Radical Prostatectomy: Prostate Cancer Surgery – Complete Guide
- What is radical prostatectomy?
- Who is a candidate for radical prostatectomy?
- Surgical approaches – open, laparoscopic, robotic
- Nerve-sparing technique – preserving erections
- Lymph node dissection – when indicated
- Recovery and hospital stay
- Side effects – ED, incontinence, dry ejaculation
- Success rates – cancer control
- Choosing a surgeon – volume matters
- Interactive FAQ – 9 questions about radical prostatectomy
What is radical prostatectomy?
Radical prostatectomy is a surgical procedure to remove the entire prostate gland, along with the seminal vesicles and sometimes nearby lymph nodes. It is the most common treatment for localized prostate cancer (cancer confined to the prostate).
The goal of radical prostatectomy is to cure prostate cancer by removing all cancer cells while preserving urinary continence and erectile function as much as possible.
Who is a candidate for radical prostatectomy?
Ideal candidates for radical prostatectomy meet the following criteria:
- Localized prostate cancer (T1-T2): Cancer confined to the prostate
- Life expectancy >10 years: Surgery provides benefit only if you live long enough to see the benefit
- Good surgical candidate: No major contraindications (severe heart disease, uncontrolled bleeding disorder)
- Intermediate or high-risk cancer: Gleason 7+ (3+4, 4+3, 8-10)
- Low-risk cancer (Gleason 6): Active surveillance is preferred; surgery is overtreatment for most
Surgical approaches – open, laparoscopic, robotic
Three main surgical approaches are available, each with different recovery profiles:
Open radical prostatectomy (retropubic):
- Incision: 8-10 cm incision from belly button to pubic bone
- Hospital stay: 2-3 days
- Catheter: 2-3 weeks
- Advantages: Lower cost, direct visualization
- Disadvantages: More blood loss, longer recovery, larger scar
Laparoscopic radical prostatectomy:
- Incision: 5-6 small incisions (5-10 mm)
- Hospital stay: 1-2 days
- Catheter: 1-2 weeks
- Advantages: Less blood loss, shorter recovery
- Disadvantages: Steeper learning curve, longer operative time
Robotic-assisted laparoscopic radical prostatectomy (da Vinci):
- Incision: 5-6 small incisions (robotic arms)
- Hospital stay: 1 day (often outpatient)
- Catheter: 7-10 days
- Advantages: 3D magnification, wristed instruments, less blood loss, faster recovery, better nerve-sparing
- Disadvantages: Higher cost, requires specialized training
Nerve-sparing technique – preserving erections
The neurovascular bundles (nerves that control erections) run along the sides of the prostate. Nerve-sparing surgery preserves these nerves, improving the chance of recovering erectile function after surgery.
Types of nerve-sparing:
- Bilateral nerve-sparing: Both neurovascular bundles preserved – best chance of erectile function recovery
- Unilateral nerve-sparing: One bundle preserved – reasonable chance of erections (may need ED medications)
- Non-nerve-sparing: Both bundles removed – very low chance of natural erections
Who qualifies for nerve-sparing?
- Low-risk or intermediate-risk cancer not involving the neurovascular bundles
- Good preoperative erectile function
- No extracapsular extension (cancer outside the prostate)
Lymph node dissection – when indicated
A pelvic lymph node dissection (PLND) removes lymph nodes to check for cancer spread (staging). It is performed during radical prostatectomy.
Indications for PLND:
- Intermediate-risk cancer with >5% risk of lymph node involvement
- High-risk or very high-risk cancer
- Elevated PSA (>20 ng/mL)
- Gleason 8-10
Risks of PLND:
- Lymphocele (fluid collection)
- Leg swelling (lymphedema) – rare
- Nerve injury (obturator nerve)
Recovery and hospital stay
Hospital stay:
- Robotic/laparoscopic: 1 day (often outpatient or 23-hour stay)
- Open: 2-3 days
Catheter:
- Robotic: 7-10 days
- Laparoscopic: 10-14 days
- Open: 14-21 days
Return to activities:
- Walking: Day of surgery
- Desk work: 2-4 weeks
- Light exercise: 4-6 weeks
- Heavy lifting: 6-8 weeks
- Sexual activity: 6-8 weeks (after catheter removal and healing)
Side effects – ED, incontinence, dry ejaculation
Radical prostatectomy has predictable side effects:
Erectile dysfunction (ED):
- Rate: 20-50% at 2 years (with bilateral nerve-sparing)
- Risk factors: Older age, poor preoperative erections, non-nerve-sparing, diabetes
- Treatment: PDE-5 inhibitors (Viagra, Cialis), penile injections, vacuum devices, implants
Urinary incontinence:
- Rate: 5-10% require pads at 12 months
- Types: Stress incontinence (leaking with cough/sneeze) – most common
- Treatment: Pelvic floor exercises (Kegels), urethral sling, artificial urinary sphincter
Dry ejaculation (anejaculation):
- Rate: 100% – no semen is produced after prostatectomy (prostate and seminal vesicles are removed)
- Effect: Orgasm still occurs but is "dry" (no fluid)
Success rates – cancer control
Radical prostatectomy has excellent cancer control outcomes:
- 10-year biochemical recurrence-free survival: 70-85% (depends on risk group)
- 10-year prostate cancer-specific survival: >95% for localized disease
- Positive margin rate: 10-20% (cancer at the edge of the specimen – higher risk of recurrence)
By risk group:
- Low-risk (Gleason 6): 10-year recurrence-free survival ~85-90%
- Intermediate-risk (Gleason 7): 10-year recurrence-free survival ~70-80%
- High-risk (Gleason 8-10): 10-year recurrence-free survival ~50-70%
Choosing a surgeon – volume matters
Surgeon experience significantly affects outcomes:
- High-volume surgeons (>50-100 cases/year): Lower complication rates, better cancer control, lower positive margin rates, better functional outcomes (continence, potency)
- Low-volume surgeons (<10 cases/year): Higher complication rates
Questions to ask a potential surgeon:
- How many radical prostatectomies have you performed?
- How many do you perform per year?
- What is your positive margin rate?
- What is your complication rate (bleeding, infection, reoperation)?
- What are your continence and potency rates?
Interactive FAQ – Radical prostatectomy
Hospital stay: 1-2 days. Catheter: 7-10 days. Return to desk work: 2-4 weeks. Full recovery: 6-8 weeks.
With bilateral nerve-sparing, 50-80% of men recover erections sufficient for intercourse (often with ED medications). Recovery takes 12-24 months.
Most men regain urinary control. At 12 months, 5-10% need pads (usually 1 pad/day for minor leakage).
Robotic: smaller incisions, less blood loss, shorter hospital stay, faster recovery. Open: larger incision, longer recovery. Cancer control is similar.
Yes – orgasms still occur but are "dry" (no semen). The sensation may be slightly different but is still pleasurable.
10-year cancer-specific survival >95% for localized disease. 10-year recurrence-free survival: 70-85% depending on risk group.
Surgery that preserves the nerves controlling erections. Improves chance of erectile function recovery without compromising cancer control.
Robotic: 7-10 days. Laparoscopic: 10-14 days. Open: 14-21 days.
Both are effective. Surgery provides definitive pathology staging but has risks of incontinence and ED. Radiation avoids surgery but has bowel and bladder side effects. Choice depends on patient preferences.
Disclaimer: This information is for educational purposes. Radical prostatectomy is a major surgery with risks. Discuss with a urologist at Vivekananda Hospital to determine if surgery is right for you.