Prostate Cancer Overview

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Treating Prostate Cancer TOPICS

Surgery for prostate cancer

Surgery is a common choice to try to cure prostate cancer if it is not thought to have spread outside the gland.

The main type of surgery for prostate cancer is known as a radical prostatectomy. In this operation, the surgeon removes the entire prostate gland plus some of the tissue around it, including the seminal vesicles. A radical prostatectomy can be done in different ways.

Open approaches to prostatectomy

In the more traditional approach to doing a prostatectomy, the surgeon operates through a single long incision to remove the prostate and nearby tissues. This is sometimes referred to as an open approach.

Radical retropubic prostatectomy: For this approach, a cut (incision) is made in the lower belly (abdomen), as shown in the picture below. You will either be in a deep sleep (under general anesthesia) or be given medicine to numb the lower half of the body (an epidural) along with drugs to make you sleepy (sedation). In this operation the doctor will remove the prostate and some nearby tissues. He or she can also remove nearby lymph nodes to check for cancer spread.

The nerves that control erections are very close to the prostate and can be injured during surgery. If special care is taken during surgery to avoid harming these nerves, it is called a nerve-sparing approach. This lowers – but does not do away with – the risk of impotence (being unable to have an erection) after surgery. If the cancer is growing into these nerves, a nerve sparing approach isn’t possible and the doctor will have to remove them.

A small tube (catheter) will be put in your penis to help drain your bladder after surgery. The catheter usually stays in place for 1 to 2 weeks while you are healing.

You will probably stay in the hospital for a few days after the surgery and be limited in your activities for about 3 to 5 weeks. The possible side effects of prostatectomy are described below.

Radical perineal approach: In the perineal approach, the surgeon makes the cut (incision) in the skin between the anus and the scrotum, as shown in the picture below. Nerve-sparing operations are harder to do with the perineal approach, and lymph nodes cannot be removed. Still, the surgeon can remove some lymph nodes another way, if needed. This operation can be an option for men who wouldn’t benefit from a nerve-sparing approach and who don't need to have lymph nodes removed. It also might be used if you have other medical problems that make retropubic surgery hard to do.

The perineal approach often takes less time than the retropubic approach, and may result in less pain.

As with the retropubic approach, a tube for draining urine (called a catheter) will be put into the bladder through the penis to drain urine while you are healing.

You will probably stay in the hospital for a few days after the surgery and be limited in your activities for about 3 to 5 weeks. The possible side effects of prostatectomy are described below.

Laparoscopic approaches to prostatectomy

Laparoscopic approaches use several smaller incisions and special surgical tools to remove the prostate. This can be done with the surgeon either holding the tools directly, or using a control panel to precisely move robotic arms that hold the tools.

Laparoscopic radical prostatectomy (LRP): For an LRP, the surgeon removes the prostate under the guidance of a laparoscope – a long thin tube with a camera at the end. This allows the doctor to skip the big incision and instead use several small cuts, through which special long surgery tools are inserted to remove the prostate.

LRP has advantages over the open approach: less blood loss and pain, a shorter hospital stay, and faster recovery time. Nerve-sparing is possible with LRP. Early studies report that the rates of most other side effects from LRP seem to be about the same as for open prostatectomy.

Robotic-assisted laparoscopic radical prostatectomy (RALRP): A newer approach is to do LRP remotely using a robotic interface. The surgeon sits at a panel near the operating table and controls robotic arms to do the surgery through several small cuts in the patient's belly (abdomen).

Like direct LRP, RALRP has advantages over the open approach in terms of pain, blood loss, and recovery time. So far though, there is little difference between direct LRP and RALRP for the patient.

In terms of the side effects men are most concerned about, such as urinary or sexual problems (described below), there does not seem to be a difference between RALRP and other approaches to prostatectomy.

No matter which type of surgery you choose, the most important factors are likely to be the skill and experience of your surgeon. Be sure to find a surgeon with a lot of experience doing the type of surgery you choose.

Risks and side effects of radical prostatectomy

There are possible risks and side effects with any type of surgery for prostate cancer.

Surgical risks

The risks with this surgery are like those of any major surgery. They can include problems from the drugs used during the operation (anesthesia), a small risk of heart attack, stroke, blood clots in the legs, infection, and bleeding. Your risk depends, in part, on your overall health, your age, and the skill of your doctors.

If lymph nodes are removed, a collection of lymph fluid (called a lymphocele) can form and may need to be drained.

Because there are many blood vessels near the prostate gland, there is a risk of bleeding during and after the surgery. Rarely, part of the intestine might be cut during surgery, which could lead to infections and might need more surgery to correct.

Side effects

The main possible side effects of radical prostatectomy are lack of bladder control (incontinence) and not being able to get an erection (impotence). These side effects can also occur with other forms of treatment for prostate cancer, although they are described here in more detail.

Urinary incontinence: Incontinence means you can't control your urine or you have trouble with leaking. Having this problem can affect you not only physically but emotionally and socially, too.

Normal bladder control returns for many men within several weeks or months after surgery. Doctors can't predict how any one man will do after prostate surgery. As a rule, older men tend to have more incontinence problems than younger men.

Most large cancer centers, where this surgery is done more often and surgeons have more experience, report fewer problems with incontinence. If you have problems with incontinence, let your doctors know. Doctors who treat men with prostate cancer should know about incontinence, and should be able to suggest ways to help you. There are exercises (called Kegel exercises) you can learn that might help to strengthen your bladder. There are medicines or even surgery that might help. There are also products to help keep you dry and comfortable.

Impotence (erectile dysfunction): Impotence means that a man can't get an erection strong enough to have sex. The nerves that allow men to get erections may be damaged during surgery, radiation treatment, or other treatments.

Your ability to have an erection after surgery depends on your age, your ability to get an erection before the operation, and whether the nerves were cut or removed. Most men can expect some decrease in the ability to have an erection, but the younger you are, the less likely you are to have problems. Each man's situation is different, so ask your doctor about his or her success rates and what the outcome is likely to be in your particular case.

If erections return after surgery, this often occurs slowly and takes at least a few months. During the first few months, you may need to use medicines or other treatments to help.

If you are concerned about erection problems, be sure and talk to your doctor. There are ways to help. There are medicines and even devices such as vacuum pumps and penile implants that could prove useful.

For more information to help you understand and cope with the sexual side effects of prostate cancer treatment, please see our document Sex and Men With Cancer Overview.

Loss of fertility: A radical prostatectomy cuts the tubes between the testicles (where sperm are made) and the urethra. This means that a man can no longer father a child by natural means. Often this is not an issue as men with prostate cancer tend to be older. But if this is a concern for you, you might talk to your doctor about "banking" your sperm before the operation.

Less common side effects include:

  • Changes in orgasm: it can become painful, less intense, or even go away completely.
  • Lymphedema: swelling of the legs and/or genital region can be a side effect of removing lymph nodes
  • Change in penis length: causing it to be shorter
  • Inguinal hernia: men who have had their prostates removed have a higher risk of having a groin hernia in the future.

More details about surgery for prostate cancer and its side effects can be found in our document Prostate Cancer.

Transurethral resection of the prostate (TURP)

This procedure is done to relieve symptoms, such as trouble passing urine, in men who can't have other types of surgery. It is not done to cure prostate cancer. The same operation is used more often to relieve symptoms of non-cancerous prostate swelling called BPH (benign prostatic hyperplasia).

During this operation, an instrument called a resectoscope is passed through the end of the penis into the urethra to the level of the prostate. Once it is in place, either electricity is passed through a wire to heat it or a laser is used to cut or destroy prostate tissue around the urethra. Either spinal anesthesia, where you are made numb from the waist down, or general anesthesia, which puts you into a deep sleep, is used.

The operation takes about an hour. After surgery you will need a tube for draining urine (called a catheter) for about a day. There may be some blood in your urine for a short time after surgery. You can usually leave the hospital after 1 to 2 days and go back to work in 1 to 2 weeks.

Last Medical Review: 08/27/2013
Last Revised: 09/12/2014