Prostate Cancer Surgery

Introduction

If you have been diagnosed with prostate cancer and surgery is one of the treatment options being discussed, you are likely weighing a number of difficult questions at once. How will surgery affect your urinary control? What about sexual function? How long is recovery? And how do the different surgical approaches — open, laparoscopic, and robotic-assisted — actually compare?

This guide is written for men who already have a prostate cancer diagnosis and are now planning the next step of care. It explains what prostate cancer surgery is, when it is considered, what alternatives exist, how the different surgical approaches differ, what to expect during preparation, the operation itself, and recovery, and how follow-up unfolds in the months and years after surgery. The aim is to help you have a more informed conversation with your urologist or uro-oncologist, not to replace that conversation.

Prostate cancer behaves very differently from one man to the next. Some cancers grow slowly and may never cause harm in a person’s lifetime; others need prompt and active treatment. Surgery is one of several options that doctors may consider, and the right path is highly personal.

What Is Prostate Cancer Surgery?

Prostate cancer surgery is an operation to remove cancer from the prostate gland. In most cases, this means removing the entire prostate gland along with the seminal vesicles — the small structures that sit just behind the prostate and produce part of the fluid in semen. This operation is called a radical prostatectomy.

The prostate is a walnut-sized gland that sits below the bladder and in front of the rectum. The urethra — the tube that carries urine out of the body — passes through the middle of it. Because of this position, surgery on the prostate is closely connected to urinary control, and the nerves that control erections lie on either side of the gland. Understanding this anatomy helps explain why urinary and sexual side effects are common concerns after surgery.

The main goals of radical prostatectomy are:

• Remove the entire prostate gland with its capsule intact
• Remove the seminal vesicles
• Sample or remove pelvic lymph nodes when the risk of cancer spread is high enough to warrant it
• Achieve clear surgical margins — meaning no cancer cells are found at the cut edges of the removed tissue
• Where possible and safe, spare the nerves and tissue that contribute to urinary control and erections

After the prostate is removed, the surgeon reconnects the bladder directly to the urethra so that urination can resume once healing has occurred.

Why Is Prostate Cancer Surgery Performed?

Surgery is one of several treatments doctors consider when prostate cancer is judged to need active treatment rather than monitoring. The most common reason to perform radical prostatectomy is to treat cancer that is still confined to the prostate, with the goal of curing the disease.

Doctors typically consider surgery in the following situations:

• Localised prostate cancer — cancer that appears to be contained within the prostate gland
• Selected locally advanced cancer — cancer that has begun to extend just beyond the prostate but has not spread to distant sites; in such cases surgery may be combined with radiation or hormone therapy
• Intermediate- or high-risk cancers in men who are otherwise healthy and have a reasonable life expectancy

Risk is judged using a combination of PSA (prostate-specific antigen) blood levels, the Gleason score or ISUP grade group (a measure of how aggressive the cancer cells look under the microscope), the extent of cancer on biopsy, and imaging such as multiparametric MRI. Major guidelines from the American Urological Association (AUA), the European Association of Urology (EAU), and the National Comprehensive Cancer Network (NCCN) group prostate cancers into risk categories that help guide whether surgery, radiation, or active surveillance is most appropriate.

Surgery is generally not the first choice when:

• Cancer has spread to distant organs or bones (metastatic disease), where systemic treatment becomes the focus rather than removal of the prostate
• Other serious medical conditions make general anaesthesia and pelvic surgery unsafe
• Life expectancy from other causes is short enough that the cancer is unlikely to cause symptoms before then
• The cancer is very low-risk and unlikely to progress, in which case active surveillance may be preferred

Who Is a Candidate?

Whether you are a candidate for prostate cancer surgery depends on several overlapping factors:

• Cancer stage and grade. Surgery is most commonly used when cancer is still inside the prostate or has only just begun to extend beyond it.
• PSA level. Very high PSA values may suggest the cancer has already spread beyond what surgery alone can address.
• General health and fitness for anaesthesia. Heart, lung, and kidney function are reviewed before surgery is offered.
• Age and life expectancy. Guidelines from AUA and EAU broadly suggest that surgery is most likely to benefit men whose life expectancy is at least around ten years, because the survival benefit takes time to appear.
• Personal priorities. Some men prioritise removing the cancer with the option of knowing exactly what was found on final pathology; others prioritise avoiding surgery if a non-surgical option offers comparable cancer control.

The decision is rarely simple, and second opinions are common and welcomed in this space. Discussion with both a surgeon and a radiation oncologist is often valuable, because each will best understand the strengths and limits of their own approach.

Alternatives to Surgery

Prostate cancer surgery is one of several treatment paths. Major societies stress that for many men with localised disease, more than one option is reasonable, and the choice depends on the cancer’s risk profile and the patient’s preferences regarding side effects.

Active Surveillance

For low-risk prostate cancer — small, low-grade tumours unlikely to spread — active surveillance is often recommended by current AUA, EAU, and NCCN guidelines as a first option. This involves close monitoring with PSA tests, repeat MRI scans, and follow-up biopsies. Treatment is started only if signs of progression appear. The aim is to avoid the side effects of treatment in men whose cancer may never need it.

Watchful Waiting

Watchful waiting differs from active surveillance. It is generally chosen for men with a shorter life expectancy or significant other illnesses, where the goal is to treat symptoms if and when they appear rather than to attempt cure.

Radiation Therapy

Radiation is the other main curative treatment for localised prostate cancer. It can be delivered as:

• External beam radiation therapy — high-energy beams aimed at the prostate over several weeks
• Brachytherapy — tiny radioactive seeds placed inside the prostate, either as a permanent low-dose implant or as a temporary high-dose treatment

For many risk categories, randomised studies have shown that radiation and surgery offer broadly comparable long-term cancer control, but with different side effect profiles. Surgery tends to carry a higher early risk of urinary incontinence and erectile dysfunction; radiation tends to carry a higher risk of bowel side effects and late urinary irritation. Hormone therapy is often combined with radiation in intermediate- and high-risk disease.

Focal Therapies

Treatments such as high-intensity focused ultrasound (HIFU) and cryotherapy aim to destroy only the cancerous part of the prostate rather than remove the whole gland. These are options in selected cases at specialist centres. Guidelines currently regard them as alternatives with less long-term outcome data than surgery or radiation, and they may not be appropriate for higher-risk disease.

Hormone Therapy

Hormone therapy (androgen deprivation therapy) lowers testosterone, which prostate cancer cells depend on to grow. It is not usually used by itself as a curative treatment for localised disease, but it is often combined with radiation in intermediate- and high-risk cancer, and it plays a central role in treating advanced or metastatic disease.

Whether one of these alternatives might suit your situation better than surgery is a clinical decision made together with your specialists.

Surgical Approaches

Radical prostatectomy can be performed through several different surgical approaches. All achieve the same basic goal — removing the prostate and seminal vesicles and reconnecting the bladder to the urethra — but they differ in how the surgeon reaches the prostate.

Open Radical Prostatectomy

In the open approach, the surgeon makes a single incision in the lower abdomen (the retropubic approach) to reach the prostate. A less common variation, perineal prostatectomy, uses an incision between the scrotum and the anus, although this is rarely performed today.

Open surgery has been performed for many decades and remains a well-established option, particularly in centres without robotic technology. It allows the surgeon to feel the tissues directly. However, it typically involves a larger incision, somewhat more blood loss, and a longer hospital stay than minimally invasive approaches.

Laparoscopic Radical Prostatectomy

In the laparoscopic approach, the surgeon makes several small incisions in the abdomen and uses long, thin instruments and a camera to perform the operation. Carbon dioxide gas is used to gently inflate the abdomen and create working space.

Compared with open surgery, laparoscopic prostatectomy generally involves smaller scars, less blood loss, and shorter hospital stay. However, performing the delicate pelvic dissection with rigid laparoscopic instruments is technically demanding, and pure laparoscopic prostatectomy is less commonly performed now that robotic-assisted surgery is widely available.

Robotic-Assisted Radical Prostatectomy

Robotic-assisted radical prostatectomy is a form of laparoscopic surgery in which the surgeon operates the instruments through a robotic console. The robot translates the surgeon’s hand movements into very precise movements of small wristed instruments inside the body. The view is magnified and three-dimensional.

In many high-volume centres around the world, including in India, robotic-assisted radical prostatectomy has become the most common surgical approach for prostate cancer. Reported advantages include very small incisions, lower blood loss, shorter hospital stay, and potentially better visualisation of the nerves that affect erectile function and the structures that affect urinary control.

Importantly, large studies comparing robotic and open prostatectomy have found that long-term cancer control outcomes are broadly similar when surgery is performed by experienced surgeons. The surgeon’s experience and the volume of cases done by the team appear to influence functional outcomes (urinary continence, erectile function) more than the choice of approach alone.

Nerve-Sparing Technique

Regardless of approach, when the cancer’s location and aggressiveness allow, the surgeon may use a nerve-sparing technique. The neurovascular bundles that supply the erectile nerves run very close to the prostate. Careful preservation of these bundles increases the chance of recovering erectile function after surgery. Nerve sparing may be done on one or both sides, depending on where the cancer is located. When cancer involves the nerves closely, the surgeon will not spare those tissues, as cancer control takes priority over function.

Pelvic Lymph Node Dissection

In men with intermediate- or high-risk cancer, the surgeon may also remove the lymph nodes in the pelvis at the same operation. This is done both to check whether cancer has spread there and, in some cases, to remove microscopic disease. Whether and how widely to perform lymph node dissection is decided based on the risk category.

Preparing for Prostate Cancer Surgery

Preparation usually takes place over several weeks. Your urological team will arrange a series of evaluations to confirm the cancer’s extent and to make sure surgery and anaesthesia are safe for you.

Typical pre-surgical evaluations include:

• PSA blood test to confirm the most recent value
• Review of the prostate biopsy — sometimes the original slides are reviewed at the treating centre
• Multiparametric MRI of the prostate if not already done, to map the cancer’s location
• Bone scan and CT scan, or PSMA PET scan in higher-risk cases, to check for signs of spread
• Routine blood tests, ECG, and chest imaging
• Cardiac and anaesthesia review to confirm fitness for general anaesthesia

Your team will also discuss the following:

• Medications. Blood thinners such as aspirin, clopidogrel, or warfarin may need to be paused several days before surgery, under medical guidance. Diabetes medications and blood pressure medications may also be adjusted.
• Pelvic floor exercises. Starting pelvic floor (Kegel) exercises before surgery is commonly suggested to support continence recovery afterwards.
• Bowel preparation. A light bowel preparation or laxative the night before surgery is often advised.
• Fasting. You will be asked not to eat or drink for several hours before the operation.
• Smoking and alcohol. Stopping or significantly reducing both well before surgery helps healing.

You will sign a consent form after a detailed discussion of the planned operation, the surgical approach, the likelihood of nerve sparing, the chance of needing further treatment after surgery, and the main risks.

What Happens During Prostate Cancer Surgery

Radical prostatectomy is performed under general anaesthesia, meaning you will be fully asleep. The operation typically takes two to four hours, although this can vary with the approach, the complexity of the case, and whether lymph node dissection is included.

A general outline of what happens during the operation:

1. Anaesthesia and positioning. You are given general anaesthesia and positioned on the operating table. For laparoscopic and robotic approaches, the table is tilted so that your head is lower than your pelvis, which helps move the intestines out of the surgical field.
2. Access. The surgeon makes either one larger incision (open surgery) or several small incisions for ports (laparoscopic or robotic surgery).
3. Exposing the prostate. The surgeon carefully works through the tissues of the pelvis to reach the prostate gland.
4. Lymph node dissection (if planned) is performed.
5. Nerve-sparing dissection (if appropriate) is carried out along the sides of the prostate.
6. Removal of the prostate and seminal vesicles. The prostate is separated from the bladder above and the urethra below, and the seminal vesicles are removed with it.
7. Reconstruction. The bladder is then carefully stitched to the remaining urethra to restore a continuous urinary passage.
8. Urinary catheter. A catheter is placed through the urethra into the bladder to allow the new connection to heal.
9. Closure. The incisions are closed. A small drain may be left in place for a day or two.

The removed tissue is sent to the pathology laboratory. The final pathology report — usually available within one to two weeks — provides important information about the true stage of the cancer, the grade, whether the surgical margins are clear, and whether any lymph nodes contain cancer cells. This report often guides whether any additional treatment is needed.

Recovery and Healing

In Hospital

Hospital stay is typically one to three days after minimally invasive surgery and a little longer after open surgery. While in hospital, you will be encouraged to:

• Get up and walk within 24 hours, which helps reduce the risk of blood clots and pneumonia
• Use breathing exercises
• Begin drinking fluids and gradually return to a normal diet
• Receive pain relief, antibiotics if needed, and blood-thinning injections to reduce clot risk

The First Few Weeks at Home

You go home with a urinary catheter in place, usually for around 7 to 14 days. The catheter allows the new connection between the bladder and urethra to heal. Your team will explain how to care for the catheter and what to watch for.

During the first one to two weeks:

• Walking gently is encouraged
• Heavy lifting (anything more than a few kilograms), driving, and strenuous activity are avoided
• Pain is usually mild to moderate and well controlled with simple medication
• Some bruising or swelling around the incisions or scrotum is common

The catheter is removed in a clinic visit. After removal, urinary leakage is normal at first, and pads are used to manage this.

Weeks Three to Six

Most men return to desk work and light activities around three to four weeks after surgery, and to more moderate activity by around six weeks. Strenuous exercise and heavy lifting are usually avoided for at least six weeks to allow internal healing.

Continence Recovery

Urinary control returns gradually. In the first weeks, leakage is common, particularly with coughing, lifting, or standing up. Pelvic floor exercises are central to recovery and are often guided by a pelvic floor physiotherapist. Most men see steady improvement over three to six months, with continued improvement up to twelve months. A smaller number of men have longer-term leakage, for which further treatments may be considered.

Sexual Function Recovery

Erectile function takes longer to recover than continence. Even when nerves are spared, the nerves are bruised by surgery and need many months to recover. Most men experience reduced erections in the early months. Recovery, when it occurs, typically takes six to eighteen months and may be incomplete.

Doctors often suggest penile rehabilitation — the use of medications such as PDE5 inhibitors (for example, sildenafil or tadalafil), vacuum devices, or other treatments early after surgery — to improve the chances of recovery. The likelihood of recovering useful erectile function depends on age, pre-operative function, whether nerves were spared on one or both sides, and other health factors. Even with nerve sparing, some men will not regain pre-surgery erectile function.

It is also important to understand that after radical prostatectomy:

• Ejaculation no longer produces semen (so-called “dry orgasm”), because the prostate and seminal vesicles, which produce most of the seminal fluid, have been removed
• Natural fertility is no longer possible after surgery, although orgasm itself is usually still possible
• Men who may wish to father children in the future are typically advised to consider sperm banking before surgery

Risks and Complications

As with any major operation, radical prostatectomy carries risks. Many are uncommon, but it is important to be aware of them.

Functional side effects

• Urinary incontinence — usually improving over months but sometimes persistent
• Erectile dysfunction — common in the early months, with variable recovery
• Change in penile length, in some men
• Climacturia (leakage of urine during orgasm) in some men

Surgical complications

• Bleeding, occasionally requiring transfusion
• Infection of wounds or the urinary tract
• Injury to nearby structures such as the rectum, ureters, or nerves (uncommon)
• Lymphocele — a collection of lymph fluid in the pelvis if lymph nodes were removed
• Bladder neck contracture — narrowing where the bladder was reconnected to the urethra
• Hernia at incision sites

General risks of major surgery and anaesthesia

• Blood clots in the legs or lungs
• Heart and lung complications, particularly in older men or those with existing conditions
• Reactions to anaesthesia

Complication rates are influenced by surgeon and centre experience. Studies consistently suggest that high-volume centres tend to report lower rates of major complications and better functional recovery.

Adjuvant and Salvage Treatments

Surgery does not always end the cancer journey. Depending on the final pathology and on PSA levels in follow-up, your team may discuss additional treatments.

Reasons additional treatment may be considered include:

• Cancer extending to the edge of the removed tissue (positive surgical margins)
• Cancer extending into the seminal vesicles or beyond the prostate capsule
• Cancer found in lymph nodes
• PSA that does not fall to very low levels after surgery, or that rises during follow-up (biochemical recurrence)

Possible treatments in these situations include:

• Radiation therapy directed at the prostate bed and sometimes nearby lymph nodes. Current guidelines from AUA and EAU describe a preference in many cases for early salvage radiation — starting radiation when the PSA begins to rise — rather than giving radiation routinely to everyone immediately after surgery.
• Hormone therapy, sometimes combined with radiation
• Newer systemic therapies in selected advanced or recurrent cases, guided by an oncologist

Close PSA monitoring after surgery makes it possible to detect recurrence early, when additional treatment is more likely to be effective.

Follow-up and Long-term Surveillance

A typical follow-up schedule includes:

• PSA blood tests every three to six months in the first years, then less frequently if PSA remains undetectable
• Periodic review with your urologist or oncologist
• Imaging only if PSA rises or symptoms appear

A rise in PSA above a defined threshold after surgery is called biochemical recurrence. It does not always mean the cancer has come back in a way that needs immediate treatment, but it triggers a careful review and discussion of next steps.

Follow-up also includes attention to:

• Urinary continence and pelvic floor recovery
• Sexual function and ongoing penile rehabilitation
• Bone health, particularly if hormone therapy is given
• General health, including cardiovascular risk factors

Life After Prostate Cancer Surgery

Most men gradually return to their usual activities over the weeks and months after surgery. Returning to work depends on the type of job: desk-based work is often possible within a few weeks, while physically demanding work may take longer.

Several aspects of life can be affected for some time after surgery:

• Continence. Many men no longer need pads after a few months. Some continue to use a thin pad as a precaution; a smaller number have ongoing leakage that may benefit from further treatment.
• Sexual function and intimacy. Open conversations with your partner, and where helpful with a counsellor or sexual health specialist, can make this adjustment easier. Treatments for erectile dysfunction range from oral medications to injections, vacuum devices, and in selected cases, penile implants.
• Fertility. Natural fertility ends after radical prostatectomy. Men who wish to father children should consider sperm banking before surgery.
• Emotional health. A cancer diagnosis and surgery can have a significant emotional impact. Anxiety about recurrence, mood changes, and adjustment to body changes are common. Support groups, counselling, and partner support all play a role.
• Lifestyle. Maintaining a healthy weight, regular physical activity, a balanced diet, not smoking, and limiting alcohol all support long-term health.

Long-term cancer control after surgery is generally good for men with localised disease, particularly when the cancer is fully removed with clear margins. Specific outcome figures vary widely depending on cancer risk category, surgeon and centre, and individual factors. Your urologist or oncologist can give you a personalised picture based on your pathology and PSA pattern.

Frequently Asked Questions

Is surgery always the best treatment for prostate cancer?

No. For many men with low-risk prostate cancer, active surveillance is recommended by current AUA, EAU, and NCCN guidelines. For intermediate- and high-risk localised cancer, both surgery and radiation therapy (often combined with hormone therapy) are accepted options with broadly comparable long-term cancer control. The right choice depends on the cancer’s risk profile, your overall health, and how you weigh the different side effect patterns. A discussion with both a urologist and a radiation oncologist is often helpful.

How long is the hospital stay after radical prostatectomy?

Hospital stay is usually one to three days after robotic or laparoscopic surgery and may be a little longer after open surgery. The catheter stays in place for about 7 to 14 days after you go home.

Will I lose urinary control permanently?

Most men experience some urinary leakage in the first weeks after surgery. Continence usually improves steadily over three to twelve months. Pelvic floor exercises play an important role in recovery. A smaller number of men have persistent leakage, which may be managed with further treatments if needed.

Will I be able to have erections after surgery?

Erectile function is often reduced in the early months after radical prostatectomy, even when nerves are spared. Recovery, when it occurs, typically takes six to eighteen months. The likelihood of recovering useful erections depends on age, pre-surgery function, whether nerves were spared on one or both sides, and other health factors. Penile rehabilitation strategies, including medications, are commonly offered after surgery.

Can I still have children after prostate cancer surgery?

Natural fertility is not possible after radical prostatectomy because the prostate and seminal vesicles are removed, and the connections that allow sperm to reach the ejaculate are interrupted. Men who may wish to father children in the future are typically advised to bank sperm before surgery.

How is robotic surgery different from open or laparoscopic surgery?

All three approaches remove the prostate and seminal vesicles. Robotic and laparoscopic approaches use small incisions and tend to involve less blood loss and shorter hospital stay than open surgery. Robotic surgery adds wristed instruments, magnified 3D vision, and very fine movement control. Long-term cancer control is broadly similar across approaches in experienced hands; surgeon experience strongly influences outcomes.

What does it mean if my PSA rises after surgery?

A rising PSA after radical prostatectomy is called biochemical recurrence. It suggests that some prostate cells may remain, but it does not always indicate cancer that needs immediate treatment. Your team will look at how quickly the PSA is rising, how soon after surgery it started rising, and the original cancer features. Options may include continued monitoring, salvage radiation, or hormone therapy depending on the situation.

Will I need radiation or hormone therapy after surgery?

Not always. Many men with localised, lower-risk cancer who have clear margins and an undetectable PSA after surgery need no further treatment. Additional treatment is considered when pathology shows extension beyond the prostate, positive margins, lymph node involvement, or when PSA begins to rise during follow-up.

How experienced should my surgeon be?

Surgeon and centre experience meaningfully influence both cancer control and recovery of urinary and sexual function. It is reasonable to ask your surgeon how many radical prostatectomies they perform each year and what their typical functional outcomes look like. High-volume centres and experienced uro-oncology teams tend to report better results.

Conclusion

Prostate cancer surgery is a major treatment decision, and the right choice is highly individual. Radical prostatectomy, performed through open, laparoscopic, or robotic-assisted approaches, is a well-established option for many men with localised prostate cancer, with the potential for long-term cancer control. At the same time, it brings real considerations around urinary control, sexual function, and fertility that deserve careful thought before treatment begins.

Equally important is that surgery is not the only path. Active surveillance, radiation therapy with or without hormone therapy, and in selected cases other options, may suit different men better depending on the cancer’s risk profile and personal priorities. Current guidelines from the AUA, EAU, and NCCN all emphasise shared decision-making between the patient and a multidisciplinary team.

If surgery is the path you and your team choose, understanding what to expect — from preparation and the operation itself to catheter care, pelvic floor recovery, sexual rehabilitation, and long-term PSA follow-up — can help you face each stage with more confidence. The months after surgery are a process, not a single event, and steady progress is the norm. Your urology and oncology team are your most important partners in shaping the plan that fits your cancer and your life.