Radical prostatectomy is surgery that attempts to cure prostate cancer. It is used most often if the cancer is not thought to have spread outside of the gland (stage T1 or T2 cancers). In this operation, your surgeon is trying to cure you by removing the entire prostate gland plus some of the tissue around it, including the seminal vesicles.

Radical retropubic prostatectomy

This is the operation used by most urologic surgeons (urologists). You will be either under general anesthesia (asleep) or be given spinal or epidural anesthesia (numbing the lower half of the body) along with sedation during the surgery.

For this operation, the surgeon makes a skin incision in your lower abdomen, from the belly button down to the pubic bone. If there is a reasonable chance the cancer may have spread to the lymph nodes (based on your PSA level, DRE, and biopsy results), the surgeon may remove lymph nodes from around the prostate at this time. If any of the nodes contain cancer cells, which means the cancer has spread, they often will not continue with the surgery because it is unlikely that the cancer can be cured.

The surgeon will pay close attention to the 2 tiny bundles of nerves that run on either side of the prostate. These nerves control erections. If you are able to have erections before surgery, the surgeon will try not to injure these nerves (known as a "nerve-sparing" approach). If the cancer is growing into or very close to the nerves the surgeon will need to remove them. If they are both removed, you will be impotent (unable to have a spontaneous erection). This means that you will need help (such as medications or pumps) to have erections. If the nerves on one side are removed, you still have a chance of keeping your ability to have an erection, but it is lower than if neither were removed. If neither nerve bundle is removed you may be able to function normally. Usually it takes at least a few months after surgery to have an erection because the nerves have been handled during the operation and won't work properly for a while.

Retropubic approach                 Perineal approach

Radical perineal prostatectomy

In this operation, the surgeon makes the incision in the skin between the anus and scrotum (the perineum), as shown in the picture above. This approach is used less often because the nerves cannot easily be spared and lymph nodes can't be removed. But it is often a shorter operation and might be an option if you don't want the nerve-sparing procedure or require lymph node removal. It also might be used if you have other medical conditions that make retropubic surgery difficult for you. It can be just as curative as the retropubic operation if done correctly.

These operations usually last from 1 1/2 to 4 hours. The perineal operation usually takes less time than the retropubic operation, and may result in less pain afterward. After surgery you will stay in the hospital for about 3 days and will probably be away from work for about 3 to 5 weeks.

In most cases, you will be able to donate your own blood before surgery. This blood can be given back to you during the operation if it's needed.

After the surgery, while you are still under anesthesia, a catheter will be put in your penis to help drain your bladder. The catheter usually stays in place for 1 to 3 weeks while you are healing. You will be able to urinate on your own after the catheter is removed.

Laparoscopic radical prostatectomy (LRP)

Both of the surgical approaches above use an "open" technique, in which the surgeon makes a long incision to remove the prostate. Another technique, known as laparoscopic radical prostatectomy (LRP), uses several smaller incisions, through which special long instruments are inserted to remove the prostate. One of the instruments has a small video camera on the end, which allows the surgeon to see inside the abdomen.

Laparoscopic prostatectomy has some advantages over the usual open radical prostatectomy, including less blood loss and pain, shorter hospital stays (usually no more than a day), and faster recovery times (although the catheter will be needed for about the same amount of time). LRP offers very good lighting and magnification, which can help the surgeon better decide which areas need to be removed.

Still, LRP is a challenging operation for surgeons to learn, and usually requires a bit more time on the operating table (and under anesthesia). Another possible drawback is that it does not allow the surgeon to use the sense of touch while operating or to have the same freedom of motion that his or her hands would have.

LRP has been used in the United States since 1999 and is more frequently being done both in community and university centers. In experienced hands, LRP appears to be as good as open radical prostatectomy, although we do not yet have long-term results from procedures done in the United States. Early studies report that the rates of side effects from LRP seem to be about the same as for open prostatectomy. A nerve-sparing approach is possible with LRP, increasing the chance of normal erections after the operation.

Robotic-assisted laparoscopic radical prostatectomy

An even newer approach is to do LRP remotely using a robotic interface (called the da Vinci system). The surgeon sits at a panel near the operating table and controls robotic arms to perform the operation through several small incisions in the patient's abdomen. For the patient, there is little difference between direct and remote (robotic) LRP, either during surgery or recovery.

For the surgeon, the robotic system may provide more maneuverability and more precision when moving the instruments than standard LRP. But the most important factor in the success of either type of LRP is the surgeon's experience, commitment, and skill.

Robotic LRP has been in use for only a few years in the United States. The machines themselves are expensive, and are available in only a limited number of medical centers across the country. Still, this approach has become more popular in recent years. Early reports have found less blood loss and shorter recovery times compared to standard radical prostatectomy. But because it is still a relatively new way of doing the surgery, reports of long-term outcomes are not yet available.

If you are thinking about treatment with either type of LRP, it's important to understand what is known and what is not yet known about this approach. Again, the most important factors are likely to be the skill and experience of your surgeon. If you decide that LRP is the treatment for you, be sure to find a surgeon with a lot of experience doing LRP.

Transurethral resection of the prostate (TURP)

This operation is more commonly used to treat men with non-cancerous enlargement of the prostate called benign prostatic hyperplasia (BPH). When it is used for prostate cancer it is palliative, which means it is done to relieve symptoms, not to cure. This surgery may be used if you are having trouble urinating because of the cancer.

During this operation, the surgeon removes the inner part of the prostate gland that surrounds the urethra (the tube through which urine exits the bladder). The skin is not cut with this surgery. 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, electricity is passed through a wire to heat it and cut or vaporize the tissue. Either spinal anesthesia (which numbs the lower half of your body) or general anesthesia (where you are asleep) is used.

The operation usually takes about an hour. After surgery, a catheter is inserted through the penis into the bladder. It remains in place for 1 to 3 days to help urine drain while the prostate heals. You can usually leave the hospital after 1 to 2 days and return to work in 1 to 2 weeks. You will likely have some blood in your urine after surgery. Other side effects from TURP include infection and any risks that come with the type of anesthesia that was used.

Surgical risks and possible side effects of radical prostatectomy (Including LRP)

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

Surgical risks: The risks with any type of radical prostatectomy are much like those of any major surgery, including risks from anesthesia. Among the most serious, there is a small risk of heart attack, stroke, blood clots in the legs that may travel to your lungs, and infection at the incision site. Because there are many blood vessels near the prostate gland, another risk is bleeding during and after the surgery. You may need blood transfusions, which carry their own small risk. In extremely rare cases, people die because of complications of this operation. Your risk depends, in part, on your overall health, your age, and the skill of your surgical team.

Side effects: The major possible side effects of radical prostatectomy are urinary incontinence (being unable to control urine) and impotence (being unable to have erections). It should be noted that these side effects are also possible with other forms of therapy, although they are described here in more detail.

Urinary incontinence is not being able to control your urine or have leakage or dribbling. There are different degrees of incontinence. Being incontinent can affect you not only physically but emotionally and socially as well. There are 3 major types of incontinence: stress incontinence, overflow incontinence, and urge incontinence.

• Stress incontinence is the most common type of incontinence after prostate surgery. Men with stress incontinence leak urine when they cough, laugh, sneeze, or exercise. It is usually caused by problems with the muscular valve that keeps urine in the bladder (the bladder sphincter). Prostate cancer treatments may damage the muscles that form this valve or the nerves that keep the muscles working.

• Men with overflow incontinence cannot empty the bladder well. They take a long time to urinate and have a dribbling stream with little force. Overflow incontinence is usually caused by blockage or narrowing of the bladder outlet by cancer or scar tissue.

• Men with urge incontinence have a sudden need to go to the bathroom and pass urine. This problem occurs when the bladder becomes too sensitive to stretching as urine fills it.

Rarely after surgery, men lose all ability to control their urine. This is called continuous incontinence.

For men who have had surgery for prostate cancer, normal bladder control usually returns within several weeks or months after radical prostatectomy. This recovery usually occurs gradually, in stages.

Doctors can't predict how any man will function after surgery. In one study of 901 men aged 55 to 74 who were treated in all different types of hospitals, researchers found that 5 years after radical prostatectomy:

• 15% of the 901 men had no bladder control or had frequent leaks or dripping of urine
• 16% leaked at least twice a day
• 29% wore pads to keep dry (Some of the men were in 2 or 3 of these groups, so adding these percentages together overstates the likelihood of urinary problems.)

Most large cancer centers, where prostate surgery is done more often and surgeons have more experience, report fewer problems with incontinence.

Treatment of incontinence depends on its type, cause, and severity. If you have problems with incontinence, let your doctors know. You might feel embarrassed about discussing this issue, but remember that you are not alone. This is a common problem. Doctors who treat men with prostate cancer should know about incontinence and be able to suggest ways to improve it, such as:

• Special exercises, called Kegel exercises, can help strengthen your bladder muscles. These exercises involve tensing and relaxing certain pelvic muscles. Not all doctors agree about their usefulness or the best way to do them, so ask your doctor about doing Kegels before you try them.

• Medication to help the muscles of the bladder or sphincter. Most of these medicines affect either the muscles or the nerves that control them. These medicines are more effective for some forms of incontinence than for others.

• Surgery may also be used to correct long-term incontinence. Material such as collagen can be injected to tighten the bladder sphincter. If your incontinence is severe and not getting better on its own, an artificial sphincter can be implanted, or a small device called a urethral sling may be implanted to keep the bladder neck where it belongs. Ask your doctor if these treatments might help you.

Even if your incontinence cannot be completely corrected, it can still be helped. You can learn how to manage and live with your incontinence. Incontinence is more than a physical problem. It can disrupt your quality of life if it is not managed well.

There is no one right way to cope with incontinence. The challenge is to find what works for you so that you can return to your normal daily activities. There are many incontinence products to help keep you mobile and comfortable, such as pads that are worn under your clothing. Adult briefs and undergarments are bulkier than pads but provide more protection. Bed pads or absorbent mattress covers can also be used to protect the bed linens and mattress.

When choosing incontinence products, keep in mind the checklist below. Some of these questions may not be important to you, or you may have others to add.

• Absorbency: How much does the product provide? How long will it protect?
• Bulk: Can it be seen under normal clothing? Is it disposable? Reusable?
• Comfort: How does it feel when you move or sit down?
• Availability: Which stores carry the product? Are they easy to get to?
• Cost: Does your insurance pay for these products?

Another option is a rubber sheath called a condom catheter that can be put over the penis to collect urine in a bag. There are also compression (pressure) devices that can be placed on the penis for short periods of time to keep urine from coming out.

For some types of incontinence, self-catheterization may be an option. In this approach, you insert a thin tube into your urethra to drain and empty the bladder. Most people can learn this safe and usually painless technique.

You can also follow some simple precautions that may make incontinence less of a problem. For example, empty your bladder before bedtime or before strenuous activity. Avoid drinking too much fluid, particularly if the drinks contain caffeine or alcohol, which can make you have to go more often. Because fat in the abdomen can push on the bladder, losing weight sometimes helps improve bladder control.

Fear, anxiety, and anger are common feelings for people dealing with incontinence. Fear of having an accident may keep you from doing the things you enjoy most -- taking your grandchild to the park, going to the movies, or playing a round of golf. You may feel isolated and embarrassed. You may even avoid sex because you are afraid of leakage. Be sure and talk to your doctor so you can begin to manage this problem.

Impotence, also known as erectile dysfunction, means you cannot get an erection sufficient for sexual penetration. The nerves that allow men to get erections may be damaged or removed by radical prostatectomy. Other treatments (besides surgery) may also damage these nerves or the blood vessels that supply blood to the penis to cause an erection.

Recovery of sexual function can take up to 2 years after surgery. During the first several months, you will probably not be able to have a spontaneous erection, so you may need to use medicines 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. Everyone can expect some decrease in the ability to have an erection, but the younger you are, the more likely it is that you will keep this ability.

There is a wide range of impotency rates reported in the medical literature. Some cancer centers that perform many radical nerve-sparing prostatectomies report impotence rates as low as 25% to 30% for men under 60, and as low as 10% for men under 50. However, other doctors have reported higher rates of impotence in similar patients. Impotence occurs in about 70% to 80% of men over 70, even if nerves on both sides are not removed.

If potency remains after surgery, the sensation of orgasm should continue to be pleasurable, but there is no ejaculation of semen -- the orgasm is "dry." This is because during the prostatectomy, the glands that made most of the fluid for semen (the seminal vesicles and prostate) were removed, and the pathways used by sperm (the vas deferens) were cut.

Most doctors feel that regaining potency is helped along by attempting to get an erection as soon as possible once the body has had a chance to heal (usually about 6 weeks after the operation). Medicines (see below) may be helpful at this time. Be sure to talk to your doctor about your situation.

Several options may help you if you have erectile dysfunction:

• Phosphodiesterase inhibitors such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are pills that can promote erections. These drugs will not work if both nerves have been damaged or removed. The most common side effects are headache, flushing (skin becomes red and feels warm), upset stomach, light sensitivity, and runny or stuffy nose. Nitrates, which are drugs used to treat heart disease, can interact with these drugs to cause very low blood pressure, which can be dangerous. Some other drugs may also cause problems, so be sure your doctor knows which medicines you are taking.

Some studies have found that these drugs may, in very rare cases, block blood flow to the optic nerve in the back of the eye. This could lead to blindness. Men who developed this complication often had a history of smoking or problems with high blood pressure, diabetes, or high levels of cholesterol or fat in their blood.

• Prostaglandin E1 is a substance naturally made in the body that can produce erections. A manmade version of this substance (alprostadil) can be injected almost painlessly into the base of the penis 5 to 10 minutes before intercourse or introduced into the tip of the penis as a suppository. You can even increase the dosage to prolong the erection. You may have side effects, such as pain, dizziness, and prolonged erection, but they are usually minimal.

• Vacuum devices are another option that may create an erection. These mechanical pumps are placed around the entire penis before intercourse to produce an erection.

• Penile implants might restore your ability to have erections if other methods do not help. An operation is needed to put them in place. There are several types of penile implants, including those using silicone rods or inflatable devices.

For more detailed information on coping with erection problems and other sexuality issues, see our document, Sexuality and Cancer: For the Man Who Has Cancer and His Partner.

Sterility: Radical prostatectomy cuts the connection between the testicles (where sperm are produced) 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 it is a concern for you, you may want to speak with your doctor about "banking" your sperm before the operation.

Lymphedema: A rare but possible complication of removing many of the lymph nodes around the prostate (either surgically or laparoscopically) is a condition called lymphedema. Lymph nodes normally provide a way for fluid to return from all areas of the body to the heart. When nodes are removed, fluid may collect in the legs or genital region over time, causing swelling and pain. Lymphedema can usually be treated with physical therapy, although it may not disappear completely.

Change in penis length: A possible minor effect of surgery is a decrease in penis length. In one study, about 1 out of 5 men had a 15% or greater decrease in the length of their penis.

Last Medical Review: 08/25/2008
Last Revised: 05/13/2009