Surgery: Radical Prostatectomy

You can download this page as a PDF file.

This page is for men who are thinking about, or have been recommended, surgery to treat their prostate cancer. It is one of several fact sheets that have been written to help you decide which treatment is best for you. It describes the operation to remove the prostate gland (radical prostatectomy), which can be done through an opening in the abdomen (retropubic) or through the area between the testicles and the back passage (perineal). This page does not cover the keyhole operation (laparoscopic prostatectomy).

Who can have surgery?
How does surgery treat prostate cancer?
What are the benefits and risks?
What are the side effects?

Erectile dysfunction
Infertility
Urinary incontinence
Bladder neck obstruction

What does treatment involve?

Before the operation
The operation
After the operation

What happens afterwards?

Care of your catheter
Your wound
Constipation
Your follow-up appointment
Going back to work
Driving
Sexual activity
When to call your GP

Questions to ask your doctor

Who can have surgery?

Surgery can be used to treat early prostate cancer that is thought to be contained within the prostate gland. It is usually offered as a good option to fit, healthy men under the age of 70. This is because men over this age are more likely to have other competing health problems, such as heart disease, that increase the risks of surgery.

Older men also, in general, experience more problems after surgery than younger men. When you discuss possible treatments with your doctors, your individual medical history and personal wishes will be taken into account. You should be given an opportunity to discuss all of your treatment options with several specialists before making your final choice.

How does surgery treat prostate cancer?

The aim of surgery is to take out the cancer, as long as it is contained within the prostate gland, and to stop it spreading to other parts of the body. This is done by removing the whole prostate gland and the seminal vesicles, which make some of the fluid of semen.

Some surgeons also remove the lymph nodes, which are part of the immune system. They may be removed if there is a risk the cancer has spread there. However, this is no longer done routinely because many cancers are detected early when the risk of spread into the lymph nodes is very low. Your surgeon should discuss this with you before your operation.

Back to the Top

What are the benefits and risks?

The benefits and risks of surgery depend on your age, health and stage of disease. Your surgeon should discuss your individual situation and options with you.

Benefits

You may be cured if the cancer is contained within the prostate gland and is completely removed
You and your doctor will find out exactly how far the cancer has developed
It will also treat BPH (non-cancerous enlargement of the prostate) and its symptoms

Risks

Prostate surgery carries the same risks as any major operation such as:

bleeding and the need for a blood transfusion
injury to nearby tissues and nerves
chest infection
blood clots in the lower leg that could travel to the lung
wound infection

This operation carries a risk of side effects. See below for more information
If the cancer has broken out of the prostate gland, it may not be possible to remove all of it and some cancer cells may be left behind. These can be treated at a later date with radiotherapy, hormone therapy or a combination of both if the PSA starts to rise.

Back to the Top

What are the side effects?

The most common side effects of surgery are urinary incontinence and erectile dysfunction. Not all men will get any or all of the side effects described here and in general, there is no way of knowing who will be affected. Ask your surgeon for more information on the risk of side effects. He or she should be willing to show you their results and to put you in touch with other patients. You can also call our Helpline on 0800 074 8383.

Erectile dysfunction

Your surgeon may try to save the nerves that control erections but even if this is possible, there is no guarantee that it will prevent erection problems. Some surgeons prescribe tablets in the first few weeks after surgery to help men recover their erections.

Your erections should improve with time but it will depend on how strong they were before surgery. At first, most men find it difficult to get an erection strong enough for intercourse¹ and it can take anything from a few months to a couple of years for erections to return. Erections are rarely as good as they were before surgery and some men will never get back the ability to maintain an erection without the help of artificial methods.

For more information on erectile dysfunction and its treatments, read our page on Sexuality and prostate cancer and visit The Sexual Dysfunction Association.

Infertility

The prostate and seminal vesicles, which produce and store some of the fluid in semen, are removed during the operation. You will still be able to experience orgasm (climax) but you will not ejaculate any semen. This is called a ‘dry’ orgasm and means that you will be infertile after the operation. If you are planning on having children, you may be able to store your sperm before the operation for use in IVF (in vitro fertilisation). If this is important to you, ask your surgeon if this option is available locally.

Back to the Top

Urinary incontinence

Continence problems range from small drips to leaking larger amounts of urine, which can be managed with a variety of different sized continence pads. Continence will improve with time and most men will be dry three to six months after surgery. A small number of men (less than five per cent²) will have long term problems and may not have any control over their urine flow. These men may need treatment with drugs or further surgery to help this problem.

You can improve your chances of regaining control of your bladder more quickly by practising pelvic floor exercises before and after the operation. Some doctors recommend that pelvic floor exercises are not done while the catheter is in place, while others advise that they can be done with care. Ask your doctor for help and advice. You will need to keep doing the exercises for weeks or months. It can be disheartening if you do not see results straight away but they will make a difference in the end.

For details of pelvic floor exercises and the devices available to help you manage continence problems, read our page on Continence Management. You can also call our confidential Helpline on 0800 074 8383 or visit the Continence Foundation.

Bladder neck obstruction

A small number of men have problems passing urine after surgery due to the build up of scar tissue around the neck of the bladder^3,4. Contact your doctor if you have these symptoms. The scar tissue can be ‘stretched’, or released under a short general anaesthetic. Occasionally this may need to be repeated a few times, but is usually successful in the long term.

Back to the Top

What does treatment involve?

Before the operation

To make sure you are fit for the anaesthetic you will have a blood test, heart tracing (ECG), chest X-ray and physical examination. This is called a pre-assessment visit and is a good time to ask any remaining questions you may have about the operation.

You will be admitted to the hospital ward on the day of your operation, or the day before. The nurses and doctors will introduce themselves and answer any questions you may have. The anaesthetist is also responsible for your pain relief after the operation and will explain how this will work. Your surgeon will ask you to sign a consent form to state that you have been fully informed of all your treatment options and any alternative treatments, and that you understand what the surgery involves and wish to go ahead with it.

You will not be able to eat or drink for six hours before the operation. If you need to take regular medication, ask the nursing or medical staff for advice. You will be given some elastic stockings to wear, which reduce the chance of blood clots forming in your legs from inactivity during and after the operation. You will keep these on until you are moving around normally again.

The operation

The operation takes between two and four hours. You will be given a general anaesthetic so you will be asleep during the whole process and will not feel anything. You may also have an epidural for pain relief after surgery. You may need to be given donated blood (blood transfusion) during the operation.

If you are having a retropubic radical prostatectomy, the surgeon will make a vertical or horizontal cut in your lower abdomen, below the belly button. If you are having a perineal prostatectomy, a cut will be made in the area between your testicles and your back passage. The type of operation you have will depend on your surgeon’s preference. Ask which type of operation you will be having. The surgeon may try to use nerve-sparing surgery that avoids damaging the bundles of nerves that control your erections. However, this is not always possible because the nerves are attached to the back of the prostate, which is the most likely place for prostate cancer to grow outside the prostate.

Back to the Top

After the operation

You will be taken to the recovery room until you are fully awake before going back to the ward. You will have a number of tubes in place when you wake up:

You may have a small tube running through your nose into your stomach to allow any extra fluid to be drained from your stomach while the anaesthetic is wearing off. This helps to prevent sickness. This will be the first tube to be removed
A drip, usually placed in your arm or hand to give you fluid whilst you are not allowed to drink. This will be removed once you are eating and drinking normally
A small tube (drain) in your wound to drain away any fluid. This tube will be removed before you go home
A catheter to drain urine from your bladder, along your penis to a bag which hangs on the side of your bed, or which can be carried around with you. Most men go home with the catheter in place, attached to a bag that can be worn inside your trousers, strapped to your thigh. During this time, you may be asked to take a low dose of an antibiotic every day. The catheter is usually removed after one to two weeks.

For the first few days in hospital after the operation, you will be given a continuous painkiller either into the spine (epidural), or into a vein in your arm (intravenous). Painkillers given into the vein use a patient controlled analgesia (PCA) pump so that you can top up your pain relief if necessary. You will be shown how to use this.

Once you are able to eat and drink normally you will be given painkilling tablets instead, which you can continue to take at home. Let your nurse know if you are in any pain so that they can find the right type and amount of painkiller for you. You may find that it hurts towel or pillow over the wound at these times.

Your stitches or clips will be removed after seven to 14 days, usually by a community (practice or district) nurse once you have gone home. You can safely shower about five to six days after the operation. After washing, dry the wound by patting it gently with a towel as the skin may not have healed firmly at this stage. You may have swelling in your scrotum and penis but this should go down after a few days. You may find the tighter fit of underpants more supportive and comfortable than boxer shorts. Some men notice that their penis seems slightly shorter after the operation. The cause of this is not fully understood, but may have something to do with the way the wound was closed.

The length of time you spend in hospital depends on your doctor and your recovery but is usually between four and six days.

What happens afterwards?

Back to the Top

Care of your catheter

Before you leave hospital, the nurse will show you how to look after your catheter. It may be possible for you to have a smaller bag than you had in hospital, which can be strapped to your leg so that you can move around easily. You may be referred to a community nurse who will keep an eye on how your wound is healing and help you to look after your catheter. Tell the district nurse if you notice any urine leaking from the outside of the catheter.

It is important to keep the tip of your penis clean to prevent irritation and redness. Use plain mild soap and water to remove any crusting and make sure the foreskin, if present, is moved forward again after cleaning. You may notice some bloody fluid seeping out around the catheter when you open your bowels. This is normal, but if there is a lot of bleeding you should contact your GP.

Before you go home, you will be given details of where and when your catheter will be removed. This is usually at an outpatient appointment around two weeks after the operation. You may find this uncomfortable but it is not painful. You will need to visit the hospital for several hours so that the medical staff can make sure you can pass urine without any problems. You will probably find that you leak anything from a few drops to a larger amount of urine, and this can continue for a few months. You may want to buy some continence pads from the chemist and take these with you when the catheter is removed, along with a clean pair of underpants. It is also helpful to wear loose fitting trousers or jogging bottoms during this time.

Your wound

The scar from the operation will shrink and fade over time. The muscle and tissue inside your body also has to heal and this may take several months. A healthy diet helps the wound healing process. Get plenty of rest in the first couple of weeks. After this time, gentle exercise, such as a short walk every day, will help you recover but avoid climbing too many stairs, lifting heavy objects or doing manual work for eight weeks after the operation.

Constipation

You may have no bowel movements for several days after surgery, but if this carries on you may need a laxative. Ask your doctor or GP for advice. To prevent constipation eat high fibre foods such as bran, prunes or apples. Drink at least eight glasses of non-alcoholic fluid each day until your catheter is removed to help prevent infection.

Your follow-up appointment

You will have a follow-up appointment around three months after surgery. This is an opportunity for you to discuss any problems you are having, such as continence problems or erectile dysfunction. Your first PSA result after surgery should be available at this appointment. If the operation has been successful the PSA level will drop to less than 0.1 nanograms per millilitre of blood. Some men will find that their PSA begins to rise several months or years after surgery. Further treatment such as radiotherapy and hormone therapy can lower the PSA again. If you would like to keep track of your PSA results, contact us for a PSA record card.

Waiting for PSA test results can be very stressful and you may need support from friends and family. Contact our Helpline on 0800 074 8383 for support.

Going back to work

Most men return to work within six to eight weeks⁵, but this will depend on how much physical effort your work involves. If you do work, ask your doctor for advice on how much time you will need to take off.

Driving

Most men are able to drive a car after four weeks but you will be able to sit in a car as a passenger while your catheter is still in. Avoid long journeys for the first two weeks after the catheter is removed to give yourself a chance to deal with any continence problems with confidence.

Sexual activity

Sexual intercourse is not recommended during the first six to eight weeks after the operation while the wound is healing⁵. Passive sexual stimulation is fine during this time. Your doctor may recommend tablets to help you gain erections as early as four weeks after surgery. For more information on this, read our page on Sexuality and prostate cancer.

When to call your GP

You should contact your GP as soon as possible if you have any of the following:

Your urine contains blood clots or turns red
Your catheter falls out
Urine stops draining out of the catheter and your bladder feels full
Your wound edges become red, swollen or painful. This can be a sign of infection
You get pain or swelling in your legs
You get sudden chest pain
You have a temperature of more than 38ºc or 101ºf
You feel sick (nauseous) or vomit
You get cramps in your stomach that won’t go away

Back to the Top

Questions to ask your doctor

Will you do retropubic or perineal surgery?

How long does the operation take?

Will I have a blood transfusion?

How many of these operations do you do a year? (Each treatment centre should do more than 50 a year²)

Will you remove the lymph nodes?

Will you try to do nerve-sparing surgery if possible?

In your experience, how successful is surgery on its own at curing prostate cancer?

How many of your patients need extra treatment for cancer after surgery?

How many of your patients develop incontinence and erectile dysfunction?

How long should I expect to be in hospital?

What pain relief will I get after the operation?

If I go home with a catheter, who will remove it and when?

When is my first appointment after I go home?

If I have continence or erectile problems after surgery, who should I contact for help?

How often will my PSA be checked?

What should the PSA be after surgery? What would happen if it didn’t reach that level?

Back to the Top

Sources used in the compilation of this page

1 BMJ Publishing Group. Best treatments: Prostate cancer: surgery (radical prostatectomy); 2005.

2 Royal College of Radiologists Clinical Oncology Information Network, British Association of Urological Surgeons. Guidelines on the management of prostate cancer; 1999.

3 Besarani D, Amoroso P, Kirby R. Bladder neck contracture after radical retropubic prostatectomy. BJU Int. 2004; 94(9): 1245-1247

4 Potter SR, Partin AW. The Clinical management of prostate cancer: the surgeon’s approach and outcomes. In Abel PD, Lalani EN (eds) Prostate cancer clinical and scientific aspects: bridging the gap. London: Imperial College Press; 2003. pp811-831

5 Kirby RS. The prostate: small gland big problem. 2nd ed. Oxford: Prostate Research Campaign UK. 2002.

Reviewed by:

Declan Cahill, Consultant Urologist, Guy's Hospital
Janette Nichol, Prostate Clinical Nurse Specialist, Guys and St Thomas NHS Foundation Trust
Mr Anup Patel, Consultant Urologist, St Mary’s Hospital, London
Ingrid Spickett, Support and Information Specialist Nurse, The Prostate Cancer Charity
The Prostate Cancer Charity Helpline nurses
The Prostate Cancer Charity Information Volunteers

The Prostate Cancer Charity makes every effort to make sure that its services provide up-to-date, unbiased and accurate facts about prostate cancer. We hope that these will add to the medical advice you have had and will help you to make any decisions you may face. Please do continue to talk to your doctor if you are worried about any medical issues.

Page last updated: September 25th 2006