Radical Prostatectomy

What is a radical prostatectomy?

Radical prostatectomy is surgery to remove the prostate gland. During the procedure, the seminal vesicles, nearby tissues, and often some pelvic lymph nodes are also removed.

The prostate gland sits below the bladder and wraps around the urethra. This is the tube that carries urine out of the body. The prostate helps make semen. The seminal vesicles are the two sacs that connect to the vas deferens. These are the tubes that carry sperm from the testicles. The pelvic lymph nodes are small oval collections of immune system tissue that filter lymph fluid. When prostate cancer spreads, these lymph nodes are often one of the first places it goes.

A common way to remove the prostate is through a cut (incision). It can be done in one of two ways:

Retropubic or suprapubic incision. A cut is made in the lower belly (abdomen).
Perineum incision. A cut is made in the skin between the scrotum and the rectum.

Radical prostatectomy is used to treat prostate cancer that is confined to the prostate gland and the seminal vesicles.

There are several ways to do a radical prostatectomy. They are described below. Sometimes laparoscopic surgery is done using a robotic system. The surgeon moves the robotic arms while sitting at a nearby computer monitor. This procedure needs special equipment, training, and experience. Not every hospital can do robotic surgery.

Radical prostatectomy with retropubic approach

An incision is made in the lower abdomen. Your healthcare provider may remove lymph nodes around the prostate gland first. Then they can be checked in the lab before the prostate is removed. In rare cases, if cancer has spread beyond the prostate gland the surgery may be stopped. This is because removing the prostate won’t remove all the cancer. Then other treatments will be used.

Another method is called the nerve-sparing prostatectomy approach. Two tiny nerve bundles that control erection are found on each side of the prostate. If the cancer is tangled with these nerves, the nerves must be cut to remove the cancer. If both nerves are cut or removed, the man won't be able to have an erection. This won’t get better over time. But there are treatments that may help erectile function. If only one of the nerve bundles is cut or removed, the person may have less erectile function. But they will possibly have some function left. If the two nerve bundles are not disturbed during surgery, function may return. But it sometimes takes months after surgery to know if a full recovery will occur. This is because the nerves will need time to heal after the procedure.

Radical prostatectomy with perineal approach

Radical perineal prostatectomy is used less often than the retropubic approach. This is because the nerves can’t be saved as easily this way. And the lymph nodes can't be removed with this method. But this method takes less time. And it may be a choice if the nerve-sparing and lymph node removal isn’t needed. With the perineal approach, there is a smaller scar hidden behind the scrotum. And it stays away from major abdominal muscle groups. So there’s often less pain and quicker recovery time.

Laparoscopic radical prostatectomy

In this method, the surgeon makes several small cuts. They put a thin tube with a video camera (laparoscope) inside one of the cuts. Long, thin tools are put through others. The camera helps the surgeon see inside as the tools are used to do the surgery.

Why might I need a radical prostatectomy?

Radical prostatectomy is used to treat prostate cancer. It’s used when the cancer is thought to be confined to the prostate gland.

There may be other reasons for your healthcare provider to recommend a prostatectomy.

What are the risks of a radical prostatectomy?

Some possible complications of retropubic and perineal methods may include:

Urinary incontinence. This is uncontrollable, involuntary leaking of urine, up to a year after surgery. This may get better over time.
Urinary leakage or dribbling. This symptom is at its worst right after the surgery. It often improves over time.
Impotence (erectile dysfunction). It may take up to two years after surgery to get sexual function back. And it may not be complete. Nerve-sparing prostatectomy lowers the chance of erectile dysfunction. But it doesn’t guarantee that it won’t happen.
Sterility. Radical prostatectomy cuts the connection between the testicles and the urethra. This leads to permanent loss of ejaculation. The man is then unable to naturally provide sperm for a biological child. A man may be able to have an orgasm. But there will be no ejaculate. In other words, the orgasm is dry.
Lymphedema . This is when fluid collects in the soft tissues, causing swelling. This may be caused by inflammation, blockages, or removal of the lymph nodes during surgery. This may need to be drained by a radiology procedure. In rare cases, if lymph nodes are removed, fluid may collect in the legs or genital area over time. Pain and swelling result. Physical therapy is often helpful in treating the effects of lymphedema.
Change in penis length. A small percentage of surgeries will result in a shorter penis.

Some risks linked to surgery and anesthesia in general include:

Bleeding
Blood clots
Infection
Reactions to medicines used during surgery

One risk of the retropubic approach is rectal injury. This can cause infection, stool incontinence, or urgency.

You may have other risks, depending on your condition. Discuss any concerns with your healthcare provider before the procedure.

How do I get ready for a radical prostatectomy?

Some things you can expect before the surgery include:

Your healthcare provider will tell you about the procedure and you can ask questions.
You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if anything isn’t clear. Ask for individual or family counseling if you need support managing this surgery.
Your healthcare provider will review your health history and do a physical exam to be sure you’re in good health before you have the surgery. You may need tests to make sure the cancer is confined to the prostate and has not spread to other parts of your body.
Follow any directions you are given for not eating or drinking before the surgery.
Tell your healthcare provider if you’re sensitive to or allergic to any medicines, latex, iodine, tape, contrast dyes, and anesthesia.
Make sure your healthcare provide has a list of all medicines, herbs, vitamins, and supplements that you are taking. This includes both prescribed and over-the-counter medicines.
Tell your healthcare provider if you have a history of bleeding disorders or if you’re taking any blood-thinning (anticoagulant) medicines, aspirin, or other medicines that affect blood-clotting. You may need to stop these medicines before the surgery.
If you smoke, stop as soon as possible. This can help improve your recovery from surgery and improve your overall health.
Follow all other instructions that your healthcare provider gives you.

What happens during a radical prostatectomy?

Radical prostatectomy needs a hospital stay. Procedures may vary depending on your condition and your healthcare provider’s practices.

Generally, a radical prostatectomy starts with this process:

You will be asked to remove any jewelry or other objects that might get in the way during surgery.
You will be asked to remove your clothing and will be given a gown to wear.
An IV (intravenous) line will be put in your arm or hand.
The healthcare provider may choose regional anesthesia instead of general anesthesia. You will also get medicine to help you relax and pain medicines.
Once you’re sedated, a breathing tube may be put through your throat into your lungs and you will be connected to a ventilator. This will breathe for you during the surgery.
The anesthesiologist will closely watch your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
A soft, flexible tube called a catheter will be put into your bladder to drain urine.
If there is a lot of hair at the surgical site, it may be shaved off.
The skin over the surgical site will be cleaned with an antiseptic solution.

Radical prostatectomy, retropubic approach

You will lie on your back on the operating table.
An incision will be made from below your belly button to the pubic area.
The healthcare provider will often remove and check lymph nodes first. If the lymph nodes don't have cancer cells in them, the nerve bundles will carefully be separated from the prostate gland.
The prostate gland will be removed. The seminal vesicles may also be removed.
A new catheter to drain your bladder will be placed.
A drain will be put in, often in the right lower area of the incision. This is to remove fluid that may build up as you heal.

Radical prostatectomy, perineal approach

You will lie on your back on a table that keeps your hips and knees fully bent with your legs spread apart and raised. Straps will be placed under your legs for support.
An upside-down, U-shaped cut will be made in the perineal area (between the scrotum and the anus).
The healthcare provider will try to reduce any damage to the nerve bundles in the prostate area.
The prostate gland and any abnormal-looking nearby tissue will be removed.
A new catheter to drain your bladder will be placed.
The seminal vesicles may be removed if there is concern there may be cancer in them.

Procedure completion, both methods

The cut will be stitched or stapled closed.
A sterile bandage or dressing will be put on the site.
The breathing tube will be taken out and you will breathe on your own.

What happens after a radical prostatectomy

In the hospital

After the surgery, you will be taken to a recovery room to be closely watched. You'll be connected to machines that will constantly display your heart beat, blood pressure, breathing rate, and your oxygen level.

Once you’re awake and stable, you may start to drink liquids and will be taken to your hospital room.

You may get pain medicine as needed, either by a nurse, or by giving it yourself through a device connected to your IV line.

You will be able to eat solid foods as you are able to handle them.

Your healthcare team will show you how to do breathing exercises and movements while in bed to help your body recover. You may wear compression stockings on your legs. These reduce your risk for blood clots. Your activity will be slowly increased. You will be urged to get out of bed and walk around for longer periods.

The drain will generally be taken out the day after surgery. The catheter that was put in to drain your urine will stay in place for about 1 to 3 weeks as you heal. You will be given instructions on how to care for your catheter at home.

Arrangements will be made for a follow-up visit with your healthcare provider.

At home

Once you’re home, it’s important to keep the surgical area clean and dry. Your healthcare provider will give you specific bathing instructions. The stitches or surgical staples will be removed during a follow-up office visit, if they weren’t removed before leaving the hospital.

The surgical incision may be tender or sore for several days. Take a pain reliever for soreness as recommended by your healthcare provider.

You should not drive until your healthcare provider tells you it’s OK. Other activity restrictions may apply, such as no heavy lifting for 3 to 4 weeks.

Once the catheter is removed, you will probably have some leaking of urine. The length of time this happens can vary. Your healthcare provider will give you suggestions for improving your bladder control. Over the next few months, you and your healthcare provider will be checking for any side effects and working to improve any problems with incontinence or erectile dysfunction.

Call your healthcare provider if you have any of the following:

Fever or chills
Redness, swelling, or bleeding or other drainage from the incision
More pain around the incision
Inability to have a bowel movement
Inability to urinate once catheter is removed
Changes in your urine output, color, or odor

Your healthcare provider may give you other instructions after the procedure, depending on your situation. Ask your healthcare team to provide all of the home instructions in writing. Be certain the information contains your provider's daytime and emergency contact phone numbers.

Next steps

Before you agree to the test or procedure make sure you know:

The name of the test or procedure
The reason you are having the test or procedure
What results to expect and what they mean
The risks and benefits of the test or procedure
What the possible side effects or complications are
When and where you are to have the test or procedure
Who will do the test or procedure and what that person’s qualifications are
What would happen if you did not have the test or procedure
Any alternative tests or procedures to think about
When and how will you get the results
Who to call after the test or procedure if you have questions or problems
How much you will have to pay for the test or procedure