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Radical prostatectomy is a surgical procedure that includes removal of the entire prostate gland and the attached seminal vesicles. In some cases lymph nodes near the prostate can be removed at the same time. Following removal of the prostate and seminal vesicles, the bladder and urethra are re-attached and a catheter is left in the bladder to allow for drainage of urine while healing takes place. In general, the catheter stays in place for 8 to 9 days following surgery. In addition to the catheter, a small drain (tube) known as a Jackson-Pratt (JP) drain is left in the pelvis and exits through a small incision in the lower left abdomen. The JP drain is almost always removed 2 days after surgery, before the patient leaves the hospital to go home.
Radical prostatectomy can be done:
1) through an incision made in the lower abdomen from the pubic bone to below the umbilicus (belly button) (radical retropubic prostatectomy-most common approach)
2) through an incision between the scrotum and the anus (radical perineal prostatectomy)
3) using laparoscopy (a newer approach in which surgery is performed from outside the body using small incisions and specially designed telescopes and instruments)
Each of these approaches has its benefits and drawbacks. Results of each approach with respect to cancer cure, urinary continence and sexual function should be discussed with your physician.
In some prostate cancer patients, removal of the lymph nodes in the area surrounding the prostate may be recommended. This is done to determine if prostate cancer has spread outside of the gland and into the lymph nodes. Patients at risk for cancer spread to the lymph nodes are those with a high PSA (more than 10 or 20 ng/ml), a large nodule or mass on prostate exam or high grade/aggressive cancer (Gleason score 8 or higher). Removal of these lymph nodes can be done at the same time as radical prostatectomy in patients undergoing a radical retropubic prostatectomy. Side effects and complications from lymph node dissection are usually minimal.
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Who is a Candidate for Radical Prostatectomy?
What is Nerve Sparing Radical Prostatectomy?
Outcomes of Radical Prostatectomy
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Who is a Candidate for Radical Prostatectomy?
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Radical prostatectomy is most appropriate for men:
1) in whom the cancer appears to be localized to the prostate gland
2) who are in good health with a 10-year life expectancy
In most cases, radical prostatectomy allows for complete removal of the cancer and therefore, an excellent chance at cure.
Potential advantages to radical prostatectomy over other forms of treatment include:
1) complete removal of the prostate gland
2) accurate assessment of the aggressiveness (grade) and extent (stage) of the cancer by examination of the entire prostate by a pathologist
3) easy and straightforward follow-up after treatment as the PSA level should be undetectable after surgery
4) the ability to give radiation after surgery to men with extensive cancers without increasing the risks or side effects of radiation.
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What is Nerve Sparing Radical Prostatectomy?
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The nerves and blood vessels (neurovascular bundles) that allow for penile erection during sexual activity travel on either side of the prostate. These nerves only influence erection, not libido (sex drive) or the ability to achieve climax.
These neurovascular bundles can be preserved in well-chosen men undergoing radical prostatectomy. Candidates for nerve-sparing surgery include sexually active men with relatively normal erections before surgery. Since the neuro-vascular bundles travel close to the prostate, leaving them in place may compromise cancer cure in some patients. As a result, good candidates for nerve sparing surgery are also those men with favorable cancer characteristics such as a relatively low PSA, low Gleason score and few biopsies involved with cancer.
The risks and benefits of nerve-sparing surgery for a specific patient should be discussed at length with his physician. Return of erectile function following radical prostatectomy is discussed below.
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Outcomes of Radical Prostatectomy
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Prostate Cancer Cure
 Typical incision placement for a radical retropubic prostatectomy. | Cure following any treatment for prostate cancer depends on many factors including serum PSA level at diagnosis, extent/stage of cancer, Gleason grade and cancer volume. For patients with cancer that appears to be confined to the prostate, cure rates with radical prostatectomy are excellent and meet or exceed all other forms of treatment.
There are many tools/tables/nomograms that can estimate the likelihood of cure following radical prostatectomy. These tools are based on results from large numbers of patients treated with radical prostatectomy, and while they may not apply exactly to your situation, they may be helpful to you when deciding between different prostate cancer treatment options. You should always talk with your doctor about your specific situation before making treatment decisions.
Urinary function/continence
Because of the location of the prostate just beneath the urinary bladder, any treatment for prostate cancer can have effects on urinary function. The major risk to urinary function following radical prostatectomy is urinary incontinence (involuntary urine leakage). It is common to have some urinary leakage immediately after your doctor removes your catheter. Your doctor will teach you exercises to strengthen your urinary sphincter muscles (Kegel exercises). You can even start these exercises before surgery. You should buy a package of male incontinence pads and bring 1 or 2 of these pads to the doctor's office at the time of catheter removal. Some men are able to control their urine completely immediately after catheter removal. For other men, regaining urinary control can take a few days to a few weeks.
Occasionally, continence may take several months to return to normal. Men with symptoms of prostatic enlargement before surgery (slow stream, urinary frequency or urgency) usually need a longer time to regain urinary control after surgery. Even when it takes time to regain full control, continence improves steadily in most patients. Continence usually returns first at night, followed by control with light activity and ultimately patients are continent with heavy activity and exercise. Overall, the likelihood of full return of continence after radical prostatectomy is approximately 95 to 96%. A small percentage of patients will have minimal leakage with heavy activity and an even smaller percentage of patients will have more bothersome incontinence.
A rare risk to urinary function following radical prostatectomy is scarring where the bladder and urethra are brought together during surgery. Such scarring can cause blockage to normal urine flow resulting in a slow urinary stream and the inability to completely empty the bladder. If you experience these symptoms, you should alert your doctor. In most cases, a simple outpatient procedure can correct the scarring and allow for normal flow of urine.
Sexual Function
Any treatment for prostate cancer can affect sexual function. All men experience erectile dysfunction immediately following radical prostatectomy. The nerves and blood vessels that travel to the penis and allow for erection are located on either side of the prostate. In many men, these neurovascular bundles can be preserved during surgery. Even when they are preserved, however, it can take some time before erections return. Improvement in erectile function can continue for more than 2 years after surgery.
Return of erectile function following radical prostatectomy is dependent on many factors including whether one or both neurovascular bundles are preserved, age at the time of surgery, ability to have normal erections before surgery and the extent of cancer present in the prostate. Each patient is very different in this regard, so it is important to talk with your doctor about the appropriateness of nerve-sparing surgery and the likelihood of regaining erectile function following surgery in your particular case.
Several erectile aids are available to help patients regain erectile function after radical prostatectomy. Use of these aids early and consistently after surgery can assist the healing process for the nerves and speed up return of erectile function. It is our practice to start patients on oral medications such as Viagra, Levitra or Cialis early after surgery. Patients are encouraged to use these medications, in combination with sexual activity, several times a week even if results are not immediately apparent.
Injections of medication directly into the penis can also be effective. These injections can result in a normal erection even early after surgery, and they can also facilitate the healing process. Other erectile aids include the vacuum erection device (pump) and rarely, patients may choose a penile implant.
It is important to know that while any treatment for prostate cancer can affect erectile function, these treatments should not affect the ability to have a good sex drive and an orgasm (climax). There will usually be no ejaculate with orgasm after treatment for prostate cancer, whether it is surgery or radiation. It is also important to realize that one can continue to be sexually active despite erectile dysfunction. There are several resources available to assist cancer patients with intimacy following treatment. Please ask your physician for information that can be helpful.
For More Information
Should your physician recommend surgery, the Prostate/Genitourinary Cancer Program Information Guide has detailed information on preparation for surgery, your stay at the hospital and post-surgical care.
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