Radical Prostatectomy (RP)
What is a radical prostatectomy?
Radical prostatectomy is surgery to remove the prostate gland. During the procedure, the seminal vesicles, nearby tissues, and often some pelvic lymph nodes are also removed.
The prostate gland is found only in males. It sits below the bladder and wraps around the urethra (the tube that carries urine out of the body). The prostate helps make semen. The seminal vesicles are the 2 sacs that connect to the vas deferens (tubes that carry sperm from the testicles). The pelvic lymph nodes are small oval collections of immune system tissue that filter lymph fluid. When prostate cancer spreads, these lymph nodes are often one of the first places it goes.
A common way to remove the prostate is through an incision (cut) done in one of two ways:
- A retropubic or suprapubic incision, which is made in the lower abdomen (belly)
- A perineum incision, which is made in the skin between the scrotum and the rectum
Radical prostatectomy is used to treat prostate cancer that is confined to the prostate gland and the seminal vesicles. There are several ways to do a radical prostatectomy:
Radical prostatectomy with retropubic (or suprapubic) approach
This is the most common method. The incision is made in the lower abdomen. If there’s a chance the cancer has spread, the healthcare provider may remove lymph nodes around the prostate gland first so they can be checked in the lab before the prostate is removed. Cancer has spread beyond the prostate gland if it's found in the lymph nodes. If that's the case, then surgery may be stopped, since removing the prostate won't remove all of the cancer. In this situation, other treatments will be used.
- Nerve-sparing prostatectomy approach. Two tiny bundles of nerves that control erection are found on each side of the prostate. If the cancer is tangled with these nerves, the nerves must be cut to remove the cancer. If both nerves are cut or removed, the man will be unable to have an erection. This won't improve over time. But, there are treatments that may help erectile function. If only one of the bundle of nerves is cut or removed, the man may have less erectile function, but will possibly have some function left. If neither nerve bundle is disturbed during surgery, function may return. Still, it sometimes takes months after surgery to know whether a full recovery will occur. This is because the nerves will need time to heal after the procedure.
Radical prostatectomy with perineal approach
Radical perineal prostatectomy is used less often than the retropubic approach. This is because the nerves can't be spared as easily, nor can lymph nodes be removed with this method. But, it takes less time and may be an option if the nerve-sparing and lymph node removal isn't needed.
With the retropubic approach, there is a smaller, hidden scar behind the scrotum for a better cosmetic effect. Also, major abdominal muscle groups are avoided. So, there's generally less pain and recovery time.
Laparoscopic radical prostatectomy
In this approach, the surgeon makes several small cuts and puts a thin tube with a video camera (laparoscope) inside one of the cuts and long, thin tools through others. The camera helps the surgeon see inside as the tools are used to do the surgery.
- Robotic-assisted laparoscopic prostatectomy. Sometimes laparoscopic surgery is done using a robotic system. The surgeon moves the robotic arms while sitting at a nearby computer monitor. This procedure requires special equipment, training, and experience. Not every hospital can do robotic surgery.
Why might I need a radical prostatectomy?
Radical prostatectomy is used to treat prostate cancer. It’s used when the cancer is thought to be confined to the prostate gland.
Other less common reasons for radical prostatectomy include:
- Inability to fully empty the bladder
- Recurrent bleeding from the prostate
- Bladder stones with prostate enlargement
- Very slow urination
- Increased pressure on the ureters and kidneys from urinary retention (called hydronephrosis)
There may be other reasons for your doctor to recommend a prostatectomy.
What are the risks of a radical prostatectomy?
Some possible complications of retropubic and perineal methods may include:
- Urinary incontinence. This is uncontrollable, involuntary leaking of urine, up to a year after surgery. This may get better over time.
- Urinary leakage or dribbling. This symptom is at its worst right after the surgery. It usually improves over time.
- Impotence (erectile dysfunction). Recovery of sexual function may take up to 2 years after surgery and may not be complete. Nerve-sparing prostatectomy lowers the chance of erectile dysfunction, but doesn't guarantee that it won't happen.
- Sterility. Radical prostatectomy cuts the connection between the testicles and the urethra and causes retrograde ejaculation. This results in a man being unable to naturally provide sperm for a biological child. A man may be able to have an orgasm, but there will be no ejaculate. In other words, the orgasm is "dry."
- Lymphedema. Lymphedema is a condition in which fluid collects in the soft tissues, causing swelling. This may be caused by inflammation, blockages, or removal of the lymph nodes during surgery. Although rare, if lymph nodes are removed, fluid may collect in the legs or genital region over time. Pain and swelling result. Physical therapy is often helpful in treating the effects of lymphedema.
- Change in penis length. A small percentage of surgeries will result in a shorter penis.
Some risks associated with surgery and anesthesia in general include:
- Reactions to medications used during surgery
- Blood clots
One risk of the retropubic approach is rectal injury. This can cause stool incontinence or urgency.
You may have other risks,depending on your condition. Be sure to discuss any concerns with your doctor before the procedure.
How do I get ready for a radical prostatectomy?
Some things you can expect before the surgery include:
- Your doctor will tell you about the procedure and you can ask questions.
- You'll be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if anything isn't clear.
- Your doctor will review your medical history and do a physical exam to be sure you're in good health before you have the surgery. You may need tests to make sure the cancer is confined to the prostate and has not spread to other parts of your body.
- You'll be asked to fast (not eat or drink anything) for 8 hours before the procedure, generally after midnight.
- Tell your doctor if you're sensitive to or are allergic to any medications, latex, iodine, tape, contrast dyes, and anesthesia.
- Make sure your doctor has a list of all medicines (prescribed and over the counter) and all herbs, vitamins, and supplements that you're taking.
- Tell your doctor if you have a history of bleeding disorders or if you're taking any anticoagulant (blood-thinning) medicines, aspirin, or other medicines that affect blood clotting. You may need to stop these medicines before the surgery.
- If you smoke, top as soon as possible to improve your recovery from surgery and to improve your overall health.
- Follow all other instructions that your healthcare provider gives you.
What happens during a radical prostatectomy?
Radical prostatectomy requires a stay in the hospital. Procedures may vary depending on your condition and your doctor's practices.
Generally, a radical prostatectomy (either retropubic or perineal approach) follows this process:
- You'll need to remove any jewelry or other objects that may get in the way during the procedure. A bracelet with your name and an ID number will be put on your wrist. You may get a second bracelet if you have allergies.
- You'll remove your clothing and put on a hospital gown.
- You'll be asked to empty your bladder.
- An intravenous (IV) line will be started in your arm or hand.
- The doctor may choose regional anesthesia instead of general anesthesia. General anesthesia puts you into a deep sleep during the surgery. Regional anesthesia is medicine delivered through an epidural (in the back) to numb the area to be operated on. You'll also get medicine to help you relax and pain medications. The doctor will decide which type of anesthesia is best for you.
- Once you're sedated, a breathing tube may be put through your throat into your lungs and you'll be connected to a ventilator. This will breathe for you during the surgery.
- The anesthesiologist will closely watch your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
- A soft, flexible tube called a Foley catheter will be put into your bladder to drain urine.
- If there is a lot of hair at the surgical site, it may be shaved off.
- The skin over the surgical site will be cleaned with an antiseptic solution.
Radical prostatectomy, retropubic or suprapubic approach
- You'll lie on your back on the operating table.
- An incision will be made from below your belly button to the pubic region.
- The doctor will usually remove and check lymph nodes first. If the lymph nodes do not have cancer cells in them, the nerve bundles will carefully be separated from the prostate gland.
- The prostate gland will be removed. The seminal vesicles may also be removed.
- A drain will be put in, usually in the right lower area of the incision, to remove fluid that may build up as you heal.
Radical prostatectomy, perineal approach
- You'll lie on your back on a table that keeps your hips and knees fully bent with your legs spread apart and raised. Straps will be placed under your legs for support.
- An upside-down, U-shaped incision (cut) will be made in the perineal area (between the scrotum and the anus).
- The doctor will try to minimize any damage to the nerve bundles in the prostate area.
- The prostate gland and any abnormal-looking nearby tissue will be removed.
- The seminal vesicles may be removed if there's concern there may be cancer in them.
Procedure completion, both methods
- The incision will be sutured or stapled closed.
- A sterile bandage or dressing will be put on the site.
- The breathing tube will be taken out and you will breathe on your own.
What happens after a radical prostatectomy?
In the hospital
After the surgery, you will be taken to a recovery room to be closely watched. You'll be connected to machines that will constantly display your heart beat, blood pressure, breathing rate, and your oxygen level.
Once you're awake and stable, you may start to drink liquids and will be taken to your hospital room.
You may get pain medication as needed, either by a nurse, or by giving it yourself through a device connected to your IV line.
You will be able to eat solid foods as you're able to handle them.
Your healthcare team will show you how to do breathing exercises and movements while in bed to help your body recover. You may wear compression stockings on your legs. These reduce your risk for blood clots. Your activity will be gradually increased, and you will be urged to get out of bed and walk around for longer periods.
The drain will generally be taken out the day after surgery.
The Foley catheter that was put in to drain your urine will stay in place for about 1 to 3 weeks as you heal. You'll be given instructions on how to care for your catheter at home.
Arrangements will be made for a follow-up visit with your doctor.
Once you're home, it'll be important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. The sutures or surgical staples will be removed during a follow-up office visit, if they weren't removed before leaving the hospital.
The surgical incision may be tender or sore for several days. Take a pain reliever for soreness as recommended by your doctor.
You shouldn't drive until your doctor tells you it’s OK. Other activity restrictions may apply, such as no heavy lifting for 3 to 4 weeks.
Once the Foley catheter is removed, you'll probably have some leaking of urine. The length of time this occurs can vary. Your doctor will give you suggestions for improving your bladder control. Over the next few months, you and your doctor will be checking for any side effects and working to improve any problems with incontinence or erectile dysfunction.
Tell your doctor if you have any of the following:
- Fever and/or chills (may be a sign of infection)
- Redness, swelling, or bleeding or other drainage from the incision
- Increase in pain around the incision
- Inability to have a bowel movement
- Inability to urinate once catheter is removed
- Changes in your urine output, color, or odor
Your doctor may give you other instructions after the procedure, depending on your situation.
Next stepsBefore you agree to the test or the procedure make sure you know:
- The name of the test or procedure
- The reason you are having the test or procedure
- The risks and benefits of the test or procedure
- When and where you are to have the test or procedure and who will do it
- When and how will you get the results
- How much will you have to pay for the test or procedure