Carlos G. Arcangeli, MD & Mark A. Rosen, MD

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Radical Prostatectomy for Localized Prostate Cancer

On this page:

• What is Radical Prostatectomy?
• How is Radical Prostatectomy Performed?
• Who is a candidate for Radical Prostatectomy?
• What are the risks of Radical Prostatectomy?
• What can I expect after Radical Prostatectomy?

What is Radical Prostatectomy?

Radical Prostatectomy is an operation to remove the entire prostate in an attempt to cure or treat prostate cancer. It was first performed more than 80 years ago, but did not become popular until the 1980’s, when the anatomy of the prostate and the nerves and blood vessels around the prostate was finally understood. Better knowledge of the anatomy allowed urologists to perform the operation with less blood loss, better urinary control, and better recovery of sexual function. Over the next two decades the operation improved dramatically, and our urologists have extensive experience with this surgery and are expert at this operation.

In the past 10 years most urologists have begun performing a less-invasive type of prostate surgery called laparoscopic radical prostatectomy. Patients recover from laparoscopic prostatectomy faster and with less risks than from open surgery, and few patients undergo open surgery at the present time. Click here to learn about this newer, less invasive type of prostate cancer surgery.

How is Radical Prostatectomy Performed?

The oldest technique for radical prostatectomy is called radical perineal prostatectomy. This operation removes the prostate through a small incision between the scrotum and the anus. This technique has a number of drawbacks, including very limited exposure of the prostate. Very few urologists still perform radical perineal prostatectomy. The modern standard approach to radical prostatectomy is called radical retropubic prostatectomy. It is performed through an midline incision from the belly button to the top of the pubic bone. The urologist can examine or remove pelvic lymph nodes, and has excellent exposure of the bladder, prostate, urethra, and pelvic nerves. The prostate is located below the bladder, and the urethra passes through the middle of the prostate.

During radical prostatectomy the prostate is separated from the bladder above, the urethra below, and the rectum behind the prostate. After the prostate is removed the bladder neck, the opening at the bottom of the bladder, is sewn to the urethra below the prostate so that the urinary tract is reconnected. The nerves that allow men to have erections pass along the side of the prostate and then along the urethra into the root of the penis. These nerves tell the blood vessels in the penis to open and allow blood to flow into the penis to cause an erection. These nerves are attached to the side of the prostate, and therefore can be damaged or removed during removal of the prostate. Radical prostatectomy has been modified to preserve these nerves and sexual function, an operation called nerve-sparing radical prostatectomy. Our urologists have extensive experience at nerve-sparing radical prostatectomy, and our patients have as high a chance of recovering sexual function as patients treated at any of the major cancer centers in the country.

Who is a candidate for Radical Prostatectomy?

Radical Prostatectomy is usually performed in men who have cancer which is thought to be localized to the prostate and therefore have a high chance of cure with surgery. It may be performed in men with more advanced cancer as part of a combined treatment strategy with radiation, hormonal therapy, or chemotherapy. There is good evidence that surgery or radiation treatments benefits men who already have spread of cancer to pelvic lymph nodes, because it may prevent urinary problems in the future and improve the long-term survival. It is not usually an option for men with cancer that has spread to the bones or other parts of the body. It is also not usually performed in men who have had open bladder or prostate surgery in the past because scarring can make the operation much more difficult. It can be performed after radiation treatment for prostate cancer if necessary, but the risks of surgery are greater after radiation treatment.

What are the risks of Radical Prostatectomy?

Radical Prostatectomy is a major cancer operation, and has a number of risks related to the surgery itself. There are also several long-term risks related to recovery from surgery. Nevertheless, most men recover from the surgery quickly and without any major health problems. Risks related to the surgery include bleeding, need for blood transfusion, injury to pelvic blood vessels, organs, or nerves, blood clots in veins of the legs or pelvis, infection, and risks of anesthesia. The risk of bleeding has decreased dramatically over the last 20 years, and varies significantly from surgeon to surgeon. In our practice the risk of bleeding enough to require a blood transfusion is less than 5%. We do not believe that it is necessary for patients to donate their own blood prior to surgery because the need for transfusion is low. It takes one month for your body to replace the blood for each unit of blood donated, so patients who donate blood right before surgery start the operation with a low blood count. If patients want to donate one unit of blood it can be arranged several weeks before surgery. The risk of an injury to the rectum during surgery is less than 1 in 1000, and the risk of a rectal injury which would require a colostomy is 1 in 10,000 surgeries.

Most patients are out of the hospital in 2-3 days after surgery, and are back to normal physical activity within 4-6 weeks. The long-term risks of radical prostatectomy include urinary incontinence and impotence. It takes some time for the urinary sphincter muscles to regain strength after surgery, and most men will wear a thin pad for several weeks after surgery. By 3 months after surgery 75% of men have normal urinary control. In our experience 95% of men will get normal urinary control back by one year after radical prostatectomy. Of the 5% of men who don’t get complete control back, roughly half will have a minimal amount of leakage that requires them to wear one thin pad per day. However, 2-3% of men will have enough incontinence after surgery that they need to wear several pads per day, and the amount of incontinence may affect their ability to play tennis or golf or other activities. It is not possible to determine prior to surgery which men will have long-term incontinence, but their are a number of effective treatments for these unusual cases.

The risk of impotence after Radical Prostatectomy is related to a patient’s level of sexual function prior to surgery, age, and general health. Men in their late 40’s or early 50’s who have normal sexual function prior to surgery have a 75% or regaining normal erections after surgery, although some may need to use a medication such as Viagra. Men in their mid 60’s have a 50% chance of regaining good erections after surgery, and men in their 70’s have a 30-40% chance of regaining good sexual function. The chances of regaining good sexual function goes down for men who are already experiencing decreased erections prior to surgery.

What can I expect after Radical Prostatectomy?

Most patients are in the hospital for 2-3 days after surgery, and are eating and walking well prior to going home. The degree of pain after surgery varies, but it is usually fairly minor. All men have a catheter in the penis to the bladder for 10-14 days after surgery. Men can wear a urinary bag which attaches to the leg, so it can be hidden by loose fitting pants. We encourage men to be active and leave the house if they feel well. After the catheter is removed men can swim or walk for exercise. Men should avoid lifting more than 10 lbs. for the first month after surgery, but after one month there are no restrictions. By 6 weeks after surgery most men will feel back to normal in almost all respects.

Most men find that they urinate with a much better stream after surgery. Most men will need a pad to catch a small amount of incontinence for several weeks after surgery. The incontinence is not a continuous “drip”, but is a small “squirt” when men stand from sitting, cough, laugh, sneeze, etc. The recovery of urinary control is gradual, so men find that they are dry at night first, and then are able to stay dry longer into the day before they leak. Over time men leak less and less until they are finally confident that they do not need to use pads.

The recovery of sexual function after surgery is gradual and occurs more slowly than the recovery of urinary control. It may take 6-24 months for men to recover completely. There is some evidence that use of a medication like Cialis or Levitra at bedtime will speed up the recovery of sexual function. Men will be able to achieve a climax after radical prostatectomy even if they do not have rigid erections, and the climax is basically the same as prior to surgery. However, there is no ejaculation after the prostate is removed.