What is a radical prostatectomy?
A radical prostatectomy is a surgery used to treat prostate cancer. If you’ve been diagnosed with prostate cancer, your doctor will discuss different options for treatment. If your cancer is only inside the prostate gland and hasn’t spread to surrounding tissue, your doctor may recommend a radical prostatectomy.
In a radical prostatectomy, a surgeon removes your entire prostate gland. The prostate is a small organ that wraps around your urethra. The urethra is the tube that moves urine from your bladder to your penis.
The surgery is called a “radical” prostatectomy because the entire prostate gland is removed. In other prostate surgeries, such as a “simple” prostatectomy, only part of the gland is removed.
A radical prostatectomy might be your best treatment option if your tumor is inside your prostate gland and hasn’t invaded surrounding areas. This treatment is done to remove the cancer before it can spread to other parts of your body. The entire prostate is removed.
Sometimes your surgeon will also remove related structures such as the seminal vesicles and the vas deferens. Removal of the seminal vesicles is very common. This is to make sure that the cancer is completely removed.
Lymph node removal
Your surgeon may also remove nearby lymph nodes. This procedure is called pelvic lymph node dissection. Lymph nodes are fluid-filled sacs that are part of your immune system. Your doctor will examine your pelvic lymph nodes to determine whether your prostate cancer has spread, or metastasized, to them. The lymph nodes are often the first place cancer spreads from the prostate. Sometimes you’ll have these lymph nodes removed before your prostate surgery.
Whether your lymph nodes are removed depends on your level of risk for cancer spreading to them. One of the ways your doctor will determine this risk is using your prostate-specific antigen (PSA) level. PSA is an enzyme produced by the prostate gland. Normally, small amounts of PSA enter the bloodstream from the prostate. Larger amounts of PSA enter the blood when the prostate gland is enlarged, infected, or diseased, such as with benign prostatic hyperplasia (BPH), prostatitis, or prostate cancer. The level of PSA in the blood can be determined by a simple blood test.
Am I a good candidate for a radical prostatectomy?
Other treatment options may be better for you if:
- your health is poor and you’re unable to undergo anesthesia or surgery
- your cancer is growing slowly
- your cancer has spread beyond your prostate gland
Your doctor will do a thorough check of your health. Some health conditions in particular need to be under control before the surgery. These include:
- heart disease
- lung problems
- high blood pressure
Your doctor will order many tests and scans before your surgery to learn as much as possible about your condition. These will likely include:
- blood tests
- an ultrasound of the prostate and nearby organs
- a biopsy of the prostate
- a CT or MRI scan of the abdomen and pelvis
Make sure that you tell all of your doctors and nurses what drugs and vitamins you take, especially any medicines that may thin your blood. These may cause complications and excessive bleeding during surgery. Problems may occur with drugs or supplements such as:
- warfarin (Coumadin)
- clopidogrel (Plavix)
- ibuprofen (Motrin, Advil)
- naproxen (Aleve)
- vitamin E
Make sure not to eat before the surgery to avoid complications from the anesthesia. You may need to drink only clear liquids and take a special laxative the day before the surgery to clear your digestive system.
The prostate is inside the pelvis and is surrounded by many other organs, including the rectum, the bladder, and the sphincter. Many important nerves and blood vessels also surround the prostate.
There are several methods for performing a radical prostatectomy. The one you undergo will depend on the location of your tumor or tumors, the extent of your cancer, and your general health and life stage.
All of these surgeries are done in the hospital and require anesthesia to prevent you from feeling pain. General anesthesia is usually used, so you’ll be asleep during the surgery. Epidural or spinal anesthesia can also be used. With this type of anesthesia, you can’t feel anything below your waist. Sometimes, both types of anesthesia are used to control potential bleeding and to provide the best pain management.
The three main types of radical prostatectomy surgery are:
1. Open radical retropubic prostatectomy
In this surgery, the doctor makes a cut just below your belly button down to your pubic bone. The surgeon moves aside muscles and organs to remove the prostate, vas deferens, and seminal vesicles. Lymph nodes are also removed. This type of surgery can also be done with a “nerve-sparing” approach. If so, your doctor tries to not cut any of the tiny nerves that are needed to maintain an erection. If the cancer has affected these nerves, this may not be possible.
2. Laparoscopic radical prostatectomy
This type of surgery requires much smaller cuts into the body. Five small “keyholes” are cut into the abdomen. Then lighted magnifying devices and cameras are put into the holes to help the surgeon remove the prostate without making a large cut. The prostate is removed through one of the holes with a small bag. This type of surgery often involves less pain afterward, requiring less recovery time. Using the “nerve-sparing” approach with this method may not be as successful as with the “open” type of surgery.
3. Open radical perineal prostatectomy
This surgery isn’t as common as the others. The operation involves cutting into the body through the perineum, which is the skin between the scrotum and the anus. The prostate is removed through this incision.
However, the lymph nodes can’t be removed through this incision. These organs can be removed through a small cut in your abdomen or with another procedure such as laparoscopic surgery.
It’s also more difficult to preserve important nerves with an open radical perineal prostatectomy. This surgery takes less time and involves less blood loss than the retropubic option.
You may be required to stay in the hospital for up to four days after the surgery. You’ll be able to drink and eat normally soon after the surgery.
While recovering in the hospital you’ll have dressings over your incision sites. You’ll also have a drain to remove excess fluid from the surgery site. The drain will be removed after a day or two.
A catheter, or tube, will be threaded through the end of your penis and into your urethra. The catheter will drain urine into a bag while you’re healing. Urine that drains from the catheter may be bloody or cloudy. You may have a catheter in place for one to two weeks.
During your recovery you may need to wear special socks. These will prevent blood clots in your legs. You may also need to use a breathing device to keep your lungs healthy.
If you have stitches in your incision, they’ll absorb into your body and won’t need to be removed. You’ll be given pain medication both in the hospital and while recovering at home.
Any surgery carries a risk for potential complications, including:
- blood clots in the legs
- breathing problems
- reactions to anesthesia
- heart attack
Your doctor and care team will work hard to prevent any of these problems.
Problems specific to prostate surgery can potentially include:
- difficulty controlling the urge to urinate
- difficulty controlling bowel movements
- a urethral stricture
- problems maintaining an erection
- injury to the rectum
Some of the nerves and blood vessels that control erection may be damaged during the surgery. As a result, you may have difficulties maintaining an erection after a radical prostatectomy. Medications and pumps may be able to help you with this problem. It’s important to talk to your doctor about management options.
After your prostate has been removed, you’ll no longer ejaculate semen. This means you’ll be infertile. You can still be sexually active even after prostate cancer treatment. You should still be able to have an orgasm with stimulation to the penis.
Depending on whether surgery completely removed all cancer cells, additional treatment with radiation or hormones may be necessary. This is usually needed only for very aggressive cancers. PSA blood tests and a pathology report will help you and your doctor decide if further treatment is necessary.
To maintain your health, you should get regular blood tests, PSA levels, and CT and MRI scans, as well as regular checkups. PSA levels are usually assessed every four to six months for the first three years after surgery.