Introduction
Radical prostatectomy is a major surgery for prostate cancer. It offers many men a chance to be cancer-free. The surgery removes the entire prostate gland and nearby tissues. Over the years, doctors have greatly improved this procedure.
If you’re facing a prostate cancer diagnosis, you need to understand all your treatment options. This guide covers everything about radical prostatectomy—from basic facts to the latest surgical methods. We’ll discuss recovery times and long-term results too.
Whether you’re considering this surgery, supporting someone who is, or just want to learn more, this guide will help answer your questions.
What Is Radical Prostatectomy?
Radical prostatectomy removes the entire prostate gland, seminal vesicles, and sometimes nearby lymph nodes. The prostate is a walnut-sized gland below the bladder. It surrounds the urethra, the tube that carries urine out of your body.
Dr. James Chen, Chief of Urologic Oncology at Pacific Medical Center, explains: “This surgery treats prostate cancer with the goal of cure. We call it ‘radical’ because we remove the whole gland along with its outer layer and sometimes nearby tissues. This helps ensure we get all the cancer.”
The main goal is to remove all cancer while trying to preserve the nerves that control urination and sexual function. Doctors usually recommend this surgery for men who have cancer that hasn’t spread beyond the prostate and who are expected to live at least 10 more years.
How the Surgery Has Evolved
Radical prostatectomy has changed a lot since the early 1900s. The first successful surgery through the perineum (area between scrotum and rectum) was done by Dr. Hugh Hampton Young in 1904 at Johns Hopkins Hospital.
In the 1940s, Dr. Terence Millin developed the approach through the lower abdomen. But these early surgeries often caused serious problems like urinary leakage and erectile dysfunction.
A major breakthrough came in the 1980s. Dr. Patrick Walsh created the nerve-sparing technique. “Walsh’s studies changed our understanding of the nerves that control erections,” notes Dr. Sarah Rodriguez from Northwestern University. “By saving these nerve bundles during surgery, we greatly improved quality of life for countless men.”
In the past 20 years, less invasive methods have developed:
- Laparoscopic surgery using small incisions began in the 1990s
- Robot-assisted surgery started in the early 2000s and is now very common
Types of Radical Prostatectomy
Surgeons can remove the prostate in several ways:
Open Surgery
Open surgery uses one larger cut to access and remove the prostate. There are two main approaches:
Through the lower abdomen: The surgeon makes a cut from the belly button to the pubic bone. This gives direct access to the prostate and nearby lymph nodes. It’s helpful when more extensive cancer removal is needed.
Through the perineum: The cut is made between the scrotum and rectum. This approach may cause less blood loss and allow faster recovery. However, it doesn’t allow access to lymph nodes and might slightly increase the risk of rectal injury.
Minimally Invasive Methods
Laparoscopic surgery: Instead of one large cut, the surgeon makes several small cuts. They use a thin tube with a camera (laparoscope) and special tools to remove the prostate. This typically causes less blood loss and allows faster recovery than open surgery.
Robot-assisted surgery: This enhances the laparoscopic approach. The surgeon controls robotic arms that translate hand movements into precise actions. The system provides a magnified 3D view and better control.
“Robot-assisted surgery has changed prostate cancer treatment,” explains Dr. Michael Wong, Director of Robotic Surgery at Memorial Cancer Institute. “The better view and precision help us save the important nerves and reconnect the bladder to the urethra more carefully. For many surgeons, this means better results for patients.”
According to the American Urological Association, no single surgical approach is clearly best for all patients. The choice depends on the surgeon’s experience, patient factors, and shared decision-making about the specific benefits and risks for each person.
Who Should Consider This Surgery
Radical prostatectomy is most often recommended for men with:
- Prostate cancer that hasn’t spread beyond the prostate (stages T1 or T2)
- A life expectancy of at least 10-15 years
- Good overall health to handle surgery
- No major medical reasons to avoid surgery
Some patients with locally advanced prostate cancer (stage T3) might have this surgery as part of a treatment plan that includes other therapies like radiation and/or hormone treatment.
Dr. Lisa Patterson, Clinical Professor of Urology, notes: “Choosing the right patients is key for good results. We look at not just the cancer details but also age, other health issues, and what side effects matter most to the patient. A healthy 75-year-old might be a better surgery candidate than a 65-year-old with serious heart disease.”
Several factors affect these discussions:
- PSA level: Lower PSA levels usually mean better surgical results
- Gleason score: Shows how aggressive the cancer is
- Clinical stage: Based on physical exam and imaging tests
- Overall health: Assessed through complete medical evaluation
- Personal preferences: How potential side effects might affect quality of life
Getting Ready for Surgery
Before radical prostatectomy, you’ll need to:
Complete Medical Tests
You’ll have a thorough checkup including:
- Complete physical exam
- Blood tests including PSA level
- Imaging studies (may include MRI, CT scan, or bone scan depending on your cancer risk)
- Heart evaluation if you have heart disease or risk factors
- Meeting with an anesthesia doctor
Follow Pre-Surgery Instructions
You’ll get specific instructions about:
- Which medications to stop (especially blood thinners)
- When to stop eating and drinking (usually after midnight before surgery)
- Bowel preparation (cleaning your bowels through diet, laxatives, or enemas)
- Arranging for someone to drive you home and help after discharge
“I urge patients to get in their best physical shape before surgery,” advises Dr. Thomas Franklin, a prostate cancer surgeon. “More exercise, better nutrition, and quitting smoking can really help recovery. I also recommend pelvic floor exercises before surgery to help with bladder control afterward.”
Prepare Mentally and Emotionally
The mental aspects of preparation matter too:
- Understanding the procedure, possible complications, and recovery process
- Setting realistic expectations about recovery time
- Arranging for support during recovery
- Considering joining a support group for men with prostate cancer
What Happens During Surgery
Radical prostatectomy is done under general anesthesia. You’ll be completely asleep. The surgery usually takes 2-4 hours, depending on the approach and complexity of your case.
Key Steps in the Procedure
Though techniques vary based on the surgical approach, radical prostatectomy generally includes:
- Access: Making a cut (open surgery) or small port placements (minimally invasive)
- Lymph node removal: Taking out pelvic lymph nodes for testing if needed based on cancer risk
- Prostate isolation: Carefully separating the prostate from surrounding structures
- Nerve preservation: Identifying and saving the nerves controlling erection when safe
- Prostate removal: Complete removal of the prostate gland and seminal vesicles
- Reconnection: Joining the bladder neck to the urethra
- Catheter placement: Inserting a urinary tube to allow healing
- Closure: Closing the cut(s) with stitches or staples
“The biggest technical challenge is achieving the triple goal: cancer control, urinary control, and preserving erectile function,” explains Dr. Robert Jenkins, who has performed over 1,000 radical prostatectomies. “Reconnecting the bladder to the urethra is especially critical—a watertight, tension-free connection is essential for quick return of urinary control.”
Nerve-Sparing Technique
When possible, surgeons use nerve-sparing techniques. These preserve the nerve bundles that run alongside the prostate and control erections.
“The decision to spare nerves depends on several factors, including cancer location, stage, and grade,” notes Dr. Jennifer Torres, urologic oncologist. “With modern imaging and diagnostic tools, we can better identify who is a good candidate for nerve preservation without compromising cancer control. However, when cancer extends close to or into these nerve bundles, complete cancer removal must come first.”
Recovery After Surgery
Recovery happens in several phases:
Hospital Stay
You’ll typically stay in the hospital:
- 1-2 days for robotic or laparoscopic surgery
- 2-3 days for open surgery
During this time, your care focuses on:
- Pain control
- Getting up and walking to prevent blood clots
- Watching for complications
- Managing your urinary catheter
First 1-2 Weeks at Home
You’ll go home with a urinary catheter. It usually stays in place for 7-14 days to allow healing where your bladder was reconnected to your urethra.
During this time, you should:
- Limit physical activity but gradually increase walking
- Avoid lifting heavy objects (nothing over 10 pounds)
- Take prescribed pain medications
- Care for your incision site(s)
- Manage your catheter and drainage bag
Dr. Elizabeth Murray, Director of Urologic Oncology Nursing, advises: “Proper catheter care is essential during early recovery. We provide detailed instructions on keeping the catheter secure, staying clean, and recognizing potential problems. Many men have bladder spasms with the catheter—medication can help with this discomfort.”
Weeks 2-6
After catheter removal, you’ll likely experience:
- Gradual improvement in bladder control
- Return to light daily activities
- Continued healing of surgical sites
“Most men have some urine leakage after catheter removal, which gets better over time,” explains Dr. Daniel Cohen, urologist. “I recommend bringing absorbent pads to your catheter removal appointment and continuing pelvic floor exercises. Patience is key—significant improvement usually happens within three months, though complete recovery may take longer.”
Weeks 6 to 1 Year
Complete recovery may take up to a year, with ongoing improvements in:
- Urinary control
- Sexual function
- Energy levels
- Return to full physical activities
During this time, you’ll have regular follow-up appointments to check PSA levels. This ensures the cancer hasn’t returned.
Possible Complications and Side Effects
While surgical techniques have improved greatly, radical prostatectomy still has risks.
Short-Term Complications
Early complications may include:
- Bleeding requiring blood transfusion (uncommon with modern techniques)
- Infection at the surgical site
- Blood clots in the legs or lungs
- Damage to nearby organs (rectum, bladder)
- Collection of lymphatic fluid
- Leakage or narrowing where the bladder is reconnected
Long-Term Side Effects
The most significant long-term concerns include:
Urinary incontinence: Loss of bladder control affects many men at first, with gradual improvement over time.
- About 80-90% of men regain good bladder control within one year
- Risk factors for ongoing incontinence include older age, obesity, and prior prostate procedures
- Treatment options range from pelvic floor therapy to surgical fixes like sling procedures or artificial sphincter placement
Erectile dysfunction (ED): The ability to get erections for sexual intercourse may be affected.
- Recovery rates vary widely based on age, function before surgery, and whether nerves were spared
- Most men notice gradual improvement over 1-2 years
- Treatment options include oral medications (like Viagra), vacuum devices, injections, and penile implants
Dr. Richard Brooks, sexual health specialist, emphasizes: “Open communication about sexual function is crucial. Many men hesitate to discuss erectile difficulties, but early treatment improves outcomes. We typically recommend starting erectile rehabilitation soon after catheter removal, rather than waiting for spontaneous recovery.”
Other possible side effects include:
- Changes in orgasm sensation (dry orgasm due to lack of ejaculate)
- Penile shortening (typically 1-2 cm)
- Inguinal hernia (occurs in about 15-20% of men)
- Lymphedema (swelling in the legs or genital area)
Cancer Control Results
The main goal of radical prostatectomy is cancer control. Results depend on several factors.
Cancer Control Rates
Long-term studies show good cancer control with radical prostatectomy:
- 10-year survival without PSA rise: 70-85% overall
- Cancer-specific survival at 15 years: About 95% for cancer contained in the prostate
“Patient selection and cancer characteristics strongly affect outcomes,” notes Dr. Helen Martinez, oncologist. “Men with favorable pathology—cancer confined to the prostate, clean surgical margins, and lower Gleason scores—have excellent long-term cancer control. For those with adverse features, additional treatments like radiation therapy may be needed.”
Factors affecting cancer control include:
- Surgical margins: Whether cancer cells are found at the edge of the removed tissue
- Extension beyond the prostate: Cancer extending beyond the prostate capsule
- Seminal vesicle invasion: Cancer spreading to the seminal vesicles
- Lymph node involvement: Cancer detected in removed lymph nodes
- PSA level and Gleason score before surgery
PSA Monitoring After Surgery
After radical prostatectomy, PSA levels should drop to undetectable levels (typically <0.1 ng/mL) since the entire prostate has been removed.
- Regular PSA testing occurs every 3-6 months at first, then yearly if stable
- A detectable or rising PSA may indicate cancer return
- “Biochemical recurrence” is typically defined as a PSA ≥0.2 ng/mL on two consecutive measurements
Managing Cancer Recurrence
If PSA rises after surgery, options may include:
- Radiation therapy to the prostate bed
- Hormone therapy
- Observation with continued monitoring (for very slow rises in older men)
- Clinical trials of newer therapies
Comparing Surgery to Other Treatments
Prostate cancer treatment options vary based on cancer features and patient factors. Major alternatives include:
Active Surveillance
For very low-risk or low-risk prostate cancer, monitoring rather than immediate treatment may be appropriate.
“Active surveillance isn’t simply ‘doing nothing,'” clarifies Dr. William Taylor, Director of the Prostate Cancer Program. “It’s a structured program of regular PSA testing, periodic biopsies, and sometimes MRI imaging to monitor the cancer closely. About one-third of men on active surveillance eventually need treatment, but this approach spares many men unnecessary treatment side effects.”
Compared to radical prostatectomy, active surveillance:
- Avoids treatment side effects
- Requires ongoing monitoring and possible repeat biopsies
- May cause anxiety about living with untreated cancer
- Is generally recommended only for lower-risk disease
Radiation Therapy
External beam radiation therapy (EBRT) and brachytherapy (internal radiation) are important alternatives.
Compared to surgery, radiation therapy:
- Avoids surgical risks and hospital stay
- May cause different side effects (e.g., bowel problems, gradual onset of erectile dysfunction)
- Typically delivers radiation over several weeks (EBRT) or in one or two outpatient procedures (brachytherapy)
- Makes later surgery technically challenging if cancer returns
According to a major clinical trial—the ProtecT study—overall survival rates at 10 years were similar between surgery, radiation therapy, and active monitoring for localized prostate cancer. However, surgery and radiation reduced disease progression compared to monitoring.
Other Treatment Options
Additional approaches include:
- Focal therapy: Targeted treatment of specific areas of cancer within the prostate
- Hormone therapy: Primarily for advanced disease but sometimes combined with other treatments
- Cryotherapy: Freezing of prostate tissue to destroy cancer cells
- High-intensity focused ultrasound (HIFU): Using ultrasound energy to heat and destroy cancer cells
“Treatment selection should be personalized based on cancer risk, patient age and health status, and personal preferences regarding potential side effects,” advises Dr. Amanda Williams, radiation oncologist. “Discussion with both urologic surgeons and radiation oncologists provides the most comprehensive guidance.”
Quality of Life After Surgery
Quality of life is a key factor in prostate cancer treatment decisions.
Physical Recovery
Physical recovery typically follows this timeline:
- 1-2 weeks: Basic daily activities
- 3-4 weeks: Light work and driving
- 6-8 weeks: More strenuous activities
- 3-6 months: Full physical recovery for most men
“I tell patients that while they may feel good within a few weeks, internal healing takes longer,” says Dr. Patricia Johnson, rehabilitation specialist. “Gradually increase activity based on how you feel, but avoid heavy lifting for 6-8 weeks to protect the healing reconnection.”
Psychological Impact
The psychological aspects of recovery are equally important:
- Worry about cancer control
- Changes in self-image and sexual confidence
- Depression related to side effects
- Relationship changes
“The emotional impact of prostate cancer treatment is significant but often overlooked,” notes Dr. Mark Thompson, psycho-oncologist. “Men typically focus on physical recovery and may struggle to express feelings about changes in urinary function or sexuality. Supportive partners, counseling, and support groups can be very helpful.”
Returning to Normal Activities
Most men can expect to:
- Return to work within 3-6 weeks (depending on job physical demands)
- Resume driving once off pain medications and physically comfortable
- Restart sexual activity after catheter removal and when comfortable (typically 4-6 weeks)
- Return to exercise gradually, with full activities by 3 months
Recent Advances and Future Directions
Prostate cancer surgery continues to evolve rapidly.
New Technology
Recent advances include:
- Single-port robotic systems: Allowing all instruments to enter through a single incision
- Fluorescence-guided surgery: Using special dyes to better see crucial structures
- Augmented reality systems: Overlaying pre-operative imaging onto the surgical field
“Using MRI and molecular imaging in surgical planning is a major advance,” explains Dr. Thomas Lee, researcher in urologic oncology. “This allows more precise identification of tumor location and extent, potentially improving both cancer control and functional outcomes.”
Personalized Approach
Treatment is becoming more tailored to individual patients:
- Genomic testing to assess cancer aggressiveness
- Advanced imaging to map cancer location within the prostate
- Artificial intelligence tools to predict outcomes and optimize treatment selection
Ongoing Research
Active areas of research include:
- Focal therapy approaches that target only the cancer while sparing healthy prostate tissue
- Novel nerve-regeneration techniques to improve post-operative erectile function
- Enhanced recovery protocols to speed return to normal activities
- Combination therapies for high-risk disease
Making an Informed Decision
Choosing the right treatment approach requires careful thought about multiple factors.
Key Considerations
Important factors in the decision-making process include:
- Cancer characteristics (stage, grade, PSA level)
- Age and overall health status
- Existing urinary or sexual function
- Personal preferences regarding potential side effects
- Surgeon experience and hospital quality measures
- Recovery time considerations
- Financial and insurance factors
Questions to Ask Your Doctor
Dr. Rachel Morris, patient advocate and prostate cancer educator, suggests asking:
- What is my risk category, and what treatment options are appropriate?
- If I choose surgery, what is your experience with radical prostatectomy?
- Would you recommend a nerve-sparing approach in my case?
- What are my personal risks for incontinence and erectile dysfunction?
- What is your patients’ experience with recovery and return to normal activities?
- If cancer is found outside the prostate, what additional treatments might I need?
- How many of these procedures do you perform annually, and what are your outcomes?
Getting a Second Opinion
Given the complexity of prostate cancer treatment decisions, second opinions are often valuable.
“I always encourage patients to seek additional viewpoints, particularly from different specialties,” recommends Dr. Samuel Green, Chief Medical Officer at Prostate Cancer Foundation. “Consulting with both a urologist and a radiation oncologist provides perspective on different treatment options. This isn’t about questioning the first doctor’s judgment but about ensuring you fully understand all your options.”
Frequently Asked Questions
How long does the surgery take? Radical prostatectomy typically takes 2-4 hours. The time depends on the surgical approach, your anatomy, and whether lymph node removal is performed.
Will I need blood transfusions? With modern surgical techniques, especially robotic and laparoscopic approaches, blood transfusions are rare. They occur in less than 5% of cases.
How painful is recovery from radical prostatectomy? Pain levels vary by person and surgical approach. Minimally invasive procedures generally cause less post-operative pain. Most pain is well-controlled with oral medications and improves significantly within a week.
How soon after surgery will I know if all the cancer was removed? The pathology report, typically available 5-7 days after surgery, will show whether cancer was found at the surgical margins. However, PSA monitoring over time provides the ultimate assessment of cancer control.
If I choose surgery, can I have radiation therapy later if needed? Yes. If cancer returns after surgery, salvage radiation therapy is a standard option. It works best when given early at the first signs of PSA rise.
Will I be incontinent forever after surgery? Permanent severe incontinence is uncommon. Most men have some degree of incontinence right after catheter removal. This typically improves substantially within 3-6 months, with continued improvement up to one year. Fewer than 5-10% of men need surgical intervention for persistent incontinence.
When will my erectile function return after surgery? Recovery of erectile function varies widely based on age, function before surgery, and surgical technique. Some men notice erections within weeks. For others, recovery may take up to 2 years. Erectile rehabilitation programs, starting shortly after catheter removal, may improve outcomes.
What happens to fertility after radical prostatectomy? Radical prostatectomy causes infertility. The prostate and seminal vesicles, which produce much of the seminal fluid, are removed. Men wishing to father children should consider sperm banking before surgery.
Do all men need radical prostatectomy for prostate cancer? No. Treatment recommendations depend on cancer risk, age, overall health, and personal preferences. Many men with low-risk prostate cancer can choose active surveillance rather than immediate treatment.
Conclusion
Radical prostatectomy is an effective treatment option for many men with prostate cancer. It offers excellent long-term cancer control. The procedure has improved greatly over the decades. New surgical techniques and technology have reduced complications and improved functional outcomes.
If you’re diagnosed with prostate cancer, the decision to have radical prostatectomy should come after careful thought. Consider your cancer details, personal health factors, possible impacts on quality of life, and available alternatives. The “best” treatment varies by individual. A personalized approach—guided by an experienced healthcare team and informed by your priorities—is essential.
Research continues to advance in this field. We can expect further improvements in surgical techniques, better prediction of individual outcomes, and more tailored approaches to prostate cancer management. These developments will help balance cancer control and quality of life—the main goal of prostate cancer treatment.