Surgery for early prostate cancer
The aim of surgery is to remove your entire prostate gland and the cancer within it. The operation is called a radical prostatectomy.
It involves removing your prostate gland and seminal vesicles, which are the glands that make semen. Sometimes lymph nodes and nearby tissues may be removed as well. The surgeon who removes your prostate gland is called a urologist.
Who can have a radical prostatectomy?
Surgery is suitable if the cancer is found only in your prostate gland and you are fit and healthy. It might not be suitable if you have health problems that can increase the risks linked to surgery, such as heart disease or being very overweight. If you are not suitable for surgery your surgeon will advise you to have one of the other treatments for early prostate cancer.
Surgery to remove your prostate gland is a big operation. It has risks such as bleeding, blood clots and infection. The average stay in hospital is 5-7 days but can be shorter or longer. You will need some time to recover at home afterwards as well.
The aim of surgery is to fully get rid of the cancer. Once the prostate gland is removed, it will be examined under a microscope in the laboratory. The doctor will check the grade of the cancer cells again and that the edges of the prostate gland are clear of cancer.
This is known as checking the margins. Margins are described as negative or positive. Negative margins means that there is no cancer cells at the edge of the prostate gland, while positive margins means, that cancer cells are present at the edge of the prostate. Checking the margins is used to predict your response to the treatment along with PSA checks. Your PSA level should drop within weeks of surgery.
What are the types of surgery?
Surgery to remove your prostate gland can be done in a number of ways. You can discuss with your doctor which type of surgery is best for you. Not all of the treatments are available in all hospitals in Ireland, so discuss your preference with your surgeon.
The main types of prostate surgery are:
Laparoscopic prostatectomy (keyhole surgery)
Robot-assisted laparoscopic prostatectomy (robotic surgery)
There are two ways of doing open surgery. The most common way is through a cut in the wall of your abdomen between your belly button and pubic bone. A radical prostatectomy can also be done through a cut between your scrotum and backpassage, although this is less commonly done. Open surgery is available in hospitals throughout Ireland.
Laparoscopic prostatectomy (keyhole surgery)
With keyhole surgery, small cuts are made in your abdomen so that special instruments can remove your prostate. Afterwards, you need less time in hospital and can move around more easily than with open surgery. There is also less risk of needing a blood transfusion or getting a wound infection after keyhole surgery. The long-term side-effects of this type of operation are the same as for open surgery. Keyhole surgery is a fairly new operation for men with early stage prostate cancer. Only a small number of surgeons in Ireland have had the special training needed to do this operation.
Open radical prostatectomy
Robot-assisted laparoscopic prostatectomy
This operation is like keyhole surgery but with the use of a computer and robotic arms to help remove your prostate. As with keyhole surgery, less time is needed to recover after the operation. There is also less risk of needing a blood transfusion or getting a wound infection. Robotic surgery is fairly new to Ireland. At present it is available to patients with private health insurance and takes place in only a few private hospitals in the country. There are a few surgeons in Ireland who are specially trained to do this operation.
Laparoscopic radical prostatectomy (keyhole surgery)
Sometimes having to remove all of the cancer cells makes it impossible to avoid nerve damage to your prostate gland. In some cases, it is possible to spare nerves on one side of your prostate only. This is called a nerve-sparing prostatectomy. It gives you a better chance of regaining erections than if you had all of the nerves removed, but not as good as if you had both bundles of nerves spared. Discuss with your surgeon if nerve-sparing surgery is possible for you or not. Very often surgeons cannot tell until the operation has begun if they can do a nerve-sparing operation or not.
Which type of surgery is best for me?
There is no evidence that one type of operation is better than another at curing prostate cancer, or that one type of operation is better in terms of side-effects. Two things you might consider are the health cover you have and the skill of the surgeon.
While open surgery and keyhole surgery are available to public and private patients, robotic surgery is only available in some private hospitals in Ireland. There are a few surgeons trained in the skills needed for keyhole surgery. Robotic surgery appears to be as good as open surgery at treating prostate cancer but long-term studies are needed to make sure.
The number of operations that a surgeon has done is important. This can affect the rate of side-effects. You can ask your surgeon how many of the particular type of operation they have done, if you wish.
If you are interested in keyhole surgery or robotic surgery, talk to your specialist team about the advantages and disadvantages of these types of surgery. Ask them where they are available. You could talk to your doctor or nurse for more information about the different types of surgery for prostate cancer. You can call our Cancer Nurseline on 1800 200 700 or visit a Daffodil Centre to speak to a cancer nurse. Find your nearest Daffodil Centre here.
Advantages and disadvantages of prostate surgery
Advantages of prostate surgery
Surgery will completely remove the cancer if it is confined only to the prostate gland.
The prostate can be removed and be fully analysed and staged in the laboratory.
The success of the treatment can be easily assessed by PSA-testing.
If the PSA were to rise after surgery you would still be able to get other treatments like radiotherapy or hormone treatment.
Disadvantages of prostate surgery
It involves a general anaesthetic and the usual risks you would expect with surgery, like the risk of bleeding, infection and blood clots.
It involves a short stay in hospital for a few days.
Recovery takes around 6 weeks.
There may be the possibility of side-effects afterwards like problems with erections and urinary incontinence
You will not be able to father children after the surgery, as the prostate, which normally makes some of the fluid needed for semen to be made, has been removed
To make sure you are fit for surgery, you will need some tests. For example, blood tests, a heart tracing (ECG), chest X-ray and a physical exam. An anaesthetist may also examine you to make sure you are fit for surgery. He or she will also discuss pain relief with you.
Prostate surgery has the same risks as any big operation. These include bleeding and the need for a blood transfusion, chest infection, blood clots and wound infection. Your doctor will discuss these risks and the side-effects of surgery before you sign a consent form.
Before surgery, a physiotherapist or nurse might show you how to do simple exercises to strengthen the muscles that help control your urinary flow. These are called pelvic floor exercises. You will also be shown how to do deep breathing and leg exercises to prevent a chest infection or blood clot afterwards. You may be given some elastic stockings to wear and an injection of an anti-clotting drug like heparin to reduce the chance of blood clots forming in your legs.
You cannot eat or drink anything for a few hours before surgery. The operation takes between 2 and 4 hours but you will spend some time in the recovery room while recovering from the anaesthetic.
When you wake up, you may have drips and tubes attached to your body.
A drip into your arm or neck to give you fluids until you can drink again.
A tube (catheter) to drain urine into a bag.
One or two small drains near your wound to drain away any fluid.
A tube into your back which gives you drugs to relieve any pain.
When you begin to drink again, the drip will be removed. All other tubes and drains will be taken out over the first couple of days, except for the urinary catheter. You will go home with this tube for between 1 and 3 weeks.
You will likely have a special pump for relieving pain. This gives you a constant supply of painkillers, either into your spine (epidural) or into a vein in your arm.
Your nurse will show you how to use it. Often the pump is a patient-controlled pump. This means there is a button on the pump that you can press to release the medication when you need it.
Once the pump is stopped, you can have painkilling tablets. Let your nurse know if you are in any pain so that they can adjust the painkillers for you. You may have mild discomfort for several weeks. Your doctor will give you a prescription for painkillers to take home with you if needed.
Healing of the wounds after surgery usually takes a few weeks. Sometimes they may appear swollen and bruised slightly but this too settles down with time. Healing on the inside of your body will take a bit longer.
The position and appearance of the scar (wound) will depend upon the type of surgery you've had. With open surgery you will have one incision or cut, which will be closed with stitches, surgical clips or staples. With keyhole or robotic surgery you will have a number of smaller cuts.
It is important to keep the wounds clean and dry until healed. Immediately after surgery your wound will be covered with a dressing. Your nurse will advise you how often this will need to be changed and when it can be removed entirely.
Your wound clips might be removed before you leave hospital. Or your practice nurse, public health nurse or GP might remove them when you go home. Contact your GP or the hospital as soon as possible if your wound becomes swollen, red or painful. This could be a sign of infection.
Avoid heavy lifting and manual work for up to eight weeks after the surgery. Your doctor or nurse will be able to advise you about this and also when you can return to driving.
The anaesthetic during surgery may slow down your bowels. As a result, it may take a day or two before you can start eating and drinking normally again. But you will quickly be able to take sips of water. The amount of fluids you can take will then be increased. This side-effect is less common with keyhole or robotic surgery.
Infection and blood clots
A physiotherapist will show you how to do breathing exercises to help prevent a chest infection. He or she will also show you how to cough without hurting yourself and move in bed. You might find it helpful to hold a pillow or folded towel over your wound when you cough for the first few days.
Even when in bed, you should move your legs and do your deep breathing exercises at least once an hour. This will help to prevent blood clots.
On the day after surgery, your nurses will help you get out of bed and take you for a short walk. These walks will become more frequent and longer as you get better. Soon you will be able to go for walks on your own.
The urinary tube will stay in place for between 1 and 3 weeks after your surgery. The urine you make will pass through the tube into a drainage bag. Before you go home, your nurse will show you how to look after the drainage bag. The catheter drainage bag will be worn inside your trousers and will be secured around your lower leg.
It is important that the urine can drain easily from your bladder and into the drainage bag. Try to drink plenty of fluids every day to reduce the risk of getting an infection: between 1.5 and 2 litres is often best. Wash your hands before and after handling the catheter. When washing the catheter entry tip, wash in a one-way direction away from your body. Speak with your nurse if you notice any leaking around the outside of the catheter or if you the notice that the catheter is not draining correctly.
You might experience bladder spasm while the tube is in place. This often feels like a strong urge to pass urine, despite the tube being there. This is normal, but talk to your nurse if this happens to you a lot. Bladder spasm may happen when your bowels move. Your doctor can prescribe medication if this becomes a problem for you.
Preparing to leave hospital
If you have surgery, it is best to plan as much as you can ahead of the discharge date. Ask to speak to a medical social worker about the community services that are available, especially if you live alone. Usually, the public health nurse in your area will visit you at home. Use whatever help is available.
If dressings are needed for your wound, make sure you have some supplies at home before you leave the hospital. Ask for a contact name and telephone number at the hospital so that you can talk to somebody if you have a problem. You may also need help in getting supplies of incontinence pads.
Talk to the public health nurse or a pharmacist about the special pads for men that are available. Make sure you have a supply at home before the urinary tube (catheter) is removed.
Regular light, gentle-paced exercise like taking short walks will help build up your strength after the surgery.
You may notice a change in your bowel habits after surgery. If you are constipated, you might need to drink more fluids and include more high-fibre foods in your diet. Remember if the problem continues, talk to your doctor or nurse who may give you medication (laxatives) to help.
On the day you go home, you will be given a date to have your urinary tube (catheter) removed and often another appointment to see the surgeon. This is usually about 6 weeks after the operation. If you have a worry or symptom that is causing you concern before your check-up date, contact your doctor, nurse or hospital ward for advice.
Removing the urinary tube
You will need to return to the hospital or to your GP to have your urinary tube (catheter) removed. This takes just a few moments. Most likely you will experience some leakage of urine once the tube is removed.
Your nurse will give you an incontinence pad to wear at this time, along with a small supply to take home. She or he can also give you information about how to get a supply of pads for yourself. You may find that you may leak after the catheter has been removed this is not unusual and normally improves with time.
You may find it helpful to read our section Urinary symptoms, catheters and prostate cancer treatment which has more information on how to manage urinary symptoms, as well as how to do pelvic floor exercises.
What are the side-effects of surgery?
The main side-effects of surgery are:
Leakage of urine (urinary incontinence)
Erectile problems (erectile dysfunction)
The length of time that these side-effects can trouble you varies. It is impossible to predict how it will be for you, as each individual differs.
Talking to your doctor and nurse, or another man who has had surgery for prostate cancer may help you to understand the impact of these side-effects might have on your daily life.
It can help to talk to another man who has had treatment for prostate cancer and who has been in a similar situation.
Call our Cancer Nurseline on 1800 200 700 and we can put you in contact with another man who has had prostate cancer who is a trained Survivor Support prostate cancer volunteer.
The risk of urinary leakage is the same for open, keyhole and robotic surgery. You can talk to your surgeon or nurse about the risk of urinary incontinence before you consent to surgery. Urinary incontinence means you cannot control the flow of your urine.
Almost all men will have trouble with leakage of urine in the first weeks and often months after surgery. This means will probably need to wear an incontinence pad to collect the leaked urine. The amount of leakage can vary - from a few drops when you exercise, cough, sneeze or laugh to a much larger amount.
As a result, you need to wear pads to cope with the amount of leakage. As time goes on, you are likely to regain control of your urine flow and will no longer need to wear pads. Or perhaps you will only need one pad a day or just when you exercise.
A small number of men do not regain complete control over their urine flow and need to continue wearing pads. You can report this to your surgeon if it happens. It is rare to need more surgery for problems with incontinence.
However, there are certain surgical techniques which may help improve the situation such as sling surgery. Your doctor will discuss with you which surgical technique would be most suited to you if it was necessary.
How to cope with urinary incontinence
Remember that urinary incontinence usually improves with time. It helps to be prepared in a practical way to cope with the leakage of urine in the first weeks after surgery. For example, make sure you have a supply of incontinence pads at home.
You can get these pads from the hospital before you leave, from your public health nurse or from a pharmacy. Your nurse will also give you information about pads made especially for men. Doing pelvic floor exercises can improve the problem. Your doctor may refer you to a physiotherapist to make sure you can do the exercises properly. She or he can also support you and help you build up some muscle strength.
If you have a medical card, your public health nurse can assess your incontinence and help with a supply of pads. If you have problems that persist, you can contact them for advice and help. If your incontinence persists for a long time, they can also refer you to a continence adviser who can show you ways to cope. You can also contact a continence adviser through your local HSE office. Click here for more information on continence support services.
Call our Cancer Nurseline on 1800 200 700 if you have any questions or need support, or visit your local Daffodil Centre.
Erectile problems after prostate cancer treatment can include:
Erectile dysfunction (impotence)
Shortening of your penis
Erectile dysfunction (impotence)
Surgery to your prostate gland often leads to problems having an erection. This is called erectile dysfunction or impotence. It is caused by damage to blood vessels or nerves near your prostate. Even a small amount of damage can lead to erections failing, especially if you are older and have high blood pressure or diabetes.
If you had problems with erectile dysfunction before surgery, you are more likely to have these problems after surgery too. Up to 7 in 10 men have erectile dysfunction after a radical prostatectomy. Remember, it can take at least a year or two after surgery to find out if the impotence will get better or not.
At first you might find it difficult to get an erection strong enough for sex. Erections are often not as good as they were before surgery and you may never get back the ability to have an erection without treatment. Nerve-sparing surgery can improve your chance of getting your erections back after surgery. Problems with erections can be discussed with your surgeon when you go for check-ups, or talk to your GP or nurse.
Questions to ask the doctor about erectile problems
How could my treatment for prostate cancer affect my sex life?
How soon after my treatment can I masturbate or have sex again?
What are the types of treatment available to help with erections and which might be the most suitable for me?
Are there other options if that treatment does not work?
What other support is available to me or my partner?
For further information please visit our section Sex, Erectile Dysfunction and Prostate Cancer. Call the Cancer Nurseline 1800 200 700 to speak with a cancer nurse in confidence. You can also talk to a cancer nurse at your local Daffodil Centre. Find your nearest Daffodil Centre here.
Early treatment for erectile dysfunction
Taking medication or using vacuum therapy for erectile dysfunction soon after surgery can improve your chance of getting erections back.
At this time you may not even be interested in sex. But taking medication or using a vacuum pump at an early stage may improve your chances of getting erections when you are ready to think about sex again. You can discuss this with your surgeon, nurse or your GP.
After prostate surgery, an orgasm will not cause an ejaculation of semen. This is known as a 'dry orgasm'. Many men describe the sensation of orgasm as different to their orgasm before surgery.
A few men describe it as lasting longer, others describe some pain after orgasm in the early days, or some simply describe it as different. A dry orgasm means that you cannot father a child in the future. If you are planning to have children, it may be possible to store your sperm before surgery.
These can then be used later in fertility treatments. In Ireland, this is done at Rotunda IVF at the Rotunda Hospital in Dublin. Discuss this with your surgeon if you think you might wish to father children after your surgery.
Shortening of your penis
Up to a year after surgery you may notice the length of your penis has shortened. It is not clear what causes this shortening.
Some treatments for erectile dysfunction that encourage blood flow into your penis, such as tablets or the vacuum pump, may help to prevent it.
Vacuum pump suppliers
Call our Cancer Nurseline on Freephone 1800 200 700 to find out about your local vacuum pump supplier.
You will usually be given an appointment to meet the urologist for a post-surgery check-up about six weeks after the operation. This meeting gives the urologist the chance to check that your wounds have healed.
The meeting is also a chance for you to talk about any side-effects that may be worrying you, like urinary or erectile problems. Your urologist will discuss with you the detailed report issued from the laboratory on the tissue that was sent off for examination after the surgery.
This report may give more information on the Gleason score and stage of the prostate cancer as well as the appearance of the margins and if they are clear. You will also have your PSA measured. It is usual for it to fall to below 1 within a few weeks of the surgery.
Other treatments for early prostate cancer
This is a type of treatment which uses special gases to freeze and kill cancer cells.
High intensity focused ultrasound (HIFU)
This is a treatment using sound waves to heat and kill cancer cells.
Both of these treatments are currently being researched to see if they are as effective at treating certain kinds of prostate cancer as other standard type treatments like surgery and radiotherapy.
At present neither of these treatments are available in Ireland but are available in some centres in Europe often under a clinical trial.