Radical Retropubic Prostatectomy

What does this procedure involve?

This involves removal of your prostate gland, seminal vesicles and, sometimes, the draining lymph glands, as well as tying off your vasa deferentia (sperm-carrying tubes). It is performed through an incision in your lower abdomen (tummy).

We only use open radical prostatectomy (perineal or retropubic) in 10% of men treated surgically. Our aims in men with cancer confined to the prostate gland are:

To remove the cancer
To achieve a clear margin away from the tumour
To drop the PSA blood level below 0.1 ng per ml
To reduce the need for any further treatment (e.g. radiotherapy or hormone treatment)
To preserve your continence
If possible and appropriate, to preserve the erection nerves to your penis

The erection nerves lie very close to your prostate, forming a cobweb of delicate strands over its surface. If your erections were normal before the procedure, it is usually possible to preserve them (nerve-sparing prostatectomy). But they may take some time to recover. We can only preserve these nerves if the cancer has not reached the layer where they lie.

Your team will explain how you can enjoy a healthy sex life after surgery, even if the nerves do not recover or need to be removed.

What are the alternatives for organ-confined cancer?

Active surveillance – no active treatment but careful monitoring of your PSA levels with repeated biopsies and further intervention only if there is definite evidence of cancer progression
Open radical perineal prostatectomy – performed through an incision just in front of your anus
Robotic-assisted laparoscopic radical prostatectomy – performed using a keyhole technique with robotic assistance
External beam radiotherapy – giving an intensive course of external irradiation to your prostate gland
Permanent seed brachytherapy – implanting radio-active seeds under ultrasound control into your prostate gland
High intensity focused ultrasound (HIFU) – external beamed ultrasound; only available in a few specialist centres and, because we do not have long-term results, needs to be given as part of a clinical trial
Cryotherapy – freezing & thawing the prostate with fine needles passed into the gland; only available in a few specialist centres and, because we do not have long-term results, needs to be given as part of a clinical trial

Deciding which treatment to have is not something you will do alone and may depend on the level of expertise available at your hospital. If you need further information, please contact your specialist nurse, surgical care practitioner or urologist.

What happens on the day of the procedure?

Your urologist (or a member of their team) will briefly review your history and medications, and will discuss the surgery again with you to confirm your consent.

An anaesthetist will see you to discuss the options of a general anaesthetic or spinal anaesthetic. The anaesthetist will also discuss pain relief after the procedure with you.

We may provide you with a pair of TED stockings to wear, and we may give you a heparin injection to thin your blood. These help to prevent blood clots from developing and passing into your lungs. Your medical team will decide whether you need to continue these after you go home.

We normally give you a small enema before surgery to ensure that your bowel is clear.

Details of the procedure

We normally carry out the procedure under a general anaesthetic
We will give you an injection of antibiotics before the procedure after checking carefully for any allergies
We make an incision in the lower part of your abdomen (tummy)
We free your prostate from the bladder and urethra (waterpipe) so it can be removed, whilst sparing the muscles and nerves that control continence and trying to preserve your erection nerves
We then re-join your urethra to your bladder using absorbable stitches
We put a catheter in your bladder to drain the urine while the new join heals
We put a small drainage tube close to the site of the prostate to drain any fluid which collects; this is usually removed within 48 hours
We close your wound with sutures or clips which are normally removed after seven to 10 days
The procedure usually takes two to three hours to perform
You should expect to be in hospital for two to four days

Are there any after-effects?

The possible after-effects and your risk of getting them are shown below. Some are self-limiting or reversible, but others are not. We have not listed very rare after-effects (occurring in less than 1 in 250 patients) individually. The impact of these after-effects can vary a lot from patient to patient; you should ask your surgeon’s advice about the risks and their impact on you as an individual:

After-effect	Risk
No semen is produced during an orgasm, effectively making you infertile	All patients
A high chance of erectile dysfunction (impotence) if a nerve-sparing operation is not possible or nerve damage is unavoidable, together with some shortening of your penis	Almost all patients
Urinary incontinence which may only require pads if temporary, but may need further surgery if it goes on for more than a year (e.g. an artificial urinary sphincter or a synthetic male sling)	Between 1 in 20 & 1 in 33 patients (3 to 5%)
Pathology tests that show cancer outside or at the margin of the prostate (positive margins) requiring observation & possible further treatment	Between 1 in 10 & 1 in 50 patients
Bleeding requiring transfusion or further surgery	Between 1 in 10 & 1 in 50 patients
Leakage of urine from the new join between bladder & urethra, delaying discharge or needing longer catheter time	Between 1 in 10 & 1 in 50 patients
Further treatment with hormones, radiotherapy or chemotherapy may be needed at a later date if your PSA blood test still shows that cancer is present	Between 1 in 10 & 1 in 50 patients
Pain, infection or hernia in your incision requiring further treatment	Between 1 in 10 & 1 in 50 patients
Lymph fluid collection (if the pelvic lymph nodes were removed or biopsied during surgery)	Between 1 in 10 & 1 in 50 patients
Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, compartment syndrome, heart attack)	Between 1 in 50 & 1 in 250 patients (your anaesthetist can estimate your individual risk)
Rectal injury or fistula requiring a temporary colostomy to allow healing	Between 1 in 50 & 1 in 250 patients
Numbness & weakness due to nerve compression caused by your position during surgery	Between 1 in 50 & 1 in 250 patients

What is my risk of a hospital-acquired infection?

Your risk of getting an infection in hospital is between 4 & 6%; this includes getting MRSA or a Clostridium difficile bowel infection. This figure is higher if you are in a “high-risk” group of patients such as patients who have had:

Long-term drainage tubes (e.g. catheters)
Long hospital stays
Multiple hospital admissions

What can I expect when I get home?

You will get some swelling and bruising of the incisions which may last several days
It may be several days before you have your bowels open
You will be discharged with a catheter in your bladder; we will show you how to manage it at home
You will be given advice about your recovery at home
You will be given a copy of your discharge summary and a copy will also be sent to your GP
Any antibiotics or other tablets you may need will be arranged & dispensed from the hospital pharmacy
A follow-up appointment will be made for you to have your catheter removed
We will arrange for you to have your stitches or clips removed after seven to 10 days
Before your catheter has been removed, you should start doing pelvic floor exercises
Do not worry if you leak some urine when your catheter comes out; almost everyone has a period of bladder recovery when they will need to wear protective pads
We will discuss the microscopic analysis of your prostate in a multi-disciplinary team (MDT) meeting
We will arrange for you to have your first PSA check six to eight weeks after the procedure

General information about surgical procedures

Before your procedure

Please tell a member of the medical team if you have:

An implanted foreign body (stent, joint replacement, pacemaker, heart valve, blood vessel graft)
A regular prescription for a blood thinning agent (e.g. warfarin, aspirin, clopidogrel, rivaroxaban, dabigatran)
A present or previous MRSA infection
A high risk of variant-CJD (e.g. if you have had a corneal transplant, a neurosurgical dural transplant or human growth hormone treatment)

Questions you may wish to ask

If you wish to learn more about what will happen, you can find a list of suggested questions called “Having An Operation” on the website of the Royal College of Surgeons of England. You may also wish to ask your surgeon for his/her personal results and experience with this procedure.

For several years, BAUS has collected data from urologists undertaking this surgery. You can view these data, by unit and by Consultant, in the Surgical Outcomes Audit section of the BAUS website.

Before you go home

We will tell you how the procedure went and you should:

Make sure you understand what has been done
Ask the surgeon if everything went as planned
Let the staff know if you have any discomfort
Ask what you can (and cannot) do at home
Make sure you know what happens next
Ask when you can return to normal activities

We will give you advice about what to look out for when you get home. Your surgeon or nurse will also give you details of who to contact, and how to contact them, in the event of problems.

Smoking and surgery

Ideally, we would prefer you to stop smoking before any procedure. Smoking can worsen some urological conditions and makes complications more likely after surgery. For advice on stopping, you can:

Contact your GP
Access your local NHS Smoking Help Online
Ring the free NHS Smoking Helpline on 0300 123 1044

Driving after surgery

It is your responsibility to make sure you are fit to drive after any surgical procedure. You only need to contact the DVLA if your ability to drive is likely to be affected for more than three months. If it is, you should check with your insurance company before driving again.