Radical prostatectomy

  • Definition
    • Radical prostatectomy (prostate removal) is surgery to remove all of the prostate gland and some of the tissue around it. It is done to treat prostate cancer.

  • Alternative Names
    • Prostatectomy - radical; Radical retropubic prostatectomy; Radical perineal prostatectomy; Laparoscopic radical prostatectomy; LRP; Robotic-assisted laparoscopic prostatectomy; RALP; Pelvic lymphadenectomy; Prostate cancer - prostatectomy; Prostate removal - radical

  • Description
    • There are 4 main types or techniques of radical prostatectomy surgery. These procedures take about 3 to 4 hours:

      • Retropubic: Your surgeon will make a cut starting just below your belly button that reaches to your pubic bone. This surgery takes 90 minutes to 4 hours.
      • Laparoscopic: The surgeon makes several small cuts instead of one big cut. Long, thin tools are placed inside the cuts. The surgeon puts a thin tube with a video camera (laparoscope) inside one of the cuts. This allows the surgeon to see inside your belly during the procedure.
      • Robotic surgery: Sometimes, laparoscopic surgery is performed using a robotic system. The surgeon moves the instruments and camera using robotic arms while sitting at a control console near the operating table. Not every hospital offers robotic surgery.
      • Perineal: Your surgeon makes a cut in the skin between your anus and base of the scrotum (the perineum). The cut is smaller than with the retropubic technique. This type of surgery often takes less time and causes less loss of blood. However, it is harder for the surgeon to spare the nerves around the prostate or to remove nearby lymph nodes with this technique.

      For these procedures, you may have general anesthesia so that you are asleep and pain free. Or, you will get medicine to numb the lower half of your body (spinal or epidural anesthesia).

      • The surgeon removes the prostate gland from the surrounding tissue. The seminal vesicles, two small fluid-filled sacs next to your prostate, are also removed.
      • The surgeon will take care to cause as little damage as possible to the nerves and blood vessels.
      • The surgeon reattaches the urethra to a part of the bladder called the bladder neck. The urethra is the tube that carries urine from the bladder out through the penis.
      • Your surgeon may also remove lymph nodes in the pelvis to check them for cancer.
      • A drain, called a Jackson-Pratt drain, may be left in your belly to drain extra fluid after surgery.
      • A tube (catheter) is left in your bladder to drain urine. This will stay in place for a few days to a few weeks.
  • Why the Procedure is Performed
    • Radical prostatectomy is most often done when the cancer has not spread beyond the prostate gland. This is called localized prostate cancer.

      Your doctor may recommend one treatment for you because of what is known about your type of cancer and your risk factors. Or, your doctor may talk with you about other treatments that could be good for your cancer. These treatments may be used instead of surgery or after surgery has been performed.

      Factors to consider when choosing a type of surgery include your age and other medical problems. This surgery is often done on healthy men who are expected to live for 10 or more years after the procedure.

  • Risks
  • Before the Procedure
    • You may have several visits with your health care provider. You will have a complete physical exam and may have other tests. Your provider will make sure medical problems such as diabetes, high blood pressure, and heart or lung problems are being controlled.

      If you smoke, you should stop several weeks before the surgery. Your provider can help.

      Always tell your provider what drugs, vitamins, and other supplements you are taking, even ones you bought without a prescription.

      During the weeks before your surgery:

      • You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), vitamin E, clopidogrel (Plavix), warfarin (Coumadin), and any other blood thinners or drugs that make it hard for your blood to clot.
      • Ask which drugs you should still take on the day of your surgery.
      • On the day before your surgery, drink only clear fluids.
      • Sometimes, you may be asked by your provider to take a special laxative on the day before your surgery. This will clean the contents out of your colon.

      On the day of your surgery:

      • Do not eat or drink anything after midnight the night before your surgery.
      • Take the drugs you have been told to take with a small sip of water.
      • You will be told when to arrive at the hospital. Be sure to arrive on time.

      Prepare your home for when you come home after the surgery.

  • After the Procedure
    • Most people stay in the hospital for 1 to 4 days. After laparoscopic or robotic surgery, you may go home the day after the procedure.

      You may need to stay in bed until the morning after surgery. You will be encouraged to move around as much as possible after that.

      Your nurse will help you change positions in bed and show you exercises to keep blood flowing. You will also learn coughing or deep breathing to prevent pneumonia. You should do these steps every 1 to 2 hours. You may need to use a breathing device to keep your lungs clear.

      After your surgery you may:

      • Wear special stockings on your legs to prevent blood clots.
      • Receive pain medicine in your veins or take pain pills.
      • Feel spasms in your bladder.
      • Have a Foley catheter in your bladder when you return home.
  • Outlook (Prognosis)
    • The surgery should remove all of the cancer cells. However, you will be monitored carefully to make sure the cancer does not come back. You should have regular checkups, including prostate specific antigen (PSA) blood tests.

      Depending on the pathology results and PSA test results after prostate removal, your provider may discuss radiation therapy or hormone therapy with you.

  • References
    • Bill-Axelson A, Holmberg L, Garmo H, Rider JR, et al. Radical prostatectomy or watchful waiting in early prostate cancer. N Engl J Med. 2014;370(10):932-942. PMID: 24597866

      Ellison JS, He C, Wood DP. Early postoperative urinary and sexual function predicts functional recovery 1 year after prostatectomy. J Urol. 2013;190(4):1233-1238. PMID: 23608677

      Resnick MJ, Koyama T, Fan KH, et al. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med. 2013;368(5):436-445. PMID: 23363497

      Schaeffer EM, Partin AW, Lepor H. Open radical prostatectomy. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 11th ed. Philadelphia, PA: Elsevier; 2016:chap 114.

      Su LM, Gilbert SM, Smith JA. Laparoscopic and robotic-assisted laparoscopic radical prostatectomy and pelvic lymphadenectomy. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 11th ed. Philadelphia, PA: Elsevier; 2016:chap 115.