Radical prostatectomy is most often done when the cancer has not spread outside of the prostate gland. The surgery removes the prostate gland, as well as the glands that produce the fluid part of semen (seminal vesicles). The surgeon also may remove nearby lymph nodes during the procedure to test them for cancer.

There are four main types of radical prostatectomy surgery:

• Radical retropubic prostatectomy
• Radical perineal prostatectomy
• Laparoscopic radical prostatectomy (LRP)
• Robotic assisted LRP

For these procedures, you will either be asleep (under general anesthesia ), or given medicine to numb the lower half of your body (spinal or epidural anesthesia).

RADICAL RETROPUBIC PROSTATECTOMY

During this procedure, the surgeon will make a surgical cut starting just below your belly button and reaching to the pubic bone.

The surgeon will remove your prostate gland, taking care to preserve the nerves on either side of the prostate that control erections (called nerve-sparing surgery). The surgeon also might take out nearby lymph nodes if there is a chance that the cancer has spread. A tube (catheter) is placed in the penis to drain fluids while you heal. The entire surgery should take 90 minutes to 4 hours.

RADICAL PERINEAL PROSTATECTOMY

In this procedure, the surgeon makes a surgical cut in the skin between the anus and base of the scrotum (the perineum). Because the cut is smaller than with the retropubic technique, it is harder for the surgeon to spare the nerves around the prostate, or to remove nearby lymph nodes. For these reasons, this surgery is not used as often as retropubic prostatectomy.

Perineal surgery usually takes less time to complete than the retropubic approach.

LAPAROSCOPIC SURGERY

With this technique, the surgeon makes several small cuts instead of one big cut. Long, thin instruments are placed inside the cuts. A thin, lighted tube with a video camera (laparoscope) is placed inside one of the cuts to help the surgeon see inside the abdomen during the procedure. It is possible to spare the nerves around the prostate and remove lymph nodes with this surgery.

ROBOTIC LRP

Sometimes laparoscopic surgery is done using a robotic system (called the da Vinci system). The surgeon moves the robotic arm while sitting at a control panel near the operating table. The robotic arm can give the surgeon more precise control over the surgery.

However, robotic surgery is not available in every hospital. It is not yet as well proven as older methods of removing the prostate gland. Robotic surgery has not been shown to have a better outcome or fewer side effects than other surgical options.

Radical prostatectomy is only recommended for men who:

• Are in generally good health and can tolerate anesthesia
• Have prostate cancer that has not spread outside of the prostate gland
• Have a life expectancy of 10 or more years

Risks associated with radical prostatectomy include:

• Difficulty controlling urine (urinary incontinence )
• Inability to have an erection (impotence )
• Heart attack
• Stroke
• Blood clots in the legs

Choosing an experienced surgeon can reduce the risks.

Risks for any anesthesia are:

• Reactions to medications
• Problems breathing

Risks for any surgery are:

• Bleeding
• Infection

You will go home with the catheter still inserted to drain urine. The urine may have blood in it for a few days after the surgery. The catheter will be removed within 1 - 3 weeks after you leave the hospital.

The surgery should remove all of the cancer cells, but your doctor will watch you carefully to make sure the cancer does not come back. You should have regular checkups, including PSA blood tests, and MRI and CT scans, if needed.

The hospital stay after radical prostatectomy is about 1 - 4 days. Complete recovery from surgery can take 3 weeks.

Drink at least 8 ounces of water a day, eat a lot of roughage, and take stool softeners to prevent constipation.

After your catheter is removed, you may have some urine leakage (incontinence). This should improve over time. You should regain normal bladder control within 3 - 6 months.

Avoid heavy lifting or strenuous exercise for 3 - 4 weeks after surgery. After that, you can slowly work back up to your normal exercise routine.

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Thompson I, Thrasher JB, Aus G, Burnett AL, Canby-Hagino ED, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol. 2007;177:2106-2131.

Meng MV, Carroll PR. Treatment of Locally Advanced Prostate Cancer. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 102.

Berryhill R, Jhaveri J, Yadav R, et al. Robotic prostatectomy: a review of outcomes compared with laparoscopic and open approaches. Urology. 2008;72:15-23.