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Prostate Cancer: Radical Prostatectomy

Medically Reviewed by Nazia Q Bandukwala, DO on May 17, 2022

Radical prostatectomy is an operation to remove the prostate gland and tissues surrounding it. This usually includes the seminal vesicles and some nearby lymph nodes.

Radical prostatectomy can cure prostate cancer in men whose cancer is limited to the prostate gland.

Who Should Get a Radical Prostatectomy?

Men younger than 75 years old with limited prostate cancer and who are expected to live at least 10 more years tend to get the most benefit from radical prostatectomy.

Before doing a radical prostatectomy, doctors first try to confirm that the prostate cancer has not spread beyond the prostate. They can figure out the statistical risk of spread by looking at tables comparing the results of a biopsy and PSA levels.

Other tests to check for signs of spread, if needed, can include CT scans, bone scans, MRI scans, ultrasound, PET scans, and bone scans.

If it appears that the prostate cancer hasn’t spread, your surgeon may first offer you other options besides surgery. These can include radiation therapy, hormone therapy, or simply watching the prostate cancer over time, since many prostate cancers grow slowly.

Depending on how high your risk of the cancer spreading is, your surgeon may also consider doing an operation called pelvic lymph node dissection.

Types of Radical Prostatectomy

The prostate gland lies just under the bladder and in front of the rectum.

Surgeons choose from two approaches to reach and remove the prostate during a radical prostatectomy. One is a traditional approach known as open prostatectomy. The other is minimally invasive. That means it involves several small cuts (incisions) and a few stitches.

Open Prostatectomy

There are two ways to do this traditional method:

Radical retropubic prostatectomy. Before the surgery, you’ll get medicine called anesthesia either to help you “sleep” or to numb the lower half of your body. Then, your surgeon will make a cut from your belly button down to your pubic bone.

If your surgeon thinks it’s possible that your prostate cancer has spread to nearby lymph nodes, they may remove some of these nodes and send them to a lab to check for cancer cells while you’re still under anesthesia.

If the lab finds cancer, your surgeon might decide not to go on with the surgery. That’s because surgery probably wouldn’t cure your cancer, and removing your prostate could bring on serious side effects.

Radical perineal prostatectomy. For this less-common surgery, your surgeon reaches your prostate through a cut they make between your anus and scrotum. You’ll get anesthesia before the operation.

Urologists don’t do radical perineal prostatectomy as often as retropubic surgery. That’s because there’s a higher chance of it leading to erection problems, and it doesn’t allow surgeons to remove nearby lymph nodes.

It’s usually a shorter surgery, though. Your surgeon might recommend it for you if you’re not concerned about erections and you don’t need any to get any lymph nodes removed. It might also be right for you if you have other medical problems that could cause retropubic surgery to take more of a toll on your health.

The American Cancer Society says a radical perineal prostatectomy can lead to a cure just as well as retropubic surgery if your surgeon does the operation right. Perineal surgery may also cause you less pain and lead to a smoother recovery.

Minimally Invasive Surgeries

There are two minimally invasive procedures used in radical prostatectomy:

Laparoscopic prostatectomy

In laparoscopic prostatectomy, surgeons make several small incisions across your belly. They insert surgical tools and a camera through the incisions and do the radical prostatectomy from outside your body. The surgeon views the entire operation on a video screen.

This type of prostatectomy has become more common over the years.

Some advantages that laparoscopic prostatectomy has over open surgery are:

  • Less pain and blood loss
  • Shorter time in hospital (often no longer than a day)
  • Quicker recovery time
  • Needing a catheter in your bladder for a shorter time

The American Cancer Society says that the rates of major side effects from laparoscopic radical prostatectomies – like trouble with erections and holding your pee – appear to be about the same as they are for open prostatectomies. If you lose some bladder control after getting the laparoscopic version, it might take you longer to recover it.

More studies need to be done to compare the side effects and the odds of prostate cancer coming back between open and laparoscopic prostatectomies. The success of either surgery mainly comes down to how skilled and experienced your surgeon is.

Robot-assisted laparoscopic prostatectomy

Your surgeon makes small incisions in your belly as in regular laparoscopic prostatectomy. Then they control an advanced robotic system of surgical tools from outside your body.

A high-tech interface lets the surgeon use natural wrist movements and a 3D screen during radical prostatectomy. This can help them be more precise when moving their instruments compared to a standard laparoscopic radical prostatectomy. But the success of either type of operation depends mainly on the experience and skill of the surgeon.

Robot-assisted surgery may lead to less pain, less blood loss, and a shorter recovery time compared to an open prostatectomy surgery. But there doesn’t seem to be a difference in terms of key side effects – like urinary and erection problems – compared to other surgeries.

Risks of Radical Prostatectomy

Radical prostatectomy has a low risk of serious complications. Death or serious disability caused by radical prostatectomy is extremely rare.

Important nerves travel through the prostate on the way to the penis. Skilled surgeons can usually protect most of these nerves during radical prostatectomy.

Still, complications from unintended nerve damage can happen after radical prostatectomy. They include:

Urinary incontinence. This means trouble controlling your urine, leaking, or dribbling. If you have incontinence, talk to your doctor about treatments that can help.

Erectile dysfunction (ED). Problems with erections are common after prostatectomy. Still, most men are able to have sex after prostatectomy while using medicines for ED (such as Viagra or Cialis), an external pump, or injectable medications. The younger you are, the higher the chance that you’ll be able to get erections after surgery.

Most doctors think you can help yourself regain your ability to get erections if you try to get one as soon as possible once your body has had time to heal – often several weeks after your surgery. This is called “penile rehabilitation.” Talk to your doctor before you try it.

Much of the skill involved in radical prostatectomy centers on sparing these nerves during the operation. A man undergoing radical prostatectomy by a surgeon at an advanced prostate cancer center has a better chance of keeping their sexual and urinary function.

Other complications of radical prostatectomy include:

  • Bleeding after the operation
  • Urinary leaks
  • Blood clots
  • Infection
  • Poor wound healing
  • Groin hernia
  • Narrowing of the urethra, blocking urine flow

Less than 10% of men have complications after prostatectomy, and these are usually treatable or short-term.

Success of Radical Prostatectomy

The goal of radical prostatectomy is to cure prostate cancer. But a prostate cancer cure is only possible from prostatectomy if your prostate cancer is limited to the prostate.

During radical prostatectomy, a member of your treatment team examines your removed prostate under a microscope to see if your cancer has reached the edge of the prostate. If so, the prostate cancer has probably spread. In these cases, you may need more treatments.

Men with no evidence of prostate cancer spread have an 85% chance of surviving 10 years after radical prostatectomy.

What to Expect After Radical Prostatectomy

Most men stay in the hospital for 1 to 3 days after radical prostatectomy. Your care team inserts a urinary catheter during the surgery, and some men may need to wear the catheter home for a few days to a few weeks. Another catheter inserted through the skin also may need to stay in place for a few days after returning home.

Pain after radical prostatectomy can generally be controlled with prescription pain medicines. It can take weeks or months for urinary and sexual function to return to their maximum levels.

After radical prostatectomy, it’s important to see your doctor for all your regular follow-up appointments to make sure your prostate cancer doesn’t return.

Show Sources

SOURCES:

American Cancer Society: “Surgery for Prostate Cancer.”

Johns Hopkins: “Radical Prostatectomy.”

Wein, A. Campbell-Walsh Urology, 9th edition, Saunders, 2007.

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