Radical Prostatectomy

Patient Story: James's Journey

James was 58 years old, a high school basketball coach, and the father of three. When his PSA came back at 8.5 and a biopsy showed Gleason 4+3 = 7 (Grade Group 3) in four of twelve cores, his urologist told him he had unfavorable intermediate-risk prostate cancer.

"Active surveillance is not the best option for you," his doctor explained. "We need to treat this."

James met with a radiation oncologist and a urologist who specialized in robotic surgery. Both presented excellent options. After weeks of research, conversations with his wife, and a second opinion at a major cancer center, James chose surgery.

"I chose surgery because I liked the idea of having the cancer physically removed," James says. "I wanted to see the pathology report and know exactly what we were dealing with. My surgeon was honest — he told me there would be side effects, but he also told me what to expect and when things would get better."

James had a robotic-assisted radical prostatectomy. He went home the next day with a catheter, which was removed a week later. The first few weeks were tough — some urinary leakage, fatigue, and no erections. But he did his pelvic floor exercises religiously, started walking daily, and by three months he was back coaching. By six months, his continence was nearly perfect. Erectile function took longer — about 18 months — but with the help of medication and patience, it returned.

"The worst part was the first month," James recalls. "But my surgeon prepared me for that. He said, 'The first three months are the hardest. After that, things get better every month.' He was right."

His PSA after surgery? Undetectable. And it has stayed that way for four years.

Part 1: What Is Radical Prostatectomy?

Radical prostatectomy (RP) is the surgical removal of the entire prostate gland, along with the seminal vesicles (the small glands behind the prostate that produce part of the semen) and, in many cases, some of the surrounding lymph nodes.¹ ²

The word "radical" does not mean extreme or dangerous. In surgery, "radical" simply means removing the entire organ — as opposed to removing just a piece of it. The goal is to remove all of the cancer while preserving as much of the surrounding healthy tissue as possible, particularly the nerves that control erections and the muscles that control urination.¹

According to the NCCN Guidelines, RP is an appropriate therapy for any patient with clinically localized prostate cancer that can be completely excised surgically, who has a life expectancy of 10 years or more, and who has no serious medical conditions that would make an elective operation too risky.¹

RP is one of the most studied and well-established treatments for prostate cancer. It has been performed for over a century, and the techniques have improved dramatically — especially in the last two decades with the introduction of robotic surgery.³

Part 2: Who Is a Good Candidate for Surgery?

Not every man with prostate cancer needs surgery, and not every man is a good candidate for it. The decision depends on several factors:

Cancer Factors:

• Risk group: Surgery is an option for low-risk through regional (node-positive) disease, though the role varies by risk group¹
• Location and extent of the cancer within the prostate
• Whether the cancer appears confined to the prostate on imaging

Patient Factors:

• Life expectancy of 10 years or more¹
• Overall health — the ability to safely undergo general anesthesia and a major operation
• Body habitus — while obesity does not prevent surgery, it can make it more technically challenging and may affect outcomes
• Baseline urinary and sexual function — these strongly predict post-surgical function⁴
• Personal preferences and priorities

Who May NOT Be a Good Candidate:

• Men with life expectancy less than 10 years (surgery is unlikely to provide benefit)
• Men with serious heart, lung, or other medical conditions that make surgery too risky
• Men with cancer that has grown into the pelvic sidewall and cannot be completely removed
• Men who prioritize avoiding urinary incontinence above all else (radiation may be preferred)

📊 Illustration 9.1 — "Am I a Good Candidate for Surgery?" checklist infographic

Part 3: Types of Radical Prostatectomy — How the Surgery Is Done

There are three main approaches to radical prostatectomy. All three remove the same organ — the difference is how the surgeon gets to it.

Open Radical Prostatectomy (ORP)

This is the traditional approach, performed through a single incision in the lower abdomen (retropubic approach) or, less commonly, through the perineum (the area between the scrotum and rectum).

• The surgeon operates with direct vision and touch
• Has been performed for decades with well-established long-term outcomes
• Typically involves a larger incision (8–10 cm), more blood loss, and a longer hospital stay (2–4 days)⁵ ⁶
• Still performed at some centers, particularly where robotic technology is not available

Laparoscopic Radical Prostatectomy (LRP)

This minimally invasive approach uses several small incisions (0.5–1 cm each) and a camera to guide the surgery.

• Less blood loss and shorter hospital stay than open surgery
• Requires significant surgical skill and experience
• Largely replaced by robotic surgery in most developed countries⁷

Robot-Assisted Radical Prostatectomy (RARP)

This is the most common approach today, accounting for the vast majority of prostatectomies performed in the United States and many other countries.³ ⁵

• Uses the da Vinci surgical system (or similar platforms) — the surgeon sits at a console and controls robotic arms that hold tiny instruments and a high-definition 3D camera
• The robot does NOT operate on its own — it is entirely controlled by the surgeon. Think of it as a very advanced tool, like power steering in a car
• Several small incisions (usually 5–6 ports, each about 1 cm)
• Advantages over open surgery include:³ ⁵ ⁶
• Less blood loss (approximately 200 mL vs. 700–800 mL)
• Shorter hospital stay (typically 1–2 days vs. 2–4 days)
• Less postoperative pain
• Fewer wound infections and blood transfusions
• Fewer bladder neck contractures (1.6% vs. 8.3% in one large study)⁵
• Faster return to daily activities

Do Outcomes Differ Between Approaches?

This is one of the most studied questions in prostate cancer surgery. The evidence shows:

• Oncological outcomes (cancer control): Multiple studies, including randomized trials and large population-based analyses, show comparable or slightly better cancer control with RARP compared to ORP.³ ⁵ ⁶ ⁸ ⁹ A large French nationwide study of nearly 28,000 men found that RARP was associated with better progression-free survival and overall survival compared to ORP at a median follow-up of 6.7 years.⁸ A Swedish prospective trial of 4,003 patients found lower prostate cancer-specific mortality with RARP at 8 years.⁹
• Functional outcomes: A randomized trial from Brazil showed that RARP had superior urinary continence at 18 months (95.4% vs. 78.8%) and better sexual outcomes at 12 months compared to ORP.⁶ A large single-center analysis of 18,805 patients found that RARP offered a slight advantage in continence recovery and significantly improved erectile function (60% vs. 45% at 12 months).¹⁰ However, a randomized trial from Australia found no significant difference in quality-of-life outcomes at 24 months between RARP and ORP at high-volume academic centers.¹¹
• Bottom line: At experienced centers, both approaches can achieve excellent results. RARP offers clear perioperative advantages (less bleeding, shorter stay, fewer complications) and likely modest functional advantages. The most important factor is the skill and experience of the individual surgeon, not the approach used.¹ ⁵

📊 Illustration 9.2 — Comparison of open, laparoscopic, and robotic approaches with key differences

Part 4: Nerve-Sparing Surgery — Protecting Your Erections

One of the most important aspects of radical prostatectomy is whether the surgeon can preserve the neurovascular bundles — the delicate bundles of nerves and blood vessels that run along both sides of the prostate and control erections.¹ ¹²

What Is Nerve Sparing?

During prostatectomy, the surgeon must decide how close to the prostate to cut. The closer the dissection is to the prostate capsule, the more nerve tissue is preserved — but the higher the risk of leaving cancer cells behind (positive surgical margin). The further from the prostate, the more nerve tissue is sacrificed — but the cancer removal is more complete.¹ ¹²

There are three levels of nerve sparing:

• Bilateral nerve sparing: Both neurovascular bundles are preserved. This gives the best chance of erectile function recovery.
• Unilateral nerve sparing: One bundle is preserved, the other is removed (usually because cancer is close to it on one side).
• Non-nerve sparing: Both bundles are removed. This is done when cancer extends outside the prostate on both sides.

How Does Nerve Sparing Affect Erectile Function?

A large systematic review and meta-analysis of 124 studies (73,448 patients) found that nerve sparing significantly reduced the risk of erectile dysfunction — by 47% at 12 months compared to non-nerve sparing.¹² The CEASAR study confirmed that bilateral nerve sparing resulted in significantly better sexual function at 3 years compared to unilateral or non-nerve sparing, particularly in men with good baseline function.¹³

The LAPPRO study demonstrated that bilateral intrafascial nerve-sparing RARP was associated with erectile function recovery in 50% of patients at 24 months, compared with fewer than 5% of patients who had non-nerve-sparing RARP.¹⁴

The NeuroSAFE Technique — A Major Advance

A groundbreaking technique called NeuroSAFE (Neurovascular Structure-Adjacent Frozen-Section Examination) has recently been validated in a landmark randomized controlled trial (NeuroSAFE PROOF).¹⁴

How it works: During surgery, the surgeon removes a thin layer of tissue from the surface of the prostate next to the neurovascular bundle. This tissue is immediately sent to a pathologist who examines it under a microscope while the surgery is still ongoing (frozen section analysis). If the margin is clear (no cancer cells), the surgeon can safely preserve the nerve bundle. If cancer cells are found at the margin, the surgeon removes more tissue on that side.

The NeuroSAFE PROOF trial showed that compared to standard RARP:¹⁴

• Significantly better erectile function scores at 12 months
• Better early urinary continence at 3 months
• Higher rates of bilateral nerve sparing
• The proportion of patients with no or mild erectile dysfunction at 12 months was almost twice as high in the NeuroSAFE group (39% vs. 23%)

A 2026 meta-analysis of 11 studies (15,639 patients) confirmed that NeuroSAFE significantly reduced positive surgical margins (OR 0.73), improved urinary continence (OR 1.55), and improved erectile function recovery (OR 2.26) without compromising biochemical control.¹⁵

Importantly, nerve sparing can also be safely performed in carefully selected patients with high-risk prostate cancer without compromising long-term oncological outcomes.¹⁶

Important: The decision about nerve sparing is made by your surgeon based on the location and extent of your cancer, your MRI findings, your biopsy results, and your baseline erectile function. It is a balance between cancer control and quality of life. Always discuss this with your surgeon before the operation.

📊 Illustration 9.3 — Diagram showing the neurovascular bundles alongside the prostate and the three levels of nerve sparing

Part 5: Pelvic Lymph Node Dissection — Checking for Spread

During radical prostatectomy, the surgeon may also remove lymph nodes from the pelvis. This is called a pelvic lymph node dissection (PLND).¹ ¹⁷

Why Is It Done?

Lymph nodes are small, bean-shaped structures that are part of the immune system. Cancer cells can travel through the lymphatic system and settle in nearby lymph nodes. Removing and examining these nodes tells your doctors whether the cancer has spread beyond the prostate — this is called staging.¹ ¹⁷

Who Needs It?

According to the NCCN Guidelines:¹

• Low-risk: PLND can generally be excluded
• Favorable intermediate-risk: PLND can be considered
• Unfavorable intermediate-risk, high-risk, very-high-risk, and regional: PLND is recommended

Nomograms (mathematical prediction tools) can estimate the probability of lymph node involvement. Published thresholds for performing PLND range from 2% to 7% predicted risk.¹

An Important Point About PSMA PET Scans:

Even if a PSMA PET scan shows no lymph node involvement, PLND should still be performed if the patient is above the threshold for PLND. The sensitivity of PSMA PET for detecting pelvic lymph node metastases is only about 40%, and the negative predictive value is about 81%. Skipping PLND based on a negative PSMA PET could miss 19% of patients with positive lymph nodes.¹

Extended vs. Limited PLND

When PLND is performed, an extended template is recommended. An extended PLND removes lymph nodes from a wider area and provides more accurate staging.¹ ¹⁷

A landmark randomized trial from Memorial Sloan Kettering Cancer Center compared limited versus extended PLND in 1,432 patients. While biochemical recurrence rates were similar, extended PLND showed a clinically and statistically significant protective effect against metastasis (HR 0.82 for any metastasis; HR 0.75 for distant metastasis).¹⁷ A multicenter study also found that PLND improved metastasis-free survival in patients with intermediate-risk (HR 0.48) and high-risk (HR 0.57) disease.¹⁸

Complications of PLND

PLND adds time to the surgery and carries its own risks:¹⁹ ²⁰

• Lymphocele (collection of lymphatic fluid) — the most common complication, occurring in approximately 1.5–5% of cases. Most are asymptomatic and resolve on their own; some require drainage.
• Lymphedema (leg swelling) — uncommon but can be persistent
• Nerve injury (obturator nerve) — rare, can cause temporary leg weakness
• Thromboembolic events — slightly increased risk of blood clots

📊 Illustration 9.4 — Diagram showing the pelvic lymph node regions and extended PLND template

Part 6: Preparing for Surgery

Before the Operation

Your surgical team will guide you through preparation, which typically includes:

• Preoperative evaluation: Blood tests, EKG, and possibly a chest X-ray to ensure you are fit for surgery. Your anesthesiologist will review your medical history and medications.
• Medications to stop: Blood thinners (warfarin, aspirin, clopidogrel), NSAIDs (ibuprofen, naproxen), GLP-1 receptor agonists (semaglutide, tirzepatide — these can affect anesthesia), and certain supplements (fish oil, vitamin E, ginkgo) should be stopped as directed by your surgeon, usually 5–10 days before surgery.
• Bowel preparation: Some surgeons recommend a light bowel prep or clear liquid diet the day before surgery. Others do not require this.
• Pelvic floor exercises (Kegels): Starting these BEFORE surgery can improve your continence recovery afterward. Your surgeon or a pelvic floor physical therapist can teach you the proper technique (see Part 10).
• Banking sperm: If you are still planning to have children, discuss sperm banking before surgery. RP will make you infertile because the seminal vesicles and vas deferens connections are removed.
• Baseline function questionnaires: Complete the EPIC-26, IPSS, and SHIM questionnaires before surgery. These establish your baseline urinary, sexual, and bowel function — critical for tracking recovery.⁴
• Nothing to eat or drink after midnight the night before surgery (or as directed).

What to Bring to the Hospital:

• Comfortable, loose-fitting clothing for going home
• A list of all medications and allergies
• Insurance information and identification
• A companion to drive you home and stay with you for the first 24–48 hours
• This book (or notes from it)

📊 Illustration 9.5 — "Preparing for Surgery" checklist infographic

Part 7: The Day of Surgery — What Happens

In the Operating Room

• You will receive general anesthesia — you will be completely asleep and feel nothing
• The surgery typically takes 2 to 4 hours, depending on the complexity, whether nerve sparing is performed, and whether lymph nodes are removed
• For robotic surgery, 5–6 small incisions (about 1 cm each) are made in the abdomen. The abdomen is inflated with carbon dioxide gas to create space for the instruments.
• The surgeon sits at a console in the operating room and controls the robotic arms. An assistant stands at the bedside.
• The prostate and seminal vesicles are carefully separated from the bladder above and the urethra below, and from the rectum behind
• If nerve sparing is planned, the neurovascular bundles are carefully preserved
• If PLND is planned, lymph nodes are removed
• The bladder is reconnected to the urethra with sutures (this is called the vesicourethral anastomosis)
• A urinary catheter (Foley catheter) is placed through the penis into the bladder to allow the connection to heal
• A small drain may be placed near the surgical site to collect any fluid

After Surgery

• You will wake up in the recovery room with the catheter in place
• Most patients go home the next day (1–2 nights in the hospital for robotic surgery; 2–4 nights for open surgery)⁵ ⁶
• You will go home with the urinary catheter, which typically stays in place for 5 to 10 days. Some surgeons remove it as early as day 4; others prefer day 7 or later.²¹ ²² Your surgeon will determine the best timing based on your specific situation.
• You will receive instructions on catheter care, activity restrictions, and when to call the doctor

📊 Illustration 9.6 — Step-by-step visual of the robotic prostatectomy procedure

Part 8: Recovery Timeline — What to Expect

Recovery after radical prostatectomy follows a general pattern, though every man's experience is different.

Week 1 (Hospital and Early Home Recovery):

• Pain is usually mild to moderate, managed with over-the-counter medications and sometimes a short course of prescription pain medicine
• The catheter is in place — this is the most bothersome part for most men
• Walking is encouraged from day 1 — start with short walks around the house and gradually increase
• No heavy lifting (nothing over 10–15 pounds), no strenuous exercise, no driving while on pain medication
• Some blood in the urine is normal
• Constipation is common — use stool softeners as directed

Weeks 2–4 (Catheter Removal and Early Recovery):

• The catheter is removed (usually day 5–10). This is a brief, mildly uncomfortable procedure done in the office.
• After catheter removal, expect some urinary leakage. This is normal and expected. Most men need pads initially.
• Begin or resume pelvic floor exercises (Kegels) as directed
• Gradually increase walking distance
• Most men can return to light desk work within 2–3 weeks²³
• No sexual activity until cleared by your surgeon (usually 4–6 weeks)

Months 1–3 (Early Functional Recovery):

• Urinary continence improves steadily. At 3 months, approximately 60–80% of men are continent (0–1 pad per day).⁶ ¹⁰ ²⁴
• Erections are typically absent or very weak during this period — this is expected
• Energy levels improve
• Most men return to full work and normal activities by 4–6 weeks²³
• Follow-up PSA is checked (should be undetectable — less than 0.1 ng/mL)

Months 3–12 (Continued Recovery):

• Continence continues to improve. At 12 months, approximately 89–95% of men are continent.⁶ ¹⁰ ²⁴
• Erectile function begins to return in men who had nerve-sparing surgery. Recovery is gradual and may be aided by medications (PDE5 inhibitors like sildenafil or tadalafil), vacuum erection devices, or other therapies.
• At 12 months after bilateral nerve-sparing RARP, approximately 20–50% of men recover erections sufficient for intercourse, depending on age, baseline function, and surgical technique.¹⁴ ²⁵

Beyond 12 Months (Late Recovery):

• An important and encouraging finding: functional recovery continues well beyond 12 months. A large study from Memorial Sloan Kettering found that among men who were still incontinent at 12 months, 30% recovered continence by 24 months, 49% by 36 months, and 59% by 48 months. Similarly, among men with erectile dysfunction at 12 months, 22% recovered by 24 months, 32% by 36 months, and 40% by 48 months.²⁶
• Another European study confirmed these findings: among patients with urinary incontinence at 12 months, 38.6% regained continence by 24 months and 49.7% by 36 months. For erectile dysfunction at 12 months, 30.8% recovered by 24 months and 36.5% by 36 months.²⁷
• The message: do not give up hope if you have not recovered by 12 months. Recovery can continue for 3–4 years.

📊 Illustration 9.7 — Recovery timeline infographic showing continence and erectile function milestones from surgery through 48 months

Part 9: Side Effects and Complications

Like any major surgery, radical prostatectomy carries risks. Understanding these risks helps you make an informed decision and know what to expect.

Urinary Incontinence

This is the most common side effect and the one that bothers most men the most in the early recovery period.

• Stress urinary incontinence (leaking with coughing, sneezing, laughing, lifting, or changing position) is the most common type after RP
• Severity varies widely — from a few drops with heavy activity to more significant leakage requiring multiple pads
• Most men experience significant improvement over the first 3–12 months
• At 12 months, approximately 89–95% of men are continent (0–1 pad/day) at high-volume centers⁶ ¹⁰ ²⁴
• At 10 years, radical prostatectomy is associated with worse urinary incontinence compared to radiation therapy or active surveillance⁴
• Factors that improve continence: younger age, lower BMI, absence of diabetes, nerve sparing, preservation of urethral length, bladder neck preservation, experienced surgeon¹ ²⁴
• For men with persistent severe incontinence (beyond 12–18 months), surgical options include an artificial urinary sphincter or a male sling

Erectile Dysfunction

• The second most common side effect
• Even with bilateral nerve sparing, erections are typically absent for weeks to months after surgery due to nerve "stunning" (neuropraxia)
• Recovery depends on: age, preoperative erectile function, degree of nerve sparing, and surgical technique¹ ²⁵
• At 12 months after bilateral nerve-sparing RARP, approximately 20–50% of men recover erections sufficient for intercourse¹⁴ ²⁵
• At 10 years, there are no significant differences in sexual function between RP and radiation therapy⁴
• Penile rehabilitation (early use of PDE5 inhibitors, vacuum devices) may help recovery — discuss with your surgeon
• For men with persistent ED, options include oral medications, penile injections, vacuum devices, and penile implants (see Chapter 18)

Other Complications:

• Bleeding: Blood loss is typically 150–250 mL with robotic surgery vs. 700–800 mL with open surgery. Blood transfusion is rarely needed with RARP (approximately 1%).⁵
• Bladder neck contracture/anastomotic stricture: Scarring at the connection between the bladder and urethra, occurring in approximately 1–8% of cases. More common with open surgery (8.3%) than robotic (1.6%).⁵ May require dilation or minor procedure.
• Lymphocele: Collection of lymphatic fluid in the pelvis after lymph node dissection. Occurs in approximately 1.5–5% of cases. Most resolve spontaneously; some require drainage.¹⁹ ²⁰
• Urinary tract infection: Occurs in approximately 3–4% of cases.²⁸
• Inguinal hernia: The risk of developing an inguinal hernia is increased after RP, occurring in approximately 3–15% of men over time. This is due to changes in pelvic anatomy.²⁸ ²⁹
• Penile shortening: Some men notice a decrease in penile length after RP, likely due to changes in pelvic anatomy and nerve injury. This is usually modest (1–2 cm) and may partially recover over time.²⁹
• Deep vein thrombosis / pulmonary embolism: Blood clots in the legs or lungs. Uncommon (less than 1–2%) with modern prevention measures (compression stockings, blood thinners, early walking).
• Rectal injury: Very rare (less than 0.5%). If it occurs, it is usually repaired during the surgery.
• Death from surgery: Extremely rare — less than 0.2%.³⁰

📊 Illustration 9.8 — Side effects summary table with approximate rates and timeline

Part 10: Pelvic Floor Exercises (Kegels) — Your Most Important Recovery Tool

Pelvic floor exercises, commonly called Kegels, are the single most important thing you can do to speed up your continence recovery after surgery.

What Are Kegel Exercises?

The pelvic floor is a group of muscles that form a hammock at the bottom of your pelvis. These muscles support the bladder and help control urination. During prostatectomy, the internal sphincter (which sits at the bladder neck) is removed along with the prostate. Your continence after surgery depends entirely on the external sphincter and the pelvic floor muscles.

Kegel exercises strengthen these muscles so they can do the job of two sphincters instead of one.

How to Do Them:

1. Find the right muscles: The easiest way is to try to stop your urine stream midflow. The muscles you squeeze to do this are your pelvic floor muscles. (Do this only to identify the muscles — do not regularly practice stopping your urine stream.)
2. The exercise: Squeeze (contract) these muscles and hold for 5 seconds, then relax for 5 seconds. Repeat 10–15 times. This is one set.
3. How often: Do 3 sets per day (morning, afternoon, evening).
4. Progression: Gradually increase the hold time to 10 seconds. Add "quick flicks" — rapid contractions and releases — to build fast-twitch muscle fibers.
5. When to start: Ideally, start 2–4 weeks BEFORE surgery. Resume after catheter removal.

Tips:

• Do NOT hold your breath, squeeze your buttocks, or tighten your abdomen — isolate the pelvic floor muscles only
• You can do Kegels anywhere — sitting, standing, lying down — and no one will know
• Consider seeing a pelvic floor physical therapist, especially if you are having difficulty identifying the right muscles or if continence is not improving as expected
• Biofeedback therapy can help you learn to contract the correct muscles

📊 Illustration 9.9 — Step-by-step Kegel exercise guide with anatomical diagram

Part 11: Understanding Your Pathology Report After Surgery

After your prostate is removed, it is sent to a pathologist who examines the entire gland under a microscope. This provides much more detailed information than the biopsy, because now the pathologist can see the entire cancer — not just small samples.

Key Items on Your Post-Surgery Pathology Report:

• Pathological stage (pT): How far the cancer extends
• pT2: Cancer is confined within the prostate
• pT3a: Cancer extends through the prostate capsule (extraprostatic extension)
• pT3b: Cancer invades the seminal vesicles
• pT4: Cancer invades adjacent structures (bladder, rectum)
• Pathological Gleason score and Grade Group: May be the same as or different from the biopsy. Upgrading (higher grade on surgery than biopsy) occurs in approximately 30–40% of cases; downgrading occurs in approximately 10–15%.
• Surgical margins: Whether cancer cells are found at the edge of the removed tissue
• Negative margins: No cancer at the edge — the surgeon removed all visible cancer
• Positive margins: Cancer cells are present at the cut edge — some cancer may have been left behind. This does not necessarily mean the cancer will come back, but it increases the risk and may lead to a recommendation for additional treatment (radiation).
• Lymph node status (pN): If lymph nodes were removed, how many were positive
• pN0: No cancer in lymph nodes
• pN1: Cancer found in one or more lymph nodes
• Other features: Perineural invasion, lymphovascular invasion, intraductal carcinoma, cribriform pattern — these provide additional prognostic information
• Tumor volume: How much of the prostate was involved by cancer

What If the Pathology Shows Adverse Features?

Adverse pathologic features include positive margins, seminal vesicle invasion, or extraprostatic extension. These increase the risk of cancer recurrence and may lead to a discussion about additional treatment — either immediate (adjuvant radiation) or delayed (salvage radiation if PSA rises). This is discussed in detail in Chapter 13.

📊 Illustration 9.10 — Annotated sample pathology report with explanations of each section

Part 12: Follow-Up After Surgery — Monitoring Your PSA

After radical prostatectomy, your PSA should drop to an undetectable level (typically less than 0.1 ng/mL) within 4–6 weeks. This is because the prostate — the only significant source of PSA — has been removed.

The Follow-Up Schedule:

• PSA is typically checked every 3–6 months for the first 2–3 years, then every 6–12 months thereafter
• A physical exam (but no longer a DRE in most cases, since the prostate is gone) is performed at follow-up visits
• Imaging is not routinely needed if PSA remains undetectable

What If PSA Rises After Surgery?

• PSA persistence: If PSA never drops to undetectable after surgery, this may indicate residual cancer (local or distant)
• PSA recurrence (biochemical recurrence): If PSA was undetectable and then rises to a detectable level on two or more measurements, this is called biochemical recurrence. The threshold used in clinical trials is typically PSA ≥0.1 or ≥0.2 ng/mL.
• A rising PSA does NOT necessarily mean the cancer has spread to other parts of the body. In many cases, it represents a small amount of residual cancer in the prostate bed that can be treated with salvage radiation therapy.
• If PSA rises, your doctor will likely order imaging (PSMA PET/CT is the most sensitive) and discuss treatment options, which may include radiation therapy with or without hormone therapy (see Chapter 13).

📊 Illustration 9.11 — PSA monitoring timeline after surgery showing expected undetectable PSA and what a rising PSA means

Part 13: Choosing Your Surgeon — The Most Important Decision

The skill and experience of your surgeon is arguably the most important factor in determining your outcomes after radical prostatectomy. This is true regardless of whether the surgery is open or robotic.¹ ⁵

Volume Matters

The NCCN states clearly: "High-volume surgeons in high-volume centers generally provide better outcomes."¹

Research consistently shows that surgeons and hospitals that perform more prostatectomies have:⁵ ⁹

• Lower rates of positive surgical margins
• Lower complication rates
• Better continence outcomes
• Better erectile function outcomes
• Shorter hospital stays
• Lower readmission rates

There is no universally agreed-upon number that defines "high volume," but most studies suggest that surgeons performing at least 50–100 cases per year achieve significantly better outcomes than those performing fewer.⁵

Questions to Ask a Potential Surgeon:

1. How many radical prostatectomies do you perform per year?
2. What is your positive surgical margin rate?
3. What percentage of your patients are continent (0–1 pad) at 12 months?
4. What percentage of your patients recover erections sufficient for intercourse (with or without medication)?
5. What is your complication rate (transfusion, infection, readmission)?
6. Do you perform nerve-sparing surgery, and do you use NeuroSAFE or frozen section analysis?
7. Will you perform the entire operation yourself, or will trainees be involved?
8. What is your approach to lymph node dissection?
9. What is your experience with my specific situation (e.g., large prostate, prior abdominal surgery, high-risk disease)?
10. What does your follow-up program look like?

A good surgeon will welcome these questions. If a surgeon is uncomfortable sharing their outcomes data, consider that a red flag.

Second Opinions

Getting a second opinion is always appropriate and should never be seen as an insult to your doctor. Many insurance plans cover second opinions, and major cancer centers often offer them. A second opinion can:

• Confirm the recommended treatment plan
• Offer alternative approaches you may not have considered
• Provide peace of mind
• Occasionally change the diagnosis or treatment recommendation (this happens more often than you might think)

📊 Illustration 9.12 — "Choosing Your Surgeon" checklist with key questions

Part 14: Special Situations

Prior Abdominal Surgery

If you have had previous abdominal surgery (hernia repair, bowel surgery, appendectomy, etc.), robotic prostatectomy is still possible in most cases. However, scar tissue (adhesions) from prior surgery may make the operation more technically challenging and slightly longer. Your surgeon should be informed of all prior surgeries.

Prior TURP (Transurethral Resection of the Prostate)

Men who have had a TURP for BPH can still undergo radical prostatectomy, but the surgery is more challenging because the anatomy has been altered. The bladder neck reconstruction may be more difficult, and there may be a slightly higher risk of bladder neck contracture and urinary incontinence. An experienced surgeon is particularly important in this situation.¹

Very Large Prostates

Prostates larger than 80–100 grams can make surgery more challenging due to limited working space, more blood vessels, and a longer operative time. However, experienced surgeons routinely operate on large prostates with good outcomes. In some cases, your surgeon may recommend a period of hormone therapy before surgery to shrink the prostate (neoadjuvant ADT), though this is not standard practice for size reduction alone.

Obesity

Higher BMI is associated with increased surgical difficulty, longer operative times, higher blood loss, and potentially worse functional outcomes. However, obesity is not a contraindication to surgery. Losing weight before surgery, if possible, can improve outcomes.

Young Men (Under 55)

Younger men generally have better functional recovery (both continence and erectile function) after surgery. However, they also have more years to live with any side effects. The decision between surgery and radiation should be carefully discussed, considering long-term quality of life and the potential need for additional treatments over a longer time horizon.

Older Men (Over 70)

Age alone should not determine treatment. What matters is overall health and life expectancy. A healthy 72-year-old with a life expectancy of 15+ years may be an excellent surgical candidate. However, older men tend to have slower functional recovery and may have more comorbidities that affect outcomes.

High-Risk and Very-High-Risk Disease

Surgery is an option even for high-risk and very-high-risk prostate cancer, particularly when the cancer appears resectable (removable) on imaging. In these cases:¹

• Extended PLND is strongly recommended
• Nerve sparing may still be possible on the side opposite the dominant tumor, depending on imaging and intraoperative findings¹⁶
• Multimodal therapy (surgery followed by radiation and/or hormone therapy) may be needed
• The pathology report after surgery provides critical information for planning any additional treatment

Node-Positive Disease Found at Surgery

If lymph node metastases are found on the final pathology report, this changes the situation significantly. Options include:¹

• Observation with close PSA monitoring (if PSA becomes undetectable)
• Adjuvant radiation therapy to the pelvis
• Adjuvant hormone therapy (ADT)
• Combination of radiation and hormone therapy

The optimal approach depends on the number of positive nodes, the PSA after surgery, and other pathologic features. This is discussed in detail in Chapter 13.

📊 Illustration 9.13 — "Special Situations" summary table

Part 15: Surgery vs. Radiation — How Do They Compare?

This is one of the most common questions men with prostate cancer ask. The honest answer is that both are excellent treatments, and for most men with localized prostate cancer, the long-term cancer control is similar.

The ProtecT Trial — The Most Important Comparison

The ProtecT trial is the only large randomized trial comparing surgery, radiation, and active monitoring for localized prostate cancer. At 15 years of follow-up:³¹

• Prostate cancer-specific mortality was approximately 3% in all three groups — no statistically significant difference
• Overall survival was approximately 78% in all three groups — no significant difference
• Metastasis rates were higher in the monitoring group (9.4%) compared to surgery (4.7%) and radiation (5.0%)
• The trial enrolled mostly low-risk and favorable intermediate-risk men, so results may not apply to higher-risk disease

Side Effect Profiles Differ:

The CEASAR study and other comparative studies show that the side effect profiles of surgery and radiation are different:⁴ ¹³

• Surgery causes more urinary incontinence and erectile dysfunction in the first 1–3 years
• Radiation causes more bowel/rectal symptoms (urgency, frequency, bleeding) and urinary irritation
• By 5–10 years, the differences in sexual function narrow considerably
• Radiation side effects tend to develop gradually over time, while surgical side effects are immediate but improve

Neither Treatment Is "Better" — They Are Different

The choice between surgery and radiation depends on:

• Your cancer characteristics (some cancers are better suited to one approach)
• Your baseline function (urinary, sexual, bowel)
• Your priorities (what side effects are most acceptable to you)
• Your age and life expectancy
• Your anatomy (prostate size, prior surgeries, rectal conditions)
• Your preferences after understanding all options

A multidisciplinary consultation — meeting with both a urologist and a radiation oncologist — is strongly recommended before making this decision.⁴

📊 Illustration 9.14 — Side-by-side comparison of surgery vs. radiation: cancer control, side effects, recovery

Part 16: Emerging Advances in Prostate Surgery

Retzius-Sparing Approach

A modification of robotic prostatectomy where the surgeon approaches the prostate from behind (posterior approach) rather than the traditional front approach. This avoids disrupting the Retzius space — the area between the pubic bone and the bladder — which contains structures important for continence. Some studies suggest faster continence recovery with this approach, though long-term data are still maturing.³²

Single-Port Robotic Surgery

Newer robotic platforms allow the entire surgery to be performed through a single small incision, rather than 5–6 ports. This may reduce pain and improve cosmesis, though oncological and functional outcomes compared to standard multi-port RARP are still being studied.

Fluorescence-Guided Surgery

Using fluorescent dyes (such as indocyanine green or PSMA-targeted fluorescent agents) to help the surgeon visualize cancer tissue, lymph nodes, and blood vessels in real time during surgery. This technology is still investigational but shows promise for improving surgical precision.

Artificial Intelligence in Surgery

AI is being explored to:

• Analyze surgical video in real time to identify anatomical structures and guide the surgeon
• Predict functional outcomes based on surgical technique
• Provide automated assessment of surgical quality
• Assist with surgical training and performance evaluation

These technologies are in early stages but represent the future of surgical oncology.

Myth vs. Fact

Myth: "The robot does the surgery."

Fact: The robot is a tool controlled entirely by the surgeon. It does not make any decisions or movements on its own. The surgeon's skill and experience are what determine outcomes.

Myth: "Robotic surgery is always better than open surgery."

Fact: RARP offers clear perioperative advantages (less bleeding, shorter stay, fewer complications), and likely modest functional advantages. However, at experienced centers, both approaches can achieve excellent cancer control. The surgeon's experience matters more than the approach.⁵ ⁶ ¹¹

Myth: "If I have surgery, I will definitely be incontinent and impotent."

Fact: While these are real risks, the majority of men recover continence (89–95% at 12 months) and many recover erectile function, especially with bilateral nerve sparing. Recovery continues for up to 3–4 years.⁶ ¹⁰ ²⁶ ²⁷

Myth: "If the margins are positive, the surgery failed."

Fact: Positive surgical margins increase the risk of recurrence but do not guarantee it. Many men with positive margins never have a PSA recurrence. And if PSA does rise, salvage radiation therapy is highly effective when given early.

Myth: "I am too old for surgery."

Fact: Age alone does not determine candidacy. Overall health and life expectancy are what matter. A healthy man in his early 70s with a life expectancy of 15+ years may be an excellent candidate.¹

Myth: "Surgery is the only way to cure prostate cancer."

Fact: Radiation therapy (external beam and/or brachytherapy) provides equivalent cancer control for most stages of prostate cancer. The ProtecT trial showed no difference in prostate cancer mortality between surgery and radiation at 15 years.³¹

Questions to Ask Your Doctor

Before Surgery:

1. What is my risk group, and is surgery the best option for me?
2. What surgical approach do you recommend (robotic, open) and why?
3. Will you be able to spare the nerves? On both sides or one?
4. Do you use NeuroSAFE or frozen section analysis during surgery?
5. Will I need a lymph node dissection? How extensive?
6. How many of these surgeries do you perform per year?
7. What are your personal outcomes for continence and erectile function?
8. What is your positive surgical margin rate?
9. Should I see a radiation oncologist before making my decision?
10. Should I bank sperm before surgery?

After Surgery:

1. What did the pathology report show? What is my pathological stage?
2. Were the surgical margins negative or positive?
3. Were any lymph nodes positive?
4. What is my PSA now? When will it be checked again?
5. Do I need any additional treatment (radiation, hormone therapy)?
6. When can I resume normal activities, exercise, and work?
7. When should I start pelvic floor exercises?
8. Should I start penile rehabilitation? When and how?
9. When can I resume sexual activity?
10. What symptoms should prompt me to call you urgently?

Key Takeaways

1. Radical prostatectomy removes the entire prostate gland and is an effective treatment for localized and some regional prostate cancers, with long-term cancer control rates comparable to radiation therapy.¹ ³¹
2. Robot-assisted surgery (RARP) is the most common approach and offers perioperative advantages over open surgery, including less blood loss, shorter hospital stay, and fewer complications. Cancer control is comparable or slightly better.⁵ ⁶ ⁸ ⁹
3. Nerve-sparing surgery preserves erectile function — the NeuroSAFE technique nearly doubles the rate of erectile function recovery at 12 months.¹⁴ ¹⁵
4. Continence recovery is excellent — 89–95% of men are continent at 12 months, and recovery continues for up to 4 years. Pelvic floor exercises (Kegels) are the most important tool for recovery.⁶ ¹⁰ ²⁶ ²⁷
5. The surgeon's experience is the most important factor — high-volume surgeons at high-volume centers achieve better outcomes. Ask about their personal results.¹ ⁵
6. The pathology report after surgery provides critical staging information that guides decisions about additional treatment.

Support Resources

• Prostate Cancer Foundation (pcf.org) — Surgery patient guides, recovery tips, and surgeon directories
• ZERO — The End of Prostate Cancer (zerocancer.org) — Helpline: 1-844-244-1309; peer support and mentoring
• Us TOO International (ustoo.org) — Local and online support groups for men after surgery
• NCCN Patient Guidelines (nccn.org/patients) — Free patient-friendly prostate cancer guidelines
• National Association for Continence (nafc.org) — Resources for managing urinary incontinence
• Sexual Medicine Society of North America (smsna.org) — Information on erectile dysfunction treatment
• Pelvic Floor Physical Therapy Directory — Ask your surgeon for a referral or search the American Physical Therapy Association (apta.org)

References

1. 1. NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer, Version 5.2026. National Comprehensive Cancer Network. PROS-J: Principles of Surgery.
2. 2. NCCN Prostate Cancer Guidelines, PROS-2 through PROS-8: Treatment by Risk Group, Version 5.2026.
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24. 24. Ficarra V, Novara G, Rosen RC, et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol. 2012;62(3):405-417.
25. 25. Alemozaffar M, Regan MM, Cooperberg MR, et al. Prediction of Erectile Function Following Treatment for Prostate Cancer. JAMA. 2011;306(11):1205-1214.
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27. 27. Mandel P, Preisser F, Graefen M, et al. Late functional recovery after radical prostatectomy. Eur Urol Focus. 2023.
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29. 29. Novara G, Ficarra V, Rosen RC, et al. Systematic review and meta-analysis of perioperative outcomes and complications after robot-assisted radical prostatectomy. Eur Urol. 2012;62(3):431-452.
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