FAQs about Radical Prostatectomy

Below you will find answers to frequently asked questions about active, curative treatment for prostate cancer.

How can localized prostate cancer be cured?

Prostate cancer may be cured by surgically removing the entire prostate gland (radical prostatectomy), by destroying the prostate cancer using ionizing radiation (external beam and brachytherapy) or by minimally invasive ablative techniques that include freezing (cryotherapy), heating (high-intensity focused ultrasound and laser) and use of light energy (photodynamic therapy). Radical prostatectomy and radiation therapy are the most common approaches for curing prostate cancer. Cryotherapy is available in the United States and is becoming more and more common, especially as a focal therapy. Smilow Center surgeons and radiation oncologists are among the most experienced physicians offering these curative treatments. HIFU, laser ablation and photodynamic therapy are all investigational, and pioneering research and studies are being conducted at the Smilow Center.

What is a radical prostatectomy (RP)?

A radical prostatectomy is the surgical removal of the prostate gland along with the adjacent seminal vesicles.

Are there different methods of performing radical prostatectomy?

There are several surgical approaches to radical prostatectomy. The ‘open’ technique involves a small surgical incision either between the belly button and pubic bone (the retropubic approach) or between the scrotum and the rectum (the perineal approach). The Smilow Center surgeons prefer the retropubic approach because it affords the opportunity to perform a pelvic lymphadenectomy through the same incision, and it is easier to spare the surrounding nerves. Smilow surgeons have pioneered the development of the nerve-sparing radical retropubic prostatectomy (Walsh PC, Lepor H, Eggleston JC. Prostate 4:473 (1983); Lepor H. Urol. Clin. North Am. Aug; 28(3):509-19 (2001)).

Prostatectomy may also be performed using a laparoscopic approach. In this method, surgery is performed with thin instruments inserted into the body through small holes. Laparoscopic techniques may be performed with or without robotic assistance. At the Smilow Center, surgeons use the da Vinci Robotic Surgical System to perform robotic prostatectomy. In this procedure, the surgeon uses joysticks to operate surgical instruments attached to robotic arms, which are inserted into the patient's body through the incisions. The surgeon views the operation by way of a video camera inserted into the body, which transmits the image of the organs to an external video monitor.

What are the advantages and disadvantages of each method of radical prostatectomy?

Surgeons who prefer the open approach claim that the ability to feel the prostate during the surgical procedure results in better control of cancer and avoidance of positive (cancerous) surgical margins at the outer surface of the surgical specimen. Surgeons who prefer the robotic approach claim that the robotic approach facilitates recovery, reduces blood loss and enhances the ability to preserve the nerves that control erections.

However, there is no definitive medical evidence supporting any of these claims of superiority. Recent publications have not shown any significant difference in length of hospital stay, pain, time to return to work or activities, continence, potency, oncological control or transfusion rates (Lepor H. Rev. Urol. 11(2):61-70 (2009)).

At the Smilow Center, we believe that the surgeon’s level of experience is more important than the particular method chosen to remove the prostate. The other factors that affect outcome are the postoperative pathways for facilitating the return of continence and erectile function. Smilow Center surgeons work closely with other members of NYU Langone Medical Center urology faculty who are internationally recognized experts in urinary continence and erectile function in order to maximize long-term quality of life outcomes.

What blood management strategies are used before radical prostatectomy?

Surgeons at the Smilow Center who perform open surgery recommend using erythropoietin-stimulating proteins (ESP) preoperatively to stimulate the body’s natural red blood cell–manufacturing mechanisms. Smilow Center physicians performed the pioneering work on this blood management technique and have published many peer-reviewed papers on the safety and effectiveness of this approach (Nieder AM, Rosenblum N, Lepor H. Urol. 57(4):737-41 (2001); Rosenblum N, Levine MA, Handler T, Lepor H. J. Urol. 163(3):829-33 (2000); Chun TY, Martin S, Lepor H. Urol. 50(5):727 (1997)). The overall blood loss has been reported to be slightly lower during robotic prostatectomy than for open prostatectomy. However, when candidates for open surgery receive erythropoietin-stimulating proteins, this benefit of robotic surgery is eliminated, as it relates to blood volume at the time of hospital discharge. In addition, it is important to note that blood transfusion rates are identical for robotic and open prostatectomy.

Will the nerves that control erections be preserved at the time of radical prostatectomy?

A Smilow Center surgeon described the anatomic location of the cavernous nerves that mediate erectile function (Lepor H, Crosby R, Gregerman M, Mostofi FK, Walsh PC. J. Urol. 133:207 (1985)). These nerves and blood vessels (the ‘neurovascular bundle’) travel very close to the prostate gland and may be inadvertently injured during radical prostatectomy, leading to transient or permanent erectile dysfunction. The decision to preserve the neurovascular bundle depends on baseline erectile function and the likelihood that the cancer has penetrated the capsule of the prostate.

Recent research at the Smilow Center has shown that factors such as serum PSA, biopsy Gleason score and the amount of cancer present in biopsy cores can help predict whether the cancer has spread beyond the prostate capsule (Sankin A, Tareen B, Lepor H. Prostate Cancer Prostatic Dis. 12(2):204-8 (2009); Taneja S, Epelbaum A, Penson D, Handler T, Melamed J, Lepor H. J. Urol. 162:1352-1358 (1999)). We have since developed a decision-making tool based on this research to help surgeons determine when to deliberately excise these nerves to ensure that all the cancer is removed (Shah O, Robbins DA, Melamed J, Lepor H. J. Urol. 169(6):2147-52 (2003)).

Will nerve-sparing surgery help me regain continence after prostatectomy?

Whether the neurovascular bundle contributes to urinary control has been controversial. Smilow Center surgeons published the most definitive paper on this topic that provided compelling evidence that preservation of the neurovascular bundle does not influence continence outcomes (Marien TP, Lepor H. BJU Int. 102(11):1581-4 (2008)). Therefore, we base our decision on preserving the neurovascular bundle on oncological and potency outcomes and not on continence outcomes.

Does radical prostatectomy cause inguinal hernias?

Several investigators have reported that open radical prostatectomy causes inguinal hernias. Smilow Center surgeons have reported that many of these hernias are pre-existing conditions (Lepor H, Robbins D. Urol. Nov; 70(5):961-4 (2007)). Smilow Center surgeons have pioneered imaging studies to improve the detection of these pre-existing hernias (Marien T, Taouli B, Telegrafi S, Babb J, Lepor H, unpublished data). Based on these clinical observations, we routinely recommend a Valsalva inguinal MRI at the time of the prostate MRI and an upright Valsalva inguinal ultrasound. If a pre-existing hernia is present, we recommend repairing it during the radical prostatectomy.

Will a pelvic lymphadenectomy be performed at the time of radical prostatectomy?

Prostate cancer has a propensity to spread to the pelvic lymph nodes. For this reason, the pelvic lymph nodes are often removed at the time of radical prostatectomy (known as pelvic lymphadenectomy).

Because the risk of pelvic lymph node metastasis is exceedingly rare in men with low-risk disease, it is controversial whether these patients require a pelvic lymphadenectomy. All men with intermediate- or high-risk disease, however, must undergo a pelvic lymphadenectomy. If the prostate cancer is found to have grossly spread to the pelvic lymph nodes, the radical prostatectomy is often aborted.

Is radical prostatectomy associated with significant pain?

Radical prostatectomy, whether open or robotic, is rarely associated with significant postoperative pain. Pain is managed similarly for both approaches: oral narcotic analgesics are usually adequate to control pain after the first postoperative day and throughout the recovery period.

How long is the hospital stay after radical prostatectomy?

At the Smilow Center, the hospital stay after radical prostatectomy is identical for patients undergoing either open or robotic surgery. Once the pelvic drain is removed, a diet of solid food is tolerated and pain is controlled, discharge from the hospital is recommended, provided there is no fever. The overwhelming majority of men reach these milestones within 24 hours after surgery. Over 95% of men are discharged by the second postoperative day.

How long does the urinary catheter remain in place after radical prostatectomy?

Historically, the catheter was left indwelling for a minimum of three weeks. Smilow Center surgeons have pioneered early catheter removal as a way to facilitate recovery from prostate surgery. Smilow center surgeons were the first to publish an article demonstrating both the inconvenience of the urinary catheter and how a urinary catheter impedes return to work and activities (Lepor H, Nieder AM, Fraiman MC. Urol. 58(3):425-9 (2001); Sultan R, Slova D, Thiel B, Lepor H. J Urol. 176(4 Pt 1):1420-3 (2006)).

The initial studies performed by Smilow Center surgeons demonstrated that the urinary catheter can be safely removed if there is no evidence of leakage at the vesicourethral anastomosis (the point where the bladder and urethra have been surgically attached). Encouraged by these studies, Smilow Center surgeons then investigated if it was feasible to remove the catheter as early as postoperative day 3. While the anastomosis had healed in 80% of these cases, over 20% of men developed acute urinary retention, which required emergency catheter replacement (Patel R, Lepor H. Urol. 61(1):156-60 (2003)). Therefore, the Smilow Center recommends performing an imaging study 8 to 10 days after surgery to assess the integrity of the anastomosis. The Smilow Center has pioneered the use of ultrasonography as a safer, less-expensive technique than fluoroscopic cystography for assessing integrity of the anastomosis (Lepor H, Kozirovsky M, Laze J, Telegrafi S. J. Urol.; 180(6):2459-62 (2008); and Telegrafi S, Lepor H, Kozirovsky M, Laze J, Ito T. J. Ultrasound Med., in press).

Smilow Center surgeons demonstrated that administration of an alpha blocker like Flomax or Rapaflo reduces the likelihood of acute urinary retention to negligible levels when the catheter is removed 8–10 days after radical prostatectomy (Patel R, Fiske J, Lepor H. Urol. 62:287-91 (2003)). Therefore, a week of an alpha blocker is initiated on the fourth postoperative day.

In the 90% of men who show little to no leakage at the anastomosis on an ultrasound exam on days 8–10, the urinary catheter is removed. The catheter will be left in place for a longer time if there is evidence of more extensive leakage. Assessing the integrity of the anastomosis provides the opportunity to remove the catheter early in over 90% of cases while also identifying the small group of men who benefit from more prolonged catheter drainage.

Is there an advantage to ‘catheterless’ radical prostatectomy?

Some doctors who specialize in robotic surgery advocate performing a radical prostatectomy without leaving a urinary catheter in place after surgery. Instead, a small tube is inserted directly into the bladder and attached to a urine bag. A ‘catheterless’ open radical prostatectomy is equally feasible.

However, at the Smilow Center, we have found that the small bladder catheter can become occluded with blood clots after a robotic radical prostatectomy , which can necessitate a visit to the emergency room for catheter irrigation. For this reason, Smilow Center surgeons do not offer catheterless open or robotic radical prostatectomy, as the risks far outweigh the benefits.

When may I expect to return to work after radical prostatectomy?

The time to return to work depends both on the type of work and one’s motivation to return to work. The Smilow Center has conducted the only prospective study on the time to return to work after prostatectomy (Sultan R, Slova D, Thiel B, Lepor H. J. Urol. 176(4 Pt 1):1420-3 (2006)). Half of men in the study who underwent open radical prostatectomy returned to work within 2 weeks. We would expect similar results after robotic surgery.

When may I resume physical activities after radical prostatectomy?

The recommendations for resuming physical activities do not depend on whether men undergo an open or robotic procedure. Light exercise such as swimming and light weight lifting may be resumed 2 weeks after surgery. After 3 weeks, we do not recommend any limitations whatsoever, unless a hernia repair has been performed.