Surgical removal of the prostate (radical prostatectomy) is a treatment option for localized prostate cancer (early-stage cancer that has not spread out of the prostate). The prostate, surrounding tissues, seminal vesicles and the portion of the urethra that runs through the prostate are all removed. The surgery takes two to four hours and is done under general anesthesia (unconscious) or, less commonly, regional anesthesia (frozen from the waist down). Patients usually stay in the hospital for two to five days after the surgery and must wear a catheter (a tube to drain urine) for 10 days to three weeks.
A prostatectomy is a one-time procedure that, in most cases, removes the cancer entirely. Many specialists believe that radical prostatectomy offers the greatest chance of long-term survival (past seven to 10 years). It is the most aggressive treatment option and, unfortunately, has the greatest risk of side effects.
The different types of prostatectomy, risks and side effects are described below.
Radical Retropubic Prostatectomy This is the most common type of prostatectomy. The surgeon makes an incision from the navel to the pubic bone and the prostate is removed. Nearby lymph nodes may be removed and examined to see if cancer has spread beyond the prostate. If the lymph nodes are free of cancer, the prostate is removed and the urethra is reconnected directly to the bladder.
Radical Perineal Prostatectomy The prostate is removed through an incision in the perineum (the area between the scrotum and the anus). This type of prostatectomy is less common because lymph nodes cannot be removed and the nerves on either side of the prostate (involved in erections) cannot easily be spared. Perineal prostatectomy takes less time and requires a shorter hospital stay than the retropubic operation. And, because there is no muscles pull on the incision, there is less pain after surgery.
Nerve-sparing Prostatectomy One of the goals of this surgery is to preserve sexual function by leaving the nerves that are involved in erections. The surgeon will not remove the two bundles of nerves on either side of the prostate if it looks like the cancer has not spread to them.
Radical Laparoscopic Prostatectomy During this minimally invasive surgery, a telescopic instrument called a laparoscope is inserted into the abdomen through a small incision at the navel. A camera is attached to the laparoscope, which allows surgeons to look inside the abdomen. Four more small incisions are made and surgical instruments are inserted into the body through these. The surgery is performed by two surgeons, one on each side of the patient.
Men who have this type of surgery have less blood loss, less pain after surgery, shorter hospital stays and a faster recovery. However, this is a relatively new technique and not available at many hospitals, so data on long-term follow-up and cancer control is not yet available.
Risks and Complications Side effects fall into two categories: surgery-related problems and prostate-specific problems.
Surgery-related complications
Prostate-specific problems
Risk of incontinence
Kegel exercises can help strengthen the pelvic floor muscles which may help reduce the symptoms of incontinence. Some men also find external devices such as a penile clamp helpful in preventing symptoms. A physician can recommend the best option.
The risk of impotence can be lowered with nerve-sparing prostatectomy. However, this type of surgery is not appropriate or possible for all men and even with it, many men (especially older men) become impotent. Your risk of erectile dysfunction (ED) varies (between 30 and 90 per cent) depending on your age, the extent of your prostate cancer and the type of surgery. Recovery of the nerves (and return of erectile function) can take one to two years. In some cases ED is permanent
Risk of erectile dysfunction
A less common side effect is stool or fecal incontinence (the loss of normal muscle control of the bowels). This is due to muscle damage or reduced elasticity in the rectum caused by surgery.
Prostatectomy is major surgery. How long you spend in hospital after surgery depends on how quickly you recover.
During surgery, a tube called a Foley catheter is inserted through your penis to drain urine from your bladder. It will be removed one to three weeks after you return home. The catheter often irritates the bladder wall, and you may feel discomfort from bladder contractions and a false sense of bladder fullness. Medications can lessen these symptoms.
When the catheter is removed, you may be incontinent (have lost bladder control). This symptom will also improve with time: most men recover full bladder control three to six months after surgery. Exercises known as Kegels can help you regain bladder control sooner. Some men will become permanently incontinent following surgery. They may consider a second operation to implant an artificial sphincter, although this surgery is usually not done until at least a year after the prostatectomy.
The average recovery period following surgery is four to six weeks. During this time you should not do any heavy lifting or straining. However, you should remain as active as possible, to speed up the recovery process.
Five to six weeks after surgery your PSA should fall to undetectable levels. Your PSA will be tested every three to six months in the first year following prostatectomy, and every six to 12 months after that.