Radical Prostatectomy

The prostate is a gland below the bladder that surrounds the urethra and produces part of the fluid in semen. In radical prostatectomy the surgeon removes the whole gland with the cancer inside it, the seminal vesicles attached to it and, depending on the risk of spread, the lymph nodes in the pelvis. The bladder is then reconnected to the urethra, a join called the anastomosis, around a catheter that stays while it heals. The word radical refers to removing the entire organ, unlike operations for benign enlargement that remove only the inner part. In robot-assisted surgery the surgeon sits at a console and controls instruments and a magnified three-dimensional camera through small cuts in the abdomen; laparoscopic surgery uses similar small cuts with hand-held instruments; open surgery uses one cut below the navel. A nerve-sparing technique preserves the delicate bundles of nerves for erection that run along the surface of the prostate, when the cancer allows it.

Radical prostatectomy is mainly recommended for prostate cancer that is confined to the gland, called localised cancer, and in selected men for cancer that extends just outside it, called locally advanced cancer, when the expected benefit of removing the cancer outweighs the side effects. It is often considered for men in good health with a life expectancy of at least about ten years and intermediate or high-risk disease, judged from the PSA level, the Gleason score or grade group on biopsy, and the MRI. For low-risk cancer, active surveillance with regular PSA tests, MRI and repeat biopsies is often the preferred first approach, because many such cancers grow slowly. Radiotherapy, with or without hormone treatment, is an alternative with similar cancer control in many situations and a different pattern of side effects. A review by a urologist and a radiation oncologist helps you compare options. Surgery is not usually used when the cancer has spread to bones or distant organs.

The operation is done under general anaesthesia. In the robot-assisted approach, the surgeon makes about five or six small cuts in the abdomen, fills it with carbon dioxide gas and docks the robotic arms, then operates from a console with a magnified view. You are tilted head-down to give access to the pelvis. The surgeon separates the bladder neck from the prostate, frees the prostate from the rectum behind it and, where safe, peels the nerve bundles away from its surface. The urethra is divided below the prostate, and the gland and seminal vesicles are removed in a bag through one of the cuts. Pelvic lymph nodes may be removed at the same time. The bladder is then stitched to the urethra over a catheter, and a drain may be left for a day or so. The operation usually takes about 2 to 4 hours. Open surgery follows the same steps through a lower abdominal incision.

Good candidates are men with localised or selected locally advanced prostate cancer who are fit for a long operation under general anaesthesia in the head-down position. Previous abdominal surgery, obesity and a large prostate make the operation more demanding but do not usually rule it out. Preparation includes reviewing the biopsy and an MRI of the prostate and, for higher-risk cancer, often a PSMA PET scan or a bone scan to check for spread. Your surgeon discusses whether nerve sparing is possible on one or both sides, based on where the cancer lies. Pelvic floor muscle exercises started a few weeks before surgery help bladder control afterwards, and some teams involve a physiotherapist. Blood thinners are adjusted on medical advice. International patients can usually send biopsy reports, MRI images and PSA results in advance, and many hospitals ask for the biopsy slides to be reviewed by their own pathologists.

After robotic or laparoscopic surgery you are usually walking the same day or the next, eating soon after, and in hospital for 1 to 3 nights. You go home with the catheter, which stays for about 1 to 2 weeks while the join between bladder and urethra heals; some teams check it with an X-ray dye test before removal. Expect tiredness, some abdominal and shoulder-tip discomfort and bruising for the first weeks. Desk work is usually possible after about 2 to 4 weeks and heavy lifting after about 6 weeks. When the catheter comes out, most men leak urine at first and use pads while continuing pelvic floor exercises. For travel, plan to stay about 2 to 3 weeks, so that the same team removes the catheter, checks early bladder control and discusses the final pathology report with you. Agree in advance who will check your PSA and support your recovery near home.

Radical prostatectomy is a major operation, and two side effects matter most to most men. Urinary incontinence is common at first; bladder control usually improves steadily over weeks to months with pelvic floor exercises, and most men regain good control, although some keep a small leak when coughing or lifting and a few need further treatment such as a sling or an artificial sphincter. Erectile dysfunction is very common early on; when nerves are spared, erections can return gradually over one to two years, often helped by tablets or other treatments, but recovery is less likely without nerve sparing or when erections were already weak. After surgery there is no ejaculation and natural fertility ends. General risks include bleeding, infection, blood clots, injury to the bowel or ureter, a leak at the join and, later, narrowing of the join. The PSA should fall to an undetectable level; a rising PSA may need further treatment such as radiotherapy.