Surgery for Prostate Cancer

Laparoscopic surgery is done through several small incisions in the abdomen, rather than one large incision. The surgeon inserts a long, thin tube called a laparoscope, with a light and tiny video camera on the end, through one of the openings so they can see inside the body. Long, thin surgery instruments are then inserted through the other incisions to perform the operation.

Robotic prostatectomy

This is the most common way prostatectomy is done in the United States. It is also called robotic-assisted laparoscopic radical prostatectomy or robot-assisted prostatectomy.

The surgeon sits at a control panel in the operating room and moves robotic arms to operate through several small incisions, usually in the abdomen, but sometimes in the perineum. The robotic system helps the surgeon move the instruments more precisely than if they were holding the laparoscopic tools directly in their hands.

This type of surgery is done less often than in the past, as robotic prostatectomy has become more common. But it's still a good option for men who have had major abdominal surgery before. That's because this approach stays outside the belly (abdominal) cavity, so it avoids scar tissue from earlier surgeries.  There are 2 main approaches for an open prostatectomy, based on where the incision is made.

Radical retropubic prostatectomy (retropubic approach)

For this operation, the surgeon makes an incision in your lower abdomen, from the belly button down to the pubic bone, as shown in the picture above.

Radical perineal prostatectomy (perineal approach)

This approach is only rarely used, when robotic prostatectomy cannot be done. For this operation, the surgeon makes the incision between the anus and scrotum (the perineum), as shown in the picture above. It has two disadvantages:

• Lymph nodes cannot be removed to help stage the cancer.
• It can be harder for the surgeon to spare the nerves that control erections.

After surgery

After the surgery, and while you are still under anesthesia, a catheter (thin, flexible tube) will be put in your penis to help drain your bladder. The catheter usually stays in place for about 1 to 2 weeks while you are healing. You will be able to urinate on your own after the catheter is removed.

You will probably stay in the hospital for a few days after the surgery, and your activities will be limited for about 4 to 6 weeks.

You may not be able to control your urine, or you may have leakage or dribbling after your surgery. Being incontinent can affect you not only physically, but also emotionally and socially. The major types of incontinence are:

• Stress incontinence: Urine might leak when coughing, laughing, sneezing, or exercising. Stress incontinence is the most common type after prostate surgery. It’s usually caused by problems with the valve that keeps urine in the bladder (the bladder sphincter). Prostate cancer treatments can damage this valve or the nerves that keep the valve working.
• Overflow incontinence: The bladder may not empty completely. This can mean it takes a long time to urinate or the urine stream is weak or dribbling. Overflow incontinence is usually caused by blockage or narrowing of the bladder outlet by scar tissue.
• Urge incontinence: A person may have a sudden need to urinate. This happens when the bladder becomes too sensitive to stretching as it fills with urine. This is less common after surgery than after having radiation therapy.
• Continuous incontinence: Very rarely after surgery, a person can lose all ability to control their urine.

After surgery for prostate cancer, bladder control usually improves slowly over several weeks or months. But doctors can’t predict for sure how any person will be affected. In general, older men tend to have more incontinence problems than younger men. People treated at large cancer centers, where prostate surgery is done often and surgeons have a lot of experience, generally report fewer problems with incontinence.

Incontinence can be treated. Even if your incontinence can’t be corrected completely, it can still be helped. To learn about managing and living with incontinence, see Bladder and Bowel Incontinence.

Erectile dysfunction means you can’t get an erection sufficient for sexual penetration.

Erections are controlled by bundles of nerves that run along either side of the prostate. If you’ve been able to have erections before surgery, the surgeon will try to use a nerve-sparing approach during the prostatectomy to avoid damaging the nerves. But if the cancer is growing into or very close to the nerves, the surgeon will need to remove them.

Your ability to have erections after prostatectomy depends on your age, your ability to get an erection before the operation, and whether the nerves are removed:

• If both nerves are removed, you won’t be able to have spontaneous erections, but you might still be able to have erections using some of the aids described below.
• If the nerves on only one side are removed, you might still have erections, but the chance is lower than if neither were removed.
• If the nerve bundles can be preserved, you might have normal erections at some point after surgery.

Erectile dysfunction is more common than incontinence after surgery. Most men will probably have at least some loss of ability to have an erection, but the younger you are, the less likely you are to be seriously affected.

Surgeons who do many prostatectomies tend to report better rates of erection function among their patients than those who do the surgery less often. A wide range of rates have been reported in the medical literature, but each person’s situation is different, so the best way to get an idea of your chances for recovering erections is to ask about your doctor’s success rates and what the outcome is likely to be in your case.

If your ability to have erections does return after surgery, it often returns slowly. In fact, it can take from a few months to 2 or more years. During the first few months, you will probably not be able to have a spontaneous erection, so you may need to use medicines or other treatments.

Many doctors feel that regaining potency is helped along by trying to get an erection as soon as possible once the body has had a chance to heal (usually several weeks after the operation). Some doctors call this penile rehabilitation. Medicines (see below) may be helpful at this time, although it’s not clear whether they work better if taken daily or just on an as-needed basis. Be sure to talk to your doctor about your situation.

There are several options for treating erectile dysfunction:

• Phosphodiesterase-5 (PDE5) inhibitors, such as sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), and avanafil (Stendra), are pills that can help with erections. These drugs won’t work if both nerves that control erections have been damaged or removed. Common side effects of these drugs include headache, flushing (skin becoming red and feeling warm), upset stomach, light sensitivity, and runny or stuffy nose. Rarely, these drugs can cause prolonged erections requiring medical attention or vision problems, possibly even blindness. Some other drugs such as nitrates, which are used to treat heart disease, can cause problems if you are taking a PDE5 inhibitor, so be sure your doctor knows what medicines you take.
• Alprostadil is a lab-made version of prostaglandin E1, a substance naturally made in the body that can produce erections. It can be injected almost painlessly into the base of the penis 5 to 10 minutes before intercourse or placed into the tip of the penis as a suppository. You can even increase the dosage to prolong the erection. You might have side effects, such as pain, dizziness, and prolonged erection, but they are not usually serious.
• Vacuum devices are another option to create an erection. These are clear, plastic tubes connected to pumps that are placed over the penis. The pump sucks the air out of the tube, which draws blood into the penis to produce an erection. After the device is removed, the erection is maintained by placing an elastic ring around the base of the penis, which keeps the blood from draining out. The ring is then removed after sex.
• Penile implants might restore your ability to have erections if other methods don’t help. Surgery is needed to put them inside the penis. There are several types of penile implants, including those using silicone rods or inflatable devices.

For more on coping with erection problems and other sexuality issues, see Sexual Side Effects.

After surgery, the sensation of orgasm should still be pleasurable, but there is no ejaculation of semen, meaning the orgasm is “dry.” This is because the glands that make most of the fluid for semen (the seminal vesicles and prostate) were removed during the prostatectomy, and the pathways used by sperm (the vas deferens) were cut. For some men, orgasms might become less intense. Less often, men might have pain with orgasm.

During a radical prostatectomy, the surgeon cuts the vas deferens, which are the pathways between the testicles (where sperm are made) and the urethra (through which sperm leave the body). Your testicles will still make sperm, but the sperm can’t leave the body when you ejaculate. This means you can no longer have a biological child through sex.

Often, this is not an issue, as men with prostate cancer tend to be older. But if it is a concern for you, ask your doctor about options, including banking your sperm before the operation. To learn more, see Fertility Problems.

This is a rare but possible complication of removing many of the lymph nodes around the prostate. Lymph nodes normally provide a way for fluid to return to the heart from all areas of the body. When nodes are removed, fluid can 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 go away completely. See Lymphedema to learn more.

Many men notice a decrease in penis length after radical prostatectomy. It's usually most noticeable in the weeks after surgery and may improve somewhat over the next year, though it may not fully return to its prior length.

Doctors don't fully understand why this happens. It was once blamed on simply removing the portion of urethra inside the prostate, but studies haven't found a link between prostate size and length loss. More likely causes include:

• The urethra and bladder shifting position as they're reconnected during surgery
• Nerve injury and reduced blood flow, which can affect penile tissue over time

A prostatectomy increases your chance of developing an inguinal (groin) hernia in the future.