Surgery for prostate cancer

Radical prostatectomy may be performed using different surgical techniques. There may be extra costs involved for some options and they are not all available at every hospital.

Open radical prostatectomy − This is usually done through a cut in the lower abdomen.

Laparoscopic radical prostatectomy − Sometimes the prostate can be removed via keyhole surgery (also called laparoscopic surgery). Small surgical instruments are inserted through several small cuts in the abdomen, and the surgeon performs the procedure by moving the instruments while watching a screen.

Robotic-assisted radical prostatectomy − Laparoscopic surgery can be performed using a robotic device, which allows the surgeon to see a three-dimensional picture and to use more advanced instruments than those used for conventional laparoscopic surgery. This is called robotic-assisted laparoscopic radical prostatectomy or RARP.

Nerve-sparing radical prostatectomy − This involves removing the prostate and seminal vesicles and trying to preserve the nerves that control erections. This procedure is more suitable for lower grade cancers and is only possible if the cancer is not in or close to these nerves. It is best performed on younger men who have good erectile function. Problems with erections are common even if nerve-sparing surgery is performed, but these can be managed.

Radical prostatectomy to remove the prostate

Talk to your surgeon about what types of surgery are available to you. Ask about the advantages and disadvantages of each option, and if you will have any out-of-pocket costs.

The surgeon’s experience is more important than the type of surgery offered. Compared to open surgery, both standard laparoscopic surgery and robotic-assisted surgery usually mean a shorter hospital stay, less bleeding, a smaller scar and a faster recovery. However, there is currently no good, long-term evidence that one approach causes fewer ongoing side effects or better cancer outcomes.

Whichever surgical approach is used, a radical prostatectomy is major surgery and requires time to recover.

You can expect to return to usual activities 4–6 weeks after surgery for prostate cancer. Most men can start driving again within a couple of weeks, but heavy lifting should be avoided for six weeks. You may experience some or all of the following side effects:

Nerve damage – The nerves needed for erections and the sphincter muscle required for bladder control are both close to the prostate. It may be very difficult to avoid these during surgery, and any damage can cause problems with erections and bladder control.

Loss of bladder control – You may have some trouble controlling your bladder after a radical prostatectomy. This condition is known as urinary incontinence. It usually improves a few months to a year after the surgery. A small number of men (about 5%) may be left with ongoing incontinence, which could need a further operation to fix. In rare cases, the incontinence may be permanent. There are various ways to manage these problems, so it is worth seeing a continence physiotherapist or continence nurse before the surgery, or soon afterwards. In particular, pelvic floor exercises can help improve bladder control.

Erection problems (impotence) – Many men experience problems getting and keeping erections after prostate surgery. It may take some months to a few years for erections to improve. Some men may not get strong erections again. Oral medicines, vacuum erection devices, injection therapy or implants may help if you have ongoing problems with erections.

Infertility – During a prostatectomy, the tubes from the testicles (vas deferens) are sealed and the prostate and seminal vesicles are removed, so semen is no longer ejaculated during orgasm. This is known as a dry orgasm and results in infertility. If having children is important to you, talk to your doctor before treatment about sperm banking or other options.

Penile shortening – In some men, the penis gradually becomes shorter after surgery. Regularly using a vacuum erection device can help maintain penis length. You can see a psychologist or counsellor for assistance coming to terms with any changes to the appearance of your penis.

Watch this short video to learn more about surgery.