Radical Prostatectomy: Complete Guide to Prostate Cancer Surgery

What Is Radical Prostatectomy?

Radical prostatectomy is a surgical procedure that removes the entire prostate gland and seminal vesicles to treat prostate cancer. It is the most common curative treatment for localized prostate cancer in men with a life expectancy of at least 10 years. The surgery achieves excellent cancer control with 10-year survival rates exceeding 95% for organ-confined disease.

The prostate is a walnut-sized gland located below the bladder and in front of the rectum. It produces fluid that forms part of semen. During radical prostatectomy, the surgeon removes the entire prostate gland along with the seminal vesicles, which are small glands that produce seminal fluid. In some cases, nearby lymph nodes are also removed to check for cancer spread.

The term "radical" means complete removal of the organ, distinguishing this procedure from partial prostate surgeries performed for benign conditions like enlarged prostate (BPH). Radical prostatectomy is considered a definitive treatment because it physically removes all prostate tissue, eliminating the cancer if it has not spread beyond the gland.

This surgery has been performed for over a century, but modern techniques have dramatically improved outcomes. The introduction of nerve-sparing techniques in the 1980s and robot-assisted surgery in the 2000s have significantly reduced side effects while maintaining excellent cancer control. Today, robot-assisted laparoscopic prostatectomy (RALP) is the most common approach in many countries.

Who Is a Good Candidate?

Radical prostatectomy is typically recommended for men with clinically localized prostate cancer who have a life expectancy of at least 10 years. The ideal candidates include:

• Men with intermediate to high-risk localized cancer who want definitive treatment
• Younger men who may benefit from the long-term cancer control
• Men who prefer surgery over radiation or active surveillance
• Patients where pathological staging is important for treatment planning

The decision between surgery and other treatments like radiation therapy or active surveillance depends on multiple factors including cancer grade, stage, PSA levels, patient age, overall health, and personal preferences. A multidisciplinary team including urologists, oncologists, and radiologists can help patients make informed decisions.

How Should I Prepare for Prostate Surgery?

Preparation for radical prostatectomy includes meeting with your surgical team, completing pre-operative tests, reviewing medications, starting pelvic floor exercises, and stopping smoking. These steps typically begin 2-4 weeks before surgery and are essential for optimal outcomes and faster recovery.

Proper preparation for prostate removal surgery significantly impacts your recovery and outcomes. The preparation process involves medical evaluations, lifestyle changes, and practical arrangements for your post-operative care. Most surgical centers provide detailed instructions, but understanding the rationale behind each step helps ensure compliance and reduces anxiety.

Your healthcare team will guide you through the preparation process, which typically begins several weeks before your scheduled surgery date. This allows time for any necessary medical optimization and helps you mentally prepare for the procedure and recovery period.

Medical Consultations and Tests

Before surgery, you will meet with your urologist who will explain the procedure, discuss risks and benefits, and answer your questions. You may also meet with an anesthesiologist who will review your medical history and plan your anesthesia. These consultations are opportunities to address any concerns and ensure you understand what to expect.

Pre-operative tests typically include blood tests to check your overall health, kidney function, and blood clotting ability. An electrocardiogram (ECG) evaluates your heart's electrical activity to ensure you can safely undergo anesthesia. Some patients may require additional tests such as chest X-rays or cardiac stress tests depending on their medical history.

Medication Review

It is essential to inform your doctor about all medications you take, including prescription drugs, over-the-counter medications, vitamins, and supplements. Certain medications need to be stopped or adjusted before surgery:

• Blood thinners (warfarin, aspirin, clopidogrel) may need to be stopped 5-10 days before surgery
• Some blood pressure medications may be adjusted on the day of surgery
• Diabetes medications often require modification, especially on the morning of surgery
• Herbal supplements (ginkgo, garlic, vitamin E) should be stopped 2 weeks before surgery as they can affect bleeding

Never stop any medication without consulting your doctor, as some medications are essential for your health and stopping them suddenly can be dangerous.

Pelvic Floor Exercises

Starting pelvic floor exercises (Kegel exercises) before surgery is one of the most important steps you can take to reduce the risk of urinary incontinence afterward. These exercises strengthen the muscles that control urination, and having stronger muscles before surgery leads to faster recovery of bladder control.

To perform Kegel exercises, identify the muscles you use to stop urinating midstream. Contract these muscles for 5-10 seconds, then relax for an equal time. Repeat 10-15 times, three times daily. Your healthcare provider or a pelvic floor physiotherapist can teach you the correct technique and ensure you are exercising the right muscles.

Lifestyle Changes Before Surgery

Smoking cessation is critical for reducing surgical complications. Smoking impairs wound healing, increases the risk of infection, and can cause breathing problems during and after anesthesia. Stop smoking at least 4 weeks before surgery, though longer is better. Your doctor can provide resources to help you quit.

Avoiding alcohol for at least 1-2 weeks before surgery reduces bleeding risk and improves healing. Maintaining good nutrition helps your body recover, so eat a balanced diet rich in protein, fruits, and vegetables in the weeks leading up to surgery.

How Is the Surgery Performed?

Radical prostatectomy is most commonly performed using robot-assisted laparoscopic surgery through six small incisions in the abdomen. The surgeon controls robotic arms that provide magnified 3D vision and precise movements. The procedure takes 2-3 hours and involves removing the prostate, seminal vesicles, and sometimes lymph nodes, then reconnecting the bladder to the urethra.

Understanding what happens during surgery can help reduce anxiety and set realistic expectations. Modern radical prostatectomy techniques have evolved significantly, with robot-assisted surgery now being the most common approach in many countries due to its precision and improved recovery times.

The surgery is performed under general anesthesia, meaning you will be completely asleep throughout the procedure. Some patients also receive regional anesthesia (epidural or spinal block) for pain control after surgery, particularly if open surgery is performed.

Robot-Assisted Laparoscopic Prostatectomy (RALP)

Robot-assisted surgery, often called "da Vinci surgery" after the most common robotic system used, has become the gold standard for radical prostatectomy in many medical centers. The surgeon sits at a console and controls robotic arms equipped with surgical instruments and a high-definition 3D camera.

The procedure begins with six small incisions (typically 8-12mm each) in the abdomen. Carbon dioxide gas is introduced to create space for the surgeon to work. The robotic instruments are inserted through these ports, and the camera provides a magnified view of the prostate and surrounding structures.

The surgeon carefully separates the prostate from surrounding tissues, including the bladder, rectum, and neurovascular bundles that control erections. When possible, a nerve-sparing technique preserves these bundles to maintain erectile function. The prostate and seminal vesicles are removed through one of the small incisions.

After removing the prostate, the surgeon reconnects the bladder to the urethra (the tube that carries urine out of the body). This anastomosis must heal properly for normal urination to return. A catheter is placed through the penis into the bladder to allow the connection to heal.

Open Radical Prostatectomy

Open surgery through an abdominal incision from the navel to the pubic bone is now less common but may still be appropriate in certain situations. These include very large prostates, previous pelvic surgery, or when robot-assisted surgery is not available. The surgical steps are similar to robotic surgery, but the incision is larger and recovery is typically longer.

Patients undergoing open surgery often receive epidural anesthesia in addition to general anesthesia, providing excellent pain control after surgery. The hospital stay is usually 2-4 days compared to 1-2 days for robotic surgery.

Lymph Node Dissection

In patients with higher-risk prostate cancer, the surgeon may also remove lymph nodes in the pelvis (pelvic lymph node dissection). These nodes are examined by a pathologist to check for cancer spread, which affects treatment recommendations and prognosis. Extended lymph node dissection removes more nodes and provides more accurate staging information.

What Is Recovery Like After Surgery?

Recovery after radical prostatectomy involves 1-2 days in hospital, wearing a urinary catheter for 1-2 weeks, and 3-6 weeks off work. Most patients can walk the day after surgery and gradually resume normal activities over 4-6 weeks. Full recovery of urinary control typically takes 3-12 months, while erectile function recovery may take 1-2 years.

Understanding the recovery timeline helps set realistic expectations and prepares you for the weeks and months following surgery. Recovery happens in phases, starting with the immediate post-operative period in hospital and continuing at home over several months.

Every patient recovers at their own pace, and outcomes vary based on factors like age, overall health, baseline function, and surgical technique. Your healthcare team will provide personalized guidance throughout your recovery.

In the Hospital

When you wake from anesthesia, you will have a urinary catheter in place. This thin tube drains urine from your bladder while the connection between your bladder and urethra heals. The catheter may feel uncomfortable, but it is essential and typically remains in place for 1-2 weeks.

You may experience some hoarseness or a sore throat from the breathing tube used during anesthesia. This usually resolves within a day or two. After robotic surgery, some patients have shoulder pain or chest discomfort from the carbon dioxide gas used during the procedure. This typically resolves within a few days as the body absorbs the gas.

Pain is generally well-controlled with medications. Most patients describe the discomfort as mild to moderate. You will be encouraged to get out of bed and walk on the day after surgery, as early mobilization reduces the risk of blood clots and speeds recovery.

Going Home

Before discharge, your healthcare team will teach you how to care for your catheter and surgical incisions. You will receive instructions on:

• Catheter care: Keeping the catheter clean and the drainage bag below bladder level
• Incision care: Keeping wounds clean and dry, signs of infection to watch for
• Activity restrictions: Avoiding heavy lifting (over 10 pounds) for 4-6 weeks
• Medications: Pain relievers, stool softeners, and any other prescribed medications
• Follow-up appointments: When to return for catheter removal and check-ups

The First Few Weeks

The first week at home focuses on rest and recovery. You should walk regularly but avoid strenuous activities. Constipation is common due to pain medications and reduced activity, so stool softeners and adequate hydration are important. Avoid straining during bowel movements as this puts pressure on the healing tissues.

The catheter is typically removed at a follow-up appointment 7-14 days after surgery. This is usually done in the outpatient clinic and takes only a few moments. After catheter removal, you will experience some degree of urinary leakage, which is expected and improves over time.

Most patients feel tired for the first few weeks. This is normal and improves gradually. Listen to your body and rest when needed, but continue regular walking to aid recovery. Most men return to work within 3-6 weeks, depending on the nature of their job and their individual recovery.

Long-Term Recovery

Urinary control typically returns gradually over 3-12 months. Most men experience some leakage initially, especially during activities like coughing, sneezing, or exercise. Continuing pelvic floor exercises after surgery is essential for faster recovery of continence. Most men regain full or near-full continence within the first year.

Erectile function recovery takes longer, typically 1-2 years. The nerves that control erections are very delicate, and even with nerve-sparing surgery, they need time to recover. Medications like sildenafil (Viagra) or tadalafil (Cialis) can help during this recovery period. Your urologist may recommend penile rehabilitation starting a few weeks after surgery.

What Are the Side Effects and Risks?

The main side effects of radical prostatectomy are erectile dysfunction (affecting 30-70% of men) and urinary incontinence (affecting 5-20% long-term). These effects depend on nerve-sparing technique, patient age, and baseline function. Surgery also causes permanent loss of ejaculation and fertility. Most men see significant improvement in the first 1-2 years after surgery.

Understanding potential side effects and complications helps you make an informed decision about surgery and prepares you for what to expect during recovery. While the surgery has excellent cancer control rates, it does carry risks that vary based on individual factors and surgical technique.

The two most significant long-term side effects are changes to urinary control and sexual function. However, surgical techniques have improved dramatically, and many men experience good functional outcomes, particularly when surgery is performed by experienced surgeons using nerve-sparing techniques.

Erectile Dysfunction

Erectile dysfunction (ED) is the most common concern for men undergoing radical prostatectomy. The nerves that control erections run alongside the prostate, and even with careful nerve-sparing surgery, some degree of erectile dysfunction is common initially.

Recovery of erectile function depends on several factors:

• Nerve-sparing surgery: When both nerve bundles can be preserved, potency rates are highest (50-70% at 1-2 years)
• Age: Younger men typically have better recovery of erectile function
• Pre-operative function: Men with good erectile function before surgery have better outcomes
• Time since surgery: Function continues to improve for up to 2 years after surgery

Various treatments can help with erectile dysfunction after prostatectomy, including oral medications (PDE5 inhibitors), vacuum erection devices, penile injections, and penile implants. Many urologists recommend starting penile rehabilitation early to improve outcomes.

Urinary Incontinence

Urinary leakage after radical prostatectomy occurs because the surgery removes the internal sphincter muscle at the bladder neck. Recovery depends on the external sphincter and pelvic floor muscles.

Most men experience some degree of incontinence immediately after catheter removal. This typically improves over time:

• At catheter removal: Almost all men have some leakage
• At 3 months: 60-80% have regained reasonable control
• At 12 months: 80-95% have little or no leakage requiring pads

Pelvic floor exercises are the most important factor in recovery. Some men benefit from formal physiotherapy. For the small percentage with persistent significant incontinence, treatments like artificial urinary sphincters or sling procedures can help.

Loss of Fertility

Radical prostatectomy causes permanent changes to fertility. The seminal vesicles are removed, and the vas deferens (tubes that carry sperm) are cut. This means you will no longer ejaculate semen, even if erections return. Orgasm is still possible, but it will be "dry" without ejaculation.

If you wish to father children in the future, discuss sperm banking before surgery. Sperm can be frozen and stored for later use with assisted reproductive techniques.

Surgical Complications

As with any surgery, radical prostatectomy carries risks of complications. These are relatively uncommon with modern techniques but include:

• Bleeding: Significant blood loss requiring transfusion is rare with robotic surgery (<1%)
• Infection: Wound infection or urinary tract infection can occur but are typically treatable with antibiotics
• Blood clots: Deep vein thrombosis or pulmonary embolism are prevented with blood thinners and early mobilization
• Anastomotic leak: Rarely, the connection between bladder and urethra may leak, requiring longer catheter time
• Lymphocele: Fluid collection after lymph node removal, usually resolves on its own
• Hernia: Incisional hernia at port sites (uncommon)

What Are the Cancer Control Outcomes?

Radical prostatectomy achieves excellent cancer control for localized prostate cancer, with 10-year cancer-specific survival rates exceeding 95% for organ-confined disease. Approximately 70-90% of men achieve undetectable PSA levels after surgery. Success depends on cancer stage, Gleason score, and achievement of negative surgical margins.

Cancer control is the primary goal of radical prostatectomy, and outcomes data from large studies and clinical trials support its effectiveness. When cancer is confined to the prostate, surgical removal eliminates the disease in most men. Even when cancer has extended beyond the prostate capsule, surgery often provides excellent long-term control.

Understanding how outcomes are measured and what factors influence them helps you interpret your own prognosis and make informed treatment decisions.

Measuring Success

After radical prostatectomy, success is primarily measured by PSA levels. Since the prostate produces PSA, removing it should result in undetectable PSA levels, typically defined as <0.1 ng/mL. Approximately 70-90% of men achieve this, depending on their cancer characteristics.

Biochemical recurrence (BCR) is defined as PSA rising to detectable levels after surgery, usually >0.2 ng/mL. This does not necessarily mean the cancer will cause symptoms or reduce survival, but it may indicate the need for additional treatment like radiation therapy or hormone therapy.

Long-Term Survival

Studies show excellent long-term survival after radical prostatectomy:

• Organ-confined disease: 10-year cancer-specific survival >95%
• Locally advanced disease: 10-year cancer-specific survival 70-90%
• Overall survival: Many men are cured and die of unrelated causes decades later

The ProtecT trial, which randomized men between surgery, radiation, and active surveillance, found that 10-year prostate cancer-specific survival was 99% regardless of treatment for men with localized disease. However, surgery and radiation were associated with lower rates of cancer progression compared to active surveillance for intermediate and high-risk disease.

Factors Affecting Outcomes

Several factors influence cancer control after surgery:

• Pathological stage: Cancer confined to the prostate (pT2) has better outcomes than cancer extending through the capsule (pT3)
• Gleason score: Lower grade cancers (Gleason 6-7) have better prognosis than higher grades (Gleason 8-10)
• Surgical margins: Negative margins (no cancer at the edge of the removed tissue) indicate complete removal
• Lymph node status: Cancer in lymph nodes indicates more advanced disease
• PSA levels: Higher pre-operative PSA is associated with more advanced disease

What Are the Alternatives to Surgery?

Alternatives to radical prostatectomy include radiation therapy (external beam or brachytherapy), active surveillance for low-risk cancers, and focal therapies. The choice depends on cancer characteristics, patient age and health, personal preferences, and treatment goals. Each option has different side effect profiles and trade-offs.

For men diagnosed with prostate cancer, surgery is one of several treatment options. Understanding the alternatives helps you make an informed decision that aligns with your values and circumstances. There is no single "best" treatment - the optimal choice varies for each individual.

Active Surveillance

For low-risk prostate cancer, active surveillance involves closely monitoring the cancer without immediate treatment. Regular PSA tests, digital rectal exams, and periodic biopsies track any changes. Treatment is offered if the cancer shows signs of progression.

Active surveillance avoids the side effects of treatment while reserving curative options for if they become necessary. It is increasingly recommended for men with low-grade, low-volume prostate cancer, as these cancers often never cause problems.

Radiation Therapy

External beam radiation therapy (EBRT) delivers high-energy rays from outside the body to kill cancer cells. Treatment typically involves daily sessions over several weeks. Modern techniques like intensity-modulated radiation therapy (IMRT) and proton therapy minimize damage to surrounding tissues.

Brachytherapy involves placing radioactive seeds directly into the prostate. These deliver radiation from inside the gland, minimizing exposure to surrounding tissues. It may be used alone for low-risk cancers or combined with external radiation for higher-risk disease.

Radiation therapy has different side effect profiles than surgery. It does not involve surgical risks but can cause bowel irritation, urinary symptoms, and erectile dysfunction. Unlike surgery, radiation effects may develop gradually over months to years after treatment.

Other Options

Focal therapies treat only the part of the prostate containing cancer, preserving healthy tissue. These include cryotherapy (freezing), high-intensity focused ultrasound (HIFU), and focal ablation. They are less established than surgery or radiation but may be options for selected patients.

Hormone therapy (androgen deprivation therapy) reduces testosterone levels to slow cancer growth. It is not curative on its own but is often combined with radiation for high-risk localized disease or used for advanced cancer.

Frequently Asked Questions