What Is a Radical Prostatectomy?
If you have been diagnosed with prostate cancer, your doctor will discuss different options for treatment. If your cancer is only inside the prostate gland and has not spread to surrounding tissue, your doctor may recommend a surgery called a radical prostatectomy.
In a radical prostatectomy, a surgeon removes your entire prostate gland. The prostate is a small organ that wraps around your urethra, the tube that moves urine from your bladder to your penis. The seminal vesicles (small glands that produce a liquid that is part of semen) and the vas deferens (a muscular cord that moves sperm from your testicles to your urethra) may also be removed in this surgery.
The surgery is called a “radical” prostatectomy because the entire prostate gland is removed. In other prostate surgeries (i.e., a “simple” prostatectomy), only part of the gland is removed.
Why Is a Radical Prostatectomy Performed?
A radical prostatectomy might be your best treatment option if your tumor is inside your prostate gland only and has not invaded surrounding areas. This treatment is done to remove the cancer before it can spread to other parts of your body. The entire prostate is removed.
Sometimes your surgeon will also remove related structures such as the seminal vesicles (very common) and the vas deferens. This is to make sure that the cancer is completely removed.
Lymph Node Removal
Your surgeon may also remove nearby lymph nodes. This procedure is called pelvic lymph node dissection. Lymph nodes are fluid-filled sacs that are part of the immune system. Your doctor will examine your pelvic lymph nodes to determine whether your prostate cancer has spread (metastasized) to them. The lymph nodes are often the first place cancer spreads to from the prostate.
Sometimes you will have these lymph nodes removed before your prostate surgery.
Whether your lymph nodes are removed depends on your level of risk for cancer spreading to them. One of the ways your doctor will determine this risk is using your prostate-specific antigen (PSA) level. PSA, is an enzyme produced by the prostate gland. Normally, small amounts of PSA enter the bloodstream from the prostate. Larger amounts of PSA enter the blood when the prostate gland is enlarged, infected, or diseased, such as with benign prostatic hyperplasia (BPH), prostatitis, or prostate cancer. The level of PSA in the blood can be determined by a simple blood test.
Your lymph nodes will likely be removed if your PSA level is above 15 ng/ml, according to the University of California San Francisco Medical Center (UCSF).
Am I a Good Candidate for a Radical Prostatectomy?
Other treatment options may be better for you if:
- your health is poor and you are unable to undergo anesthesia or surgery
- your cancer is growing slowly
- your cancer has spread beyond your prostate gland
How Is a Radical Prostatectomy Performed?
The prostate is inside the pelvis and is surrounded by many other organs, including the rectum, the bladder, and sphincter (muscles that control urine flow), as well as many important nerves and blood vessels.
There are several methods for performing a radical prostatectomy. The one you undergo will depend on the location of your tumor(s), the extent of the cancer, and your general health and life stage.
All of these surgeries are done in the hospital and require anesthesia to prevent you from feeling pain. Usually, general anesthesia is used, so you will be asleep during the surgery. Epidural or spinal anesthesia can also be used. This is when you cannot feel anything below your waist. Sometimes, both types of anesthesia are used to control potential bleeding and to provide the best pain management.
The main types of radical prostatectomy surgery are:
- open radical retropubic prostatectomy—In this surgery, the doctor makes a cut just below your belly button down to your pubic bone. The surgeon moves aside muscles and organs in order to remove the prostate, vas deferens, and seminal vesicles. Lymph nodes are also removed. This type of surgery can also be done with a “nerve-sparing” approach. If so, your doctor tries to not cut any of the tiny nerves that are needed to maintain an erection. If the cancer has affected these nerves, this may not be possible.
- laparoscopic radical prostatectomy—Much smaller cuts into the body are required for this type of surgery. Five small “keyholes” are cut into the abdomen. Then lighted magnifying devices and cameras are put into the holes to help the surgeon remove the prostate without making a large cut. The prostate is removed through one of the holes with a small bag. This type of surgery often involves less pain afterward, requiring less recovery time. Using the “nerve-sparing” approach with this method may not be as successful as with the “open” type of surgery. Sometimes, this surgery is done using robotic tools; the doctor moves the scalpels and instruments using a computer-assisted robot.
- open radical perineal prostatectomy—This is not done as often as the other surgeries. This operation involves cutting into the body through the perineum (the skin between the scrotum and the anus). The prostate is removed through this incision. The lymph nodes cannot be removed through this incision, however. These organs can be removed through a small cut in your abdomen or with another procedure, which is often done laproscopically. It is also more difficult to preserve important nerves with this type of surgery. However, this surgery takes less time and involves less blood loss than the retropubic option.
In all of these surgeries, after the prostate is removed, the surgeon must move the urethra. The prostate wraps around this tube that leads from your bladder to your penis, so the urethra must be repositioned. After this, the surgeon reattaches the urethra to the base of the bladder. The surgeon may leave a drain (tube) in place to remove extra fluid that may gather following the procedure. The drain is inserted through a small cut in the skin of your stomach. Fluid collects in a bulb attached to the end of the tube on the outside of your body.
What Happens After a Radical Prostatectomy?
You may be required to stay in the hospital for up to four days after the surgery. You will be able to drink and eat normally soon after the surgery.
While recovering in the hospital you will have:
- dressings over your incision sites
- a drain to remove excess fluid from the surgery site. The drain will be removed after a day or two.
- a catheter (tube) threaded through the end of your penis and into your urethra to drain urine into a bag while you are healing. Urine that drains from the catheter may be bloody or cloudy. You may have a catheter in place for one to two weeks.
During your recovery you may need to wear special socks to prevent blood clots in your legs or use a breathing device to keep your lungs healthy.
If you have stitches in your incision, they will absorb into your body and do not need to be removed. You will be given pain medication both in the hospital and while recovering at home.
You will likely still have a catheter when you go home. Sometimes your doctor will allow you to remove this at home when it is time. Otherwise, you will need to have this done at an office visit.
How Do I Prepare for a Radical Prostatectomy?
Your doctor will do a thorough check of your health. If you have health conditions such as diabetes, heart disease, lung problems, or high blood pressure, they need to be under control before surgery.
Your doctor will order many tests and scans before your surgery to learn as much as possible about your condition. These will likely include:
- blood tests to check for other health conditions
- an ultrasound to get images of the prostate and nearby organs
- a biopsy of the prostate (in which a small sample in removed so it can be analyzed under a microscope)
- a computed tomography (CT) or magnetic resonance imaging (MRI) scan of the abdomen and pelvis
Make sure that you tell all of your doctors and nurses what drugs and vitamins you take, especially any medicines that might thin your blood. These might cause complications and excessive bleeding during surgery. For example, problems may occur with warfarin (Coumadin), clopidogrel (Plavix), aspirin, ibuprofen (Motrin, Advil), naproxen (Aleve), and vitamin E.
Do not eat before the surgery or you may have complications from the anesthesia. You may need to drink only clear liquids and take a special laxative the day before the surgery to clear your digestive system.
What Are the Risks of Radical Prostatectomy?
Any surgery carries a risk for potential complications, including blood clots in the legs, breathing problems, reactions to anesthesia, bleeding, infection, heart attack, and stroke. Your doctor and care team will work hard to prevent any of these problems.
Problems specific to prostate surgery can potentially include:
- urinary incontinence (problems with controlling the urge to urinate)
- bowel incontinence (difficulty controlling bowel movements)
- urethral stricture (scar tissue blocking part of the urethra)
- problems maintaining an erection (impotence)
- injury to the rectum
What Can Be Expected in the Long Term?
You may have difficulties maintaining an erection after a radical prostatectomy. Some of the nerves and blood vessels that control erection may be damaged during the surgery. Medications and pumps may be able to help you with this problem. It is important to talk to your doctor about management options.
After your prostate has been removed, you will no longer ejaculate semen. This means you will be infertile. However, you can still be sexually active even after prostate cancer treatment. You should still be able to have an orgasm with stimulation to the penis.
Depending on whether surgery completely removed all cancer cells, additional treatment with radiation or hormones may be necessary. This is usually needed only for very aggressive cancers. PSA blood tests and the pathology report (which explains what was found when your prostate was examined under a microscope) will help you and your doctor decide if further treatment is necessary.
The University of Pittsburgh Cancer Institute reported an excellent outlook for men who had cancer inside the prostate only and underwent a radical prostatectomy. In one study, 90 percent of men in this category remained cancer-free for five years after surgery. Of men in the study with cancer that had spread outside the prostate, 70 percent remained cancer-free after five years if the cancer had not invaded the seminal vesicles.
To maintain your health, you should get regular blood tests, PSA levels, and CT and MRI scans, as well as regular checkups. PSA levels are usually assessed every four to six months for the first three years after surgery.