Radical prostatectomy

Surgery Overview

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A radical prostatectomy is an operation to remove the prostate gland and some of the tissue around it. It is done to remove prostate cancer. This operation may be done by open surgery or by laparoscopic surgery through small incisions.

Laparoscopic surgery is most often done by hand. A few doctors now do it by guiding robotic arms that hold the surgery tools. This is called robot-assisted prostatectomy.

Open surgery

In open surgery, the surgeon uses an incision to reach the prostate gland. Depending on the case, the incision is made either in the lower belly or in the groin between the anus and the penis.

When the incision is made in the lower belly, it is called the retropubic approach. A radical prostatectomy using the retropubic approach is the most common treatment for prostate cancer. In this procedure, the surgeon may also remove lymph nodes in the area so that they can be tested for cancer.¹

When the incision is made in the groin, it is called the perineal approach. The recovery time after this surgery may be shorter than with the retropubic approach. If the surgeon wants to remove lymph nodes for testing, he or she must make a separate incision. If the lymph nodes are believed to be free of cancer based on the grade of the cancer and results of the PSA test, the surgeon may skip the lymph node removal.

Laparoscopic surgery

For laparoscopic surgery, the surgeon makes several small incisions in the belly. A lighted viewing instrument called a laparoscope is inserted into one of the incisions. The surgeon uses special instruments to reach and remove the prostate through the other incisions.

Men who have laparoscopic surgery tend to lose less blood during the operation and to recover faster than men who have open surgery.² Laparoscopic prostatectomy is not yet widely available, and because it is a relatively new technique, no results from long-term follow-up after treatment are available.

The main goal of either type of surgery is to remove all the cancer. Sometimes that means removing the prostate as well as the tissues around it, including a set of nerves to the penis that affect the man's ability to have an erection. Some tumors can be removed using a nerve-sparing technique, which means carefully cutting around those nerves to leave them intact. Nerve-sparing surgery sometimes preserves the man's ability to have an erection.

What To Expect After Surgery

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Prostatectomy usually requires general anesthesia and a hospital stay of 2 to 4 days. A thin, flexible tube called a catheter usually is left in your bladder to drain your urine for 1 to 3 weeks. Your doctor will give you instructions about how to care for your catheter at home. Bladder control can be poor for a few months after the catheter is removed.

Although prostatectomy often removes all cancer cells, it is important to receive follow-up care, which may lead to early identification and treatment if your cancer comes back. Your regular follow-up program may include:

• Physical exams.
• Prostate-specific antigen (PSA) tests, to monitor PSA levels and to measure the speed of any changes in those levels.
• Digital rectal exams.
• Biopsies as needed, to examine suspicious tissue.

Why It Is Done

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Radical prostatectomy is most often used if testing shows that the cancer has not spread outside the prostate (stages I and II).

Although radical prostatectomy is occasionally used to relieve urinary obstruction in men with more advanced (stage III) cancer, a different operation, called a transurethral resection of the prostate (TURP), is most often used for that purpose. Surgery usually is not considered a cure for advanced cancer, but it can help relieve symptoms.

How Well It Works

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Radical prostatectomy is generally effective in treating prostate cancer that has not spread. This is called early-stage cancer. Following surgery, the stage of the cancer can be determined based on how far it has spread. PSA levels will drop almost to zero if the surgery successfully removes the cancer and the cancer has not spread. If cancer has spread, advanced cancer may develop even after the prostate has been removed.

Compared with watchful waiting for early-stage cancer, radical prostatectomy lowers the risk that the cancer will grow or spread. And it lowers the long-term risks of death from cancer.³ This is important to know if you expect to live 10 or more years. (If you are already in poor health or are in your later years and you have an early-stage prostate cancer, it may not grow or spread during your lifetime.)

Risks

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Erection problems

Up to 80% of men experience erection problems after a prostatectomy.⁴ The nerves that control a man's ability to have an erection lie next to the prostate gland. They often are damaged or removed during surgery. In the months and years after surgery, most men who had erection problems after prostatectomy are able to regain their ability to have erections:⁵

• 76% of men younger than 60
• 56% of men age 60 to 65
• 47% of men older than 65

Recovery depends on:⁵

• Whether the man was able to have an erection before surgery.
• How the surgery affected the nerves that control erections.
• How old the man was at the time of surgery.

Urinary incontinence

Up to half of all men who have a radical prostatectomy develop urinary incontinence, ranging from a need to wear urinary incontinence pads to occasional dribbling. Studies show that one year later, between 15% and 50% of men report urinary problems.⁴

The urethra—the tube that carries urine from your bladder—runs through the middle of the doughnut-shaped prostate gland. In order to remove the prostate, the surgeon must cut the urethra and later reconnect it to the bladder. Evidence shows that the greater the surgeon's experience and skill in making this reconnection, the lower the rate of incontinence.⁶

Some men may require treatment for incontinence after prostatectomy, if urinary leakage continues longer than 1 year.

Complications

Radical prostatectomy is major surgery, so it carries the same general risks as other major operations, including heart problems, blood clots, allergic reaction to anesthesia, blood loss, and infection of the wound.

These additional complications can be caused by radical prostatectomy:

• Erection problems
• Urinary incontinence
• Damage to the urethra
• Damage to the rectum

What To Think About

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A surgeon who is new to laparoscopy can take 80 to 100 surgeries before mastering prostatectomy.⁷ Before choosing the surgeon and type of surgery you will have, look for a surgeon with the most experience and surgery success. This can help lower your risks of problems after surgery.

When considering prostatectomy, take into account your personal wishes, age, other medical conditions you may have, the stage and grade of your cancer, and your PSA level. Radiation treatment or watching and waiting may be reasonable alternatives.

Robot-assisted prostatectomy may be best suited to a younger man in good health with a small prostate and a small, lower-grade cancer. This technology is not yet widely used.

Surgery may completely remove your prostate cancer. However, it is not possible to know ahead of time whether the cancer has spread beyond the prostate and is not curable with surgery alone.

Prostate cancer often spreads to the nerves that surround the prostate. These nerves control a man's ability to have an erection. When the nerves are removed along with the cancer, the man will most likely have erection problems. A nerve graft sometimes may be done to reduce this chance. For this, the surgeon removes part of a nerve that goes down the back of the leg and attaches it to the nerves where the prostate gland was. This surgery seems to be helpful for some men, but not for all. More research is needed to see how well this surgery works to preserve the man's ability to have an erection.

Complete the surgery information form (PDF) (What is a PDF document?) to help you prepare for this surgery.

References

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Citations

1. Jani AB, Hellman S (2003). Early prostate cancer: Clinical decision-making. Lancet, 361(9362): 1045–1053.

2. Scher HI, et al. (2005). Cancer of the prostate. In VT DeVita Jr et al., eds., Cancer: Principles and Practice of Oncology, 7th ed., pp. 1192–1259. Philadelphia: Lippincott Williams and Wilkins.

3. Bill–Axelson A, et al. (2005). Radical prostatectomy versus watchful waiting in early prostate cancer. New England Journal of Medicine, 352(19): 1977–1984.

4. Wilt T (2004). Prostate cancer (non-metastatic). Clinical Evidence (11): 1169–1185.

5. Eastham JA, Scardino PT (2002). Radical prostatectomy. In PC Walsh et al., eds., Campbell's Urology, 8th ed., vol. 4, pp. 3080–3106. Philadelphia: W.B. Saunders.

6. Kantoff PW (2002). Prostate cancer. In DC Dale, DD Federman, eds., Scientific American Medicine, section 12, chap. 9. New York: WebMD.

7. Ahlering TE, et al. (2003). Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: Initial experience with laparoscopic radical prostatectomy. Journal of Urology, 170(5): 1738–1741.

Credits

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Author	Kathe Gallagher, MSW
Author	Ralph Poore
Editor	Kathleen M. Ariss, MS
Editor	Renée Spengler, RN, BSN
Associate Editor	Michele Cronen
Associate Editor	Terrina Vail
Primary Medical Reviewer	Martin Gabica, MD - Family Medicine
Primary Medical Reviewer	Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer	Christopher G. Wood, MD, FACS - Urology/Oncology
Last Updated	July 24, 2006