Prostatectomy — Procedure Guide, Recovery & Risks | MyMedicPlus

Radical prostatectomy is the surgical removal of the entire prostate gland, bilateral seminal vesicles, and the proximal vas deferens for localised or locally advanced prostate cancer. It is performed via three surgical approaches: open retropubic prostatectomy (via a lower abdominal incision), laparoscopic prostatectomy, or the now-predominant robotic-assisted laparoscopic prostatectomy (RARP, also called da Vinci prostatectomy). RARP is performed at high-volume urological cancer centres in over 85% of radical prostatectomies worldwide due to its high-definition 3D visualisation, wristed instrument precision, and demonstrated benefits of reduced intraoperative blood loss and shorter hospital stay. Radical prostatectomy is one of three curative treatment options for localised prostate cancer alongside radical radiotherapy and active surveillance for low-risk disease. Radical prostatectomy (RP) is the surgical removal of the entire prostate gland and seminal vesicles, with or without pelvic lymph node dissection, for the treatment of localised or locally advanced prostate cancer. It is one of two curative-intent primary treatments for localised prostate cancer (alongside radical radiotherapy) and remains the standard treatment for young, fit patients with life expectancy over 10 years and localised high-risk disease. Modern robotic-assisted radical prostatectomy (RARP) using the da Vinci surgical system has become the dominant approach in high-income countries, offering superior ergonomics, magnification, and instrument dexterity compared to open retropubic radical prostatectomy (RRP). Key oncological outcomes include positive surgical margin rate (a predictor of biochemical recurrence) and PSA nadir (target undetectable PSA at 6 weeks post-surgery). Nerve-sparing prostatectomy, where oncologically safe, preserves the neurovascular bundles running along the lateral surfaces of the prostate to maximise post-operative erectile function recovery.

Radical prostatectomy is indicated for clinically localised prostate cancer (cT1–T2, selected cT3a) with life expectancy over 10 years, PSA under 20 ng/mL, and no evidence of distant metastases on staging investigations. It is appropriate for low-risk (Gleason Grade Group 1–2) patients who prefer surgery over active surveillance or radiotherapy, and for intermediate-risk (Grade Group 2–3) and high-risk (Grade Group 4–5) localised disease as part of multimodal treatment. Pelvic lymph node dissection is performed simultaneously in intermediate- and high-risk disease for pathological staging. Absolute contraindications include metastatic disease, severe cardiorespiratory comorbidity precluding general anaesthesia, and life expectancy under 10 years from non-cancer causes. Relative contraindications include prior pelvic radiotherapy (increasing surgical complexity) and prior extensive pelvic surgery. The treatment decision is made through multidisciplinary team discussion and patient-centred shared decision-making.

Robotic-assisted laparoscopic prostatectomy (RARP) is the predominant approach at high-volume urological cancer centres, performed under general anaesthesia with the patient in steep Trendelenburg position (head tilted down approximately 30 degrees) to allow the bowel to fall away from the pelvis.

Port placement and docking: Five or six small ports (5-12 mm) are placed across the lower abdomen — typically one umbilical camera port and four working ports. Carbon dioxide pneumoperitoneum is established at 12-15 mmHg. The robotic system (da Vinci Xi or SP) is docked and robotic instruments are inserted, providing the surgeon with 3D high-definition magnification and wristed instrument motion at a console remote from the patient.

Posterior approach and seminal vesicle dissection: The peritoneum over the rectovesical pouch is incised. The seminal vesicles and vasa deferentia are dissected from the adjacent rectum and lateral fascial attachments, then divided proximally at the level of their junction with the prostate base.

Bladder neck transection: The bladder neck is identified by the perivesical fat and the anatomy of the prostate-bladder junction. The anterior bladder neck is divided followed by the posterior bladder neck, dropping into the plane between the prostate and the trigone. The ureters are visualised and preserved during posterior bladder neck dissection.

Nerve-sparing dissection: The neurovascular bundles (NVBs) — which carry the autonomic nerves responsible for erectile function — run posterolaterally to the prostate within the lateral prostatic fascia. When oncologically safe (no extracapsular extension on MRI, PSA under 10, Gleason Grade Group 1-2), bilateral nerve-sparing is attempted using a retrograde or antegrade intrafascial dissection technique with cold scissors (no energy devices near the nerves) to maximise nerve preservation. Unilateral nerve-sparing is used when one side has higher cancer risk.

Apical dissection and urethral transection: The puboprostatic ligaments are divided, the dorsal venous complex is secured with sutures or stapled, and the urethra is divided at the apex of the prostate with maximum urethral length preservation — critical for early continence recovery. The prostate is placed in a specimen retrieval bag.

Vesicourethral anastomosis: The bladder neck is reconstructed to match the urethral calibre and the vesicourethral anastomosis is created with a running 3-0 monocryl suture in 2 layers (van Velthoven continuous anastomosis), providing a watertight connection. A urinary catheter (16-18 Fr) is placed through the anastomosis. Pelvic lymph node dissection is performed in a separate phase for intermediate- and high-risk disease, removing the obturator, external iliac, and in high-risk cases the common iliac and presacral nodal packets.

Radical prostatectomy achieves 10-year cancer-specific survival of 92–98% for organ-confined disease. PSA recurrence-free survival at 10 years is 80–85% for low-risk and 70% for intermediate-risk disease. Robotic surgery offers lower blood loss, transfusion rates, and shorter hospitalisation compared with open prostatectomy, with equivalent long-term oncological and functional outcomes in experienced hands. Nerve-sparing prostatectomy in men under 65 with pre-operative erectile function preserves erections in 50–80% at 24 months. Urinary continence (0–1 pads per day) is achieved by 90% of patients within 12 months with pelvic floor physiotherapy. Radical prostatectomy achieves 10-year biochemical relapse-free survival of 85–90% for low-risk and 65–75% for high-risk localised prostate cancer in high-volume centres with experienced surgeons. PSA nadir to undetectable levels within 6 weeks confirms complete gland removal. Continence recovery occurs in 80–90% of patients within 12 months, with most using 0–1 pads daily. Bilateral nerve-sparing prostatectomy achieves erections sufficient for intercourse in 40–70% of appropriately selected patients at 12–24 months with phosphodiesterase inhibitor support. Pelvic lymph node dissection provides accurate nodal staging and may have therapeutic benefit by removing micrometastatic disease.

The two most significant functional complications are urinary incontinence and erectile dysfunction. Stress urinary incontinence from sphincter trauma occurs in virtually all patients immediately post-catheter removal, improving to under 10% long-term with pelvic floor physiotherapy. Erectile dysfunction affects 30–80% depending on nerve-sparing extent, patient age, and pre-operative potency; recovery continues for 12–24 months with phosphodiesterase-5 inhibitor support. Anastomotic stricture (bladder neck stenosis) occurs in 3–5% and is managed by urethral dilatation. Rectal injury occurs in under 1% and requires immediate intraoperative repair. Positive surgical margins — cancer cells extending to the resection surface — are found in 10–30% and may require salvage radiotherapy. Deep vein thrombosis prophylaxis with low-molecular-weight heparin is routine. Intraoperative risks include rectal injury (less than 1%), ureteral injury (rare), and bleeding requiring transfusion (1–3% for RARP). Post-operative urinary incontinence requiring pad use beyond 12 months affects 5–15% of patients. Erectile dysfunction rates range from 30–70% depending on nerve-sparing status, patient age, and pre-operative erectile function — phosphodiesterase-5 inhibitors, vacuum erection devices, and penile rehabilitation programmes are used. Bladder neck contracture (anastomotic stricture) occurs in 2–5% requiring urethral dilatation. Biochemical recurrence (rising PSA after surgery) occurs in 20–30% at 10 years and may require salvage radiotherapy.

A urinary catheter remains in place for 7–14 days. After catheter removal, urinary incontinence is common and improves with pelvic floor physiotherapy (Kegel exercises, 3–4 sets of 10–15 contractions daily). Most patients achieve social continence (one pad or fewer per day) by 6–12 months. Erectile rehabilitation starts within 4–6 weeks of surgery with phosphodiesterase-5 inhibitors (sildenafil, tadalafil), vacuum erection devices, or penile injection therapy to maintain penile oxygenation and smooth muscle health during nerve recovery. Light activity resumes within 2–4 weeks; driving at 4–6 weeks; strenuous exercise at 6–8 weeks. PSA monitoring begins at 6–8 weeks and every 3–6 months thereafter. Biochemical recurrence (PSA above 0.2 ng/mL on two occasions) occurs in 20–30% within 10 years and is managed with salvage radiotherapy, achieving remission in 50–70% of patients with early recurrence.