Treatment

Surgery: radical prostatectomy

Radical prostatectomy is an operation to remove the prostate and the cancer contained inside it. The seminal vesicles are also removed.

Surgery is an option for men with cancer that is contained inside the prostate (localised prostate cancer) and who are otherwise fit and healthy. It is just as good at treating localised prostate cancer as external beam radiotherapy or brachytherapy.

It may also be an option for some men with cancer that has spread to the area just outside the prostate (locally advanced prostate cancer). This will depend on how far the cancer has spread.

A radical prostatectomy is a major operation. You have to be fit enough for surgery. It may not be suitable for you if you have other health problems such as heart disease, you’re over 75 or you’re overweight as you’re more likely to have problems during and after surgery.

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Types of surgery

There are several ways of removing the prostate.

Keyhole surgery
Keyhole surgery (also called laparoscopy or minimally invasive surgery).

  • Keyhole surgery by hand – your surgeon makes five or six small cuts in your abdomen (stomach area) and removes the prostate using a thin, lighted tube with a small camera on the tip and special surgical tools.
  • Robot-assisted surgery – your surgeon uses three robotic arms (one for the camera and two for the surgical tools) to do the operation. Your surgeon controls the robotic arms from a computer. You may hear this called the ‘Da Vinci® Robot’.

Robot-assisted surgery is not available in all hospitals in the UK. If your hospital doesn’t have it, they may be able to refer you to one that does.

Open surgery
Your surgeon makes a single cut in your stomach area to reach the prostate. This is called retropubic prostatectomy.

All of these types of surgery appear to be just as good as each other at treating prostate cancer.

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What are the advantages and disadvantages?

The advantages and disadvantages of all types of surgery depend on your age, health and the stage of your cancer.

What may be an advantage for one person might not be for someone else.

Advantages

  • If the cancer is completely contained inside the prostate, surgery will aim to remove all of it.
  • The prostate is removed and sent for testing which will give a clearer picture about how aggresive the cancer is and how far it may have spread.
  • It is easy to measure the success of your surgery was, as your PSA should drop to less than 0.1 ng/ml at six to eight weeks after the operation.
  • If your PSA starts to rise, you may be able to have radiotherapy or hormone therapy.

Disadvantages

  • There are risks in having a surgery, as with any major operation.
  • You will need to stay in hospital – this may be for one to seven days.
  • If the cancer has broken out of the prostate, the surgeon may not be able to remove all of it.
  • You won’t be able to have children naturally after surgery.

Advantages and disadvantages of different types of surgery
There isn’t much evidence at the moment to show that one type of surgery is better than another.Some studies suggest you may be less likely to have erection problems after keyhole surgery (by hand or robot-assisted) than with open surgery. Some research also suggests robot-assisted surgery may be better at removing all the cancer cells than open surgery. This might mean your cancer may be less likely to come back after robot-assisted surgery than with open surgery. But we need more research into this.

There isn’t good evidence to show robot-assisted surgery is any better than keyhole surgery by hand.The main advantages of keyhole surgery (by hand or robot-assisted) are that you will lose less blood, have less pain, spend less time in hospital and you will heal more quickly. Robot-assisted surgery is only available in a few hospitals in the UK. Doctors also need specialist equipment and training to carry it out.

The main advantage of open surgery is that it’s available across the UK.

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Risks of surgery

A radical prostatectomy is a major operation, and as with any major operation, there are some risks.

Risks of surgery include: 

  • bleeding and the possible need for a blood transfusion
  • injury to nearby organs such as the bowel and nerves
  • blood clots in the lower leg that could travel to the lung
  • wound infection
  • side effects such as leaking urine and erection problems.

The success of surgery and risk of side effects will depend on your surgeon’s experience and skill. Your surgeon should be able to tell you how many operations they have done, how successful these were, and the rate of side effects. Surgeons who do at least 20 radical prostatectomies each year, and ideally more than 35 a year, have better results, including lower rates of side effects.

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What does surgery involve?

Before the operation
A few weeks before your operation you will have tests at the hospital to make sure you are fit enough for surgery.

Doing pelvic floor muscle exercises for a few weeks before your operation may help you recover more quickly from urinary problems caused by surgery.

If you take drugs to thin the blood such as warfarin or clopidrogel, you may need to stop taking them a week before your operation to reduce the risk of bleeding.

The operation
The operation will take two to four hours. You’ll have a general anaesthetic so you will be asleep during the operation and won't feel anything.

There are two bundles of nerves attached to the prostate which control erections. These nerves can be damaged during the operation and cause problems with getting an erection. Your surgeon will try to save them. This is called nerve-sparing surgery. But if the cancer has spread too close to the nerves, your surgeon may need to remove one or both bundles of nerves.

These nerves only control erections. They don’t control feeling in the penis or the surrounding area. Even if the nerves are damaged or removed, you won’t lose any feeling and may still be able to have orgasms.

After the operation
When you wake up from the operation, you may be given fluids to drink. Let your doctor or nurse know if you feel any pain or feel sick – they can give you medicine to help with this.

Catheter
You’ll have a thin tube (called a catheter) passed through your penis into the bladder to drain urine out of your body. Most men go home with the catheter. You nurse will show you how to look after your catheter.

You’ll also have a thin tube in your stomach area to drain fluid from the wound. This is usually removed 24 to 48 hours after the operation.

Pain
You will be given pain-relieving drugs after the operation. These should control any pain you have, but tell your doctor or nurse if you are in any pain.

The drugs are usually given into a vein in your arm or hand (intravenous). You may have a pump so that you can top up your pain relief yourself if you need to.

After keyhole surgery, you may have some pain in your shoulders for a few days. Carbon dioxide gas is pumped into your stomach area during the operation. This can irritate the nerves and cause the pain. Your stomach may also feel bloated and this can cause some cramping and tightness.

Swelling
You may have some bruising and swelling around your testicles and penis. This can take several weeks to clear, but if you have a lot of swelling, tell your doctor. You may find underpants more comfortable than boxer shorts.

Eating and drinking
You will normally be allowed to eat and drink as soon as you feel able to after the operation.

Getting out of bed
You will be encouraged to get out of bed and start moving around as soon as you can. This reduces your risk of having a blood clot.

You may need to take daily injections for up to a month after surgery to reduce the risk of blood clots. If you need injections, your nurse will teach you how to inject yourself before you go home.

You will go home one to seven days after your operation, depending on your recovery and your doctor’s advice.

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Going home

You will have the name of someone to contact if there’s a problem after you go home. A district nurse may also visit you at home during the first few weeks.

Care of your catheter
Before you go home, your nurse will show you how to look after your catheter.

The catheter will be attached to a bag that can be worn inside your trousers, strapped to your leg. Make sure the urine drains freely into the bag. If urine builds up in the bladder, it can put pressure on the wound and the stitches.

Urine infections can be common if you have a catheter. The following tips can help lower your chances of getting a urine infection.

  • Always wash your hands before and after handling your catheter.
  • Wash the area near the tip of your penis with a downward movement away from the tip. Use unscented soap and water, and dry the area afterwards.
  • Drink plenty of fluids (about 1.5 to 2 litres or 3 to 4 pints a day). Your doctor or nurse should tell you how much.
  • Eat plenty of fibre to avoid constipation as this can stop the catheter draining properly.

The catheter is removed at the hospital one to three weeks after the operation. This can be uncomfortable but it shouldn’t be painful. Your doctor or nurse will make sure you are able to urinate before you go home.

You may leak urine when the catheter is removed. Take some absorbent (incontinence) pads and a spare pair of underpants and trousers to the hospital. Some hospitals will provide a few absorbent pads. You can get more from the chemist or your GP. You may also be able to order them directly from the supplier without paying VAT.

If you decide to have surgery, our surgery support pack might be helpful.

Your wound
After keyhole surgery, the cuts are usually closed with a type of glue or stitches that slowly dissolve as the cuts heal. If you had open surgery, the cut is usually closed with stitches or clips. These are removed after one to two weeks.

It may take several months for your body to fully recover from surgery. You will need to take it easy for the first couple of weeks after surgery. Gentle exercise around the home and eating a healthy diet will help your recovery. Then light exercise such as a short walk every day will help improve your fitness. Avoid climbing too many stairs, lifting heavy objects or doing manual work for eight weeks after the operation.

Wait until you feel ready before having sex. It is fine to masturbate.

Constipation
You may not have a bowel movement for several days after surgery. If this carries on you may need medicine to help empty your bowels (called a laxative). Bowel habits may take a few weeks to return to normal. It’s important you don’t strain. Ask your doctor, nurse or GP for advice.

Eating high fibre foods (such as bran and fruit), drinking plenty of fluids, and gentle physical activity will help.

Going back to work
The amount of time you take off work will depend on how quickly you recover and how much physical effort your work involves. If you have keyhole surgery you’re more likely to get back to your usual activities more quickly than after open surgery. Ask your doctor or nurse about how much time you need to take off.

Driving
You will be able to sit in a car as a passenger while your catheter is still in. You may want to avoid long journeys for the first two weeks after the catheter is removed, until you are used to dealing with any problems, such as leaking urine.

Speak to your doctor about when it’s safe for you to drive. It should not be before you feel you can do an emergency stop comfortably. Check with your insurance company how soon after surgery you are insured to drive.

Watch Colin's story for one man's experience of surgery. He and his wife talk about how he recovered from the operation.

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When to call your doctor or nurse

You should contact your doctor or nurse as soon as possible if you have any of the following symptoms.

  • Your bladder feels full or you notice your catheter isn’t draining urine.
  • Your catheter leaks or falls out.
  • Your urine contains blood clots, turns cloudy, dark or red, or has a strong smell.
  • The area around your wound becomes red, swollen or painful.
  • You have a fever (high temperature of more than 38ºC or 101ºF).
  • You feel sick or are sick.
  • You get cramps in your stomach that will not go away.
  • You get pain or swelling in your legs.

Your doctor or nurse may ask you to come into the hospital, or they may tell you to go to your nearest accident & emergency (A&E) department.

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Follow-up

You will have regular check-ups to monitor your progress (called follow-up). Your check-ups will usually start between six to eight weeks after surgery. Then they could be every three to six months. After two years, you might have a check-up once a year. But your check-ups might be more often than this, so check with your doctor or nurse.

PSA test
You will have a PSA test a week before your check-up.

After surgery, your PSA level should drop so low that it’s not possible to detect it (less than 0.1 ng/ml). A rise in your PSA levels can suggest some prostate cancer cells were left behind. If this happens, your doctor will talk to you about further treatment.

The prostate
After your prostate is removed it is sent to a laboratory to be looked at under a microscope. This can give a better idea of how aggressive the cancer might be and whether it has spread.

You may hear your doctor talk about ‘positive surgical margin’ or ‘negative or clear margin’.

  • Positive surgical margin – this means an area right on the edge of the prostate contains cancer cells. It suggests that some cancer cells may have been left behind. This might mean you’re more likely to need further treatment.
  • Negative or clear margin – this means the cancer cells in the prostate are surrounded by a rim of normal tissue. It suggests all the cancer was removed.

Further treatment
If your results suggest some cancer cells may have been left behind, you might be offered radiotherapy on its own or with hormone therapy. You may also be able to take part in a clinical trials. Read more about cancer that has come back.

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What are the side effects?

The most common side effects of surgery are leaking urine (urinary incontinence) and problems with getting and keeping an erection (erectile dysfunction).

Your risk of getting these side effects depends on your overall health and age, the stage and grade of your cancer, and your surgeon’s skill and experience.

Watch Paul's story for one man's experience of managing urinary problems after surgery:

Erection problems after surgery
After surgery, most men find it difficult to get an erection strong enough for sexual intercourse and it can take anything from a few months to three years for erections to return. Erections are often not as strong as they were before surgery and some men will never be able to get an erection without the help of treatments.

Treatments for erection problems include: tablets called PDE5 inhibitors, vacuum pump, injections, gels or pellets.

Your doctor may suggest that you start treatments for erection problems in the first few weeks after surgery. Even if you are not ready to start any sexual activity, starting treatment soon after surgery may improve your chances of getting erections later on. You may hear this called penile rehabilitation. Read more about how prostate cancer treatment can affect your sex life.

If you’re gay, bisexual or a man who has sex with men, and are the active partner (the ‘top’) during anal sex, then erection problems after surgery may be a particular issue. Read our information for gay and bisexual men.

Penis shortening
Some men find that their penis gets shorter after surgery. Taking PDE5 inhibitor tablets may help to prevent the penis getting shorter, or help it return to its normal length. Using a vacuum pump, on its own or with a PDE5 inhibitor, may also help to prevent shortening and improve erections.

Dry orgasm
The prostate and seminal vesicles make some of the fluid in the semen. Both are removed during the operation. This means you won’t ejaculate when you have sex or masturbate. Instead you may have a ‘dry orgasm’ – where you feel the sensation of orgasm but don’t ejaculate. This may feel different to the orgasms you’re used to.

Having children
After your operation, you won’t be able to father a child naturally. You may want to think about storing your sperm before having surgery, so that you can use it later for fertility treatment – if needed. Ask your doctor or nurse about sperm storage locally.

Watch Kevin's story for one man's experience managing side effects of surgery:

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Questions to ask your doctor or nurse

You may find it helpful to keep a note of any questions you have to take to your next appointment.

  • What type of surgery do you recommend for me and why?
  • How many of these operations have you done and how many do you do a year?
  • Will you try to do nerve-sparing surgery if possible?
  • How long should I expect to be in hospital?
  • What pain relief will I get after the operation?
  • How soon will we know whether the operation has been successful?
  • How often will my PSA level be checked?
  • What is the chance of needing more treatment after surgery?
  • What is the risk of having urinary problems and what support can you offer me?
  • What is the risk of having erection problems and what treatment is available to help me get erections after surgery? When will I start it?
  • Who should I contact if I have any problems?
  • What support can you offer me if I have long-term side effects?

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References

The following references have been used to produce this information.

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  • Berookhim BM, Nelson CJ, Kunzel B, et al. Prospective analysis of penile length changes after radical prostatectomy. BJU Int 2014;113(5b):E131–36.
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This publication was written and edited by Prostate Cancer UK’s Health Information Team.

It was reviewed by:

  • Susan Asterling, Urology Research Nurse, Sunderland Royal Hospital, Sunderland
  • Simon F Brewster, Consultant Urologist, Churchill Hospital, Oxford
  • Declan Cahill, Consultant Urological Surgeon, Guy's and St Thomas’ NHS Trust, London
  • Ben Challacombe, Consultant Urological Surgeon and Honorary Senior Lecturer Guy's Hospital & Kings College London, London
  • Debbie Gray, Uro-oncology CNS, Darlington Memorial Hospital, Darlington, Co Durham
  • Bruce Turner Uro-oncology Nurse Practitioner, Homerton University Hospital NHS Foundation Trust and Bart’s Health Trust, London.
  • Prostate Cancer UK Volunteers
  • Prostate Cancer UK Specialist Nurses