Lippincott Williams and Wilkins.

3. Bill–Axelson A, et al. (2005). Radical prostatectomy versus watchful waiting in early prostate cancer. New England Journal of Medicine, 352(19): 1977–1984.

4. Badani KK, et al. (2007). Evolution of robotic radical prostatectomy: Assessment after 2,766 procedures. Cancer, 110(9): 1951–1958.

5. Wilt T (2004). Prostate cancer (non-metastatic). Clinical Evidence (11): 1169–1185.

6. Eastham JA, Scardino PT (2002). Radical prostatectomy. In PC Walsh et al., eds., Campbell's Urology, 8th ed., vol. 4, pp. 3080–3106. Philadelphia: W.B. Saunders.

7. Kantoff PW (2007). Prostate cancer. In DC Dale, DD Federman, eds., ACP Medicine, section 12, chap. 9. New York: WebMD.

8. Agency for Healthcare Research and Quality (2008). Comparative Effectiveness of Therapies for Clinically Localized Prostate Cancer: Executive Summary (AHRQ Pub. No. 08-EHC010-1). Rockville, MD: Agency for Healthcare Research and Quality. Available online: http://effectivehealthcare.ahrq.gov/healthInfo.cfm?infotype=rr&ProcessID=9&DocID=79.

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