Surgery: Radical prostatectomy

Surgical removal of your prostate gland (radical prostatectomy) is an option to treat prostate cancer. The goal of surgery is to remove all cancer. Men who have this operation — and have no evidence that cancer has spread beyond the local area — have an 80 percent to 85 percent chance of survival at 15 years.

This surgery should be performed by a urologist with experience doing this specific procedure. This treatment option may be most appropriate for men with a 10-year or longer life expectancy.

Retropubic or perineal radical prostatectomy

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Prostatectomy incisions

During a radical prostatectomy, your surgeon removes the entire prostate and if necessary, the nearby lymph nodes, while trying to spare the muscles and nerves that control urination and sexual function (called nerve-sparing techniques).

The procedure is usually performed while you're under general anesthesia, but spinal anesthesia can sometimes be used.

During your operation, a catheter is inserted through the penis and into the bladder to drain urine from the bladder during your recovery.

Surgical approaches for a radical prostatectomy include:

• Retropubic
• Perineal

Retropubic. In retropubic surgery, your doctor removes the entire prostate through an incision in the lower abdomen that typically runs between the navel and the public bone, a couple of inches above the base of the penis. It's the most commonly used form of open-prostate removal for two reasons:

• Your surgeon can use the same incision to remove pelvic lymph nodes, which are tested to determine if the cancer has spread.
• Your surgeon has good access to your prostate, making it easier to save the nerves that help control bladder function and erections. Removal of the prostate requires detaching it from the bottom of the bladder. The urethra is also severed below the prostate gland. Your surgeon then reattaches the urethra to the bladder below where the prostate is removed.

During surgery, your surgeon may remove lymph nodes near the prostate and send samples to a pathologist, who may be able to tell your doctor within 15 to 30 minutes if the lymph tissue is cancerous — meaning, the cancer has spread beyond the prostate.

If cancer is found in the lymph tissue, your surgeon may close the incision without removing the prostate gland or proceed with the surgery. The decision to proceed in light of positive lymph nodes depends on the number of lymph nodes involved, your age and other planned treatments. The fewer nodes that contain cancer and the younger your age, the more likely your doctor will be to continue with surgery to remove the prostate and other cancerous tissue.

Perineal. With the perineal approach, which is less commonly used, your doctor removes the entire prostate through a half-moon incision between the anus and scrotum. Perineal surgery generally results in less bleeding, but has a higher risk of rectal injury. Also, your surgeon isn't able to remove nearby lymph nodes unless a second incision is made. It may be more difficult to perform nerve-sparing operations with this technique.

Following surgery

After surgery, you'll be in the hospital for one to three days. You'll likely have a catheter for one to two weeks while your urinary tract heals. After surgery:

• You'll learn how to care for the catheter.
• You'll need to drink plenty of fluids during this time to keep urine flowing freely and to reduce the chance of a blockage.
• Try to walk or do some other type of physical activity. Movement helps prevent blood clots in your legs.
• See your doctor if you develop redness or tenderness in the area of a leg vein. Clots can become life-threatening.

Risks and side effects of radical prostatectomy

Prostatectomy is a procedure with some potential short- and long-term risks and side effects.

Short-term complications

• Urinary incontinence. After the catheter is removed, you'll likely have some bladder control problems (urinary incontinence) that may last for weeks or even months. Most men eventually regain complete bladder control.
• Fecal incontinence. Radical prostatectomy rarely causes fecal incontinence; the degree may vary depending on the surgical method. After perineal surgery, a small percentage of men develop temporary fecal incontinence and bowel problems tend to improve over time.

Long-term complications

• Stress incontinence. A few men experience significant stress incontinence, meaning they can't hold their urine flow when there's increased bladder pressure, as occurs when you sneeze, cough, laugh or lift, or even simply with standing or walking. In some men, major urinary leakage is severe, and additional surgery may be needed to try to treat the problem.

• Erectile dysfunction Erectile dysfunction is another common side effect because nerves on both sides of your prostate that help control erections may be damaged or removed during surgery. Even with current surgical nerve-sparing techniques, partial or delayed erectile function can occur. There is a wide variation in rates of erectile function recovery, from as low as 9 percent to as high as 86 percent.

  Key factors in predicting recovery of sexual function are your potency status before surgery and the extent of nerves spared during surgery. Newer surgical techniques including minimally invasive surgery may offer 60 percent to 85 percent recovery of erectile dysfunction in men who had normal erectile function before surgery. It also seems that your age when you have surgery can affect the likelihood of erectile problems Men younger than 65 are more than twice as likely to return to their previous sexual function as are men older than 65.

  Several options are available to help restore erections, such as oral medications, penile injections or insertion of medications into the urethra, and vacuum pumps.

• Change in penis length. Some limited data suggest that penile length may decrease slightly after surgery in some men.
• Death. There is a very rare chance of death from radical prostatectomy surgery. The risk is low because attempts are made to screen out high-risk surgical candidates, such as older and frail men, from undergoing this procedure. Modern anesthesia techniques and postoperative management also contribute to very low death rates with this surgery.