What Is Prostate Cancer Surgery: Procedure & Side Effects

Prostate cancer surgery, formally called radical prostatectomy, removes the entire prostate gland along with surrounding tissue to eliminate cancer that has not spread beyond the pelvis. It is one of the most common surgical cancer treatments performed worldwide, and it comes with a well-studied set of trade-offs: strong cancer control on one hand, and a real risk of urinary and sexual side effects on the other. The procedure itself has evolved considerably over the past two decades, with robotic-assisted surgery now the dominant approach in many countries, but the core operation and its consequences remain broadly similar regardless of how the surgeon gets access to the gland.

What Actually Gets Removed

During radical prostatectomy, the surgeon removes the prostate gland in its entirety, along with the seminal vesicles (the small glands behind the prostate that produce part of the seminal fluid). The urethra, which passes directly through the prostate, is cut and then reconnected to the bladder neck. This reconnection, called the vesicourethral anastomosis, is one of the technically demanding parts of the operation, and the quality of this reconstruction has a measurable influence on how quickly urinary control returns afterward.

Depending on the cancer’s aggressiveness, the surgeon may also remove pelvic lymph nodes. This step, called pelvic lymph node dissection, serves a dual purpose: it provides the most accurate staging information about whether cancer has spread to nearby nodes, and it may offer a therapeutic benefit by clearing small pockets of disease that imaging cannot detect.¹ An extended dissection that includes the external iliac, obturator, and hypogastric nodes is now recommended for patients undergoing the procedure.² For low-risk cancers, however, the benefit of lymph node dissection remains uncertain.

Open, Laparoscopic, and Robotic Approaches

There are three basic ways to perform a radical prostatectomy. Open surgery uses a single incision in the lower abdomen (or, less commonly, the perineum) and gives the surgeon direct manual access to the prostate. Laparoscopic surgery uses several small incisions and long instruments guided by a camera. Robot-assisted laparoscopic prostatectomy, often called RARP, uses the same keyhole approach but with a surgical robot that the surgeon controls from a console. The robot adds three-dimensional magnified vision and instruments that bend and rotate beyond what a human wrist can do.

Compared with open surgery, robotic and laparoscopic approaches tend to result in substantially less blood loss, fewer transfusions, and a shorter hospital stay, though the operations themselves take longer.³ On the cancer-control side, robotic surgery has been linked to fewer positive surgical margins for organ-confined tumors, meaning cancer cells are less likely to be found at the cut edge of tissue. Sexual and urinary outcomes at twelve months also tend to favor the robotic approach over open surgery.⁴

These differences sound decisive, but they deserve context. The skill of the individual surgeon matters at least as much as the tool used. A highly experienced open surgeon can produce outcomes comparable to, or better than, a less experienced robotic surgeon. Still, the trend in high-volume centers has moved decisively toward robotic surgery, and most patients in countries where the technology is available will encounter RARP as the default recommendation.

Nerve-Sparing Technique and Why It Matters

Running along each side of the prostate are the neurovascular bundles, delicate clusters of nerves and blood vessels that control erections and play a supporting role in urinary control. The central technical challenge of radical prostatectomy is separating the prostate from these bundles without damaging them. When the cancer’s location allows it, the surgeon performs a “nerve-sparing” approach, carefully peeling the prostate away from the bundles on one or both sides.

Preserving the pelvic floor structures around the prostate, including a layer of tissue called the endopelvic fascia and the connective tissue near the prostatic apex, is critical to maintaining both continence and erectile function after surgery.⁵ The different planes of dissection the surgeon chooses (intrafascial, interfascial, or extrafascial) represent a sliding scale between preserving as much nerve tissue as possible and removing as wide a margin around the cancer as possible. When cancer sits close to or touches the neurovascular bundle on one side, the surgeon may sacrifice that bundle to avoid leaving cancer behind.

Urinary Incontinence After Surgery

Leaking urine is the side effect that catches many patients off guard, both in how common it is early on and in how much it can improve over time. Nearly every man has some degree of urinary incontinence immediately after the catheter is removed, typically one to two weeks post-surgery.⁶ This happens because the internal sphincter at the bladder neck, which was supported by the prostate, is gone. The external urinary sphincter lower down must now do the full job of keeping you dry.

For most men, continence improves substantially over the first year. One large series found that by two years, about 95 percent of patients achieved continence when a refined surgical technique was used, with the median time to continence around a month and a half.⁷ But recovery is not guaranteed for everyone. Several factors push the odds in the wrong direction: older age at the time of surgery, higher body weight, pre-existing urinary symptoms, shorter anatomic urethral length, damage to the neurovascular bundles during surgery, and development of scar tissue at the reconnection site.⁸

Pelvic floor muscle training, essentially Kegel exercises, is the first-line approach to regaining continence. A meta-analysis found that men who did these exercises showed significant improvement at every time point from one month through twelve months after surgery.⁹ Starting the exercises before surgery may also help. One randomized trial found that men who began pelvic floor training before their operation were roughly twice as likely to be continent at one and three months compared to those who started only afterward.¹⁰ A broader review, however, suggests this preoperative benefit accelerates early recovery rather than changing long-term outcomes: the advantage was clear at three months but disappeared by six months.¹¹ Still, earlier return to continence matters for quality of life, so most surgical teams now encourage patients to start pelvic floor work before the operation date.

When Incontinence Persists

For the minority of men whose leakage does not resolve with time and exercises, surgical options exist. The artificial urinary sphincter, a small implanted device with an inflatable cuff around the urethra and a manual pump placed in the scrotum, has been the gold standard for severe post-prostatectomy incontinence for decades.¹² Male slings, which use a strip of material to compress and support the urethra, offer a less mechanically complex alternative that does not require the patient to operate a pump.¹³ Both approaches reduce pad use by about three pads per day on average, with cure rates around 60 percent and meaningful improvements in quality of life.¹⁴ Slings tend to work best for mild to moderate leakage, while the artificial sphincter is better suited for more severe cases.

Erectile Dysfunction and Sexual Changes

Erectile dysfunction is the other major side effect, and the one many men worry about most. Even with a full bilateral nerve-sparing operation performed by an expert, erections are disrupted after surgery because the cavernous nerves that run along the prostate are bruised or stretched during dissection. These nerves control the release of nitric oxide, the chemical signal that relaxes smooth muscle in the penis and allows blood to flow in and produce an erection. After surgery, those nerves can take eighteen to twenty-four months to recover, and during that window, natural erections from sexual arousal or sleep may be absent entirely.¹⁵

This slow nerve-healing timeline explains a frustrating paradox that patients encounter: the oral medications that work for most other types of erectile dysfunction, such as sildenafil (Viagra) and tadalafil (Cialis), are often ineffective in the months right after surgery. These drugs work by preserving nitric oxide once it is released. When the nerves are not yet producing nitric oxide at all, there is nothing for the pill to preserve. As the nerves gradually recover, oral medications become progressively more useful.

The concept of “penile rehabilitation” emerged from the idea that keeping blood flowing to erectile tissue during the nerve-recovery window might prevent structural changes (like scarring and shrinkage) that would make erections harder to achieve later. In practice, this usually means starting oral medications, vacuum erection devices, or penile injections soon after surgery. A meta-analysis found that these rehabilitation methods do improve erectile function during the treatment period, but after stopping the medications, there was no clear improvement in spontaneous erections compared to doing nothing.¹⁶ The clinical evidence remains mixed enough that rehabilitation is still widely recommended, but expectations should be realistic: it helps maintain function while you are using the treatments, and biological recovery of the nerves sets the ultimate ceiling.¹⁷

A less-discussed sexual side effect is climacturia, the involuntary leakage of urine during orgasm. A systematic review across more than five thousand procedures found an overall prevalence of about 27 percent.¹⁸ Many men never hear about it before surgery, and the surprise can be distressing. Pelvic floor exercises and techniques like constricting the base of the penis before climax can reduce it. Surgeons and patients rarely discuss this preoperatively, which is a gap worth closing.

Surgical Complications Beyond Continence and Erections

Radical prostatectomy is a major operation, and like any major surgery it carries general perioperative risks. In a large population-based study, about one in five men had at least one complication within thirty days, and the thirty-day mortality rate was around 0.5 percent. Older age and existing health conditions both increased the likelihood of cardiac, respiratory, and other medical complications.¹⁹ Robotic surgery appears to have improved these numbers in experienced hands: a single-surgeon series of 2,500 robotic prostatectomies found complications in about 5 percent of patients, nearly all of them minor, with no deaths.²⁰ The gap between these numbers reflects both the evolution from open to robotic surgery and the reality that a high-volume surgeon’s complication rate will look very different from a population average that includes every hospital in a country.

Preoperative frailty, independent of age, is an emerging factor in predicting who will do poorly. A meta-analysis found that frail patients had roughly triple the risk of dying from any cause and nearly double the risk of severe postoperative complications compared to non-frail patients.²¹ Frailty screening and overall fitness, rather than age alone, should factor heavily into the decision to operate.²²

Enhanced Recovery Protocols and the Hospital Stay

The experience of being in the hospital for prostate cancer surgery has changed considerably with the adoption of “enhanced recovery after surgery” (ERAS) protocols. These are structured care plans that bundle together elements like limiting fasting before surgery, reducing opioid use, encouraging early walking, and removing drains sooner. Meta-analyses consistently show that ERAS protocols shorten hospital stays significantly.²³ One study of robotic prostatectomy found that an opioid-sparing ERAS pathway cut the average stay from about 1.7 days to 1.2 days and more than halved postoperative opioid consumption.²⁴ ERAS also reduces complication rates and gets patients back to eating and walking sooner.²⁵ If your surgical center does not use an ERAS protocol, it is reasonable to ask why.

Cancer Control and Positive Surgical Margins

The primary goal of the operation is to remove all the cancer. One of the key quality markers examined on the pathology report afterward is whether the surgical margins are “positive” or “negative.” A positive surgical margin means cancer cells extend to the inked edge of the removed tissue, suggesting that some cancer may have been left behind. Positive margins are consistently linked to a higher risk of biochemical recurrence, which is a rise in PSA after surgery that signals the cancer may be returning.²⁶

Not all positive margins carry the same weight. The size of the margin, how many spots are positive, where on the prostate they occur, and the aggressiveness of the cancer cells at the margin all influence the actual risk of recurrence. One study found that patients with positive margins experienced biochemical recurrence at a median of about 19 months, compared to about 28 months for those with negative margins.²⁷ A positive margin does not mean the cancer will inevitably return, but it does raise a conversation about whether additional treatment like salvage radiation should follow. When salvage radiation is given early, particularly when the PSA is still very low, close to half of patients remain disease-free at six years.²⁸

Surgery Versus Other Treatments

Prostate cancer treatment decisions are rarely straightforward because for many men, particularly those with low-risk disease, the cancer grows so slowly that aggressive treatment may cause more harm than the disease itself would. A clinical decision analysis modeling 65-year-old men with low-risk prostate cancer found that surgery added about 0.3 years of life expectancy over active surveillance, but also added an average of 1.6 extra years living with impotence or incontinence.²⁹ When quality of life was factored in, the net benefit effectively disappeared.

When comparing surgery to radiation therapy for localized disease, randomized trials have found no clear difference in overall survival or prostate-cancer-specific survival. Short-term trade-offs differ: surgery causes worse early continence and erectile function, while radiation causes more early urinary irritation and bowel problems. By five years, these functional differences between the two treatments largely narrow.³⁰ Surgery does offer one structural advantage: it produces a pathology specimen that can be examined in detail, giving the clearest possible picture of the cancer’s extent. This information can guide whether additional treatment is needed. Radiation, by contrast, leaves the prostate in place, which makes monitoring for residual or recurrent disease more complex.

Psychological Impact and Quality of Life

Surgery’s effect on mental health is an underappreciated dimension. The period between diagnosis and treatment is often marked by significant anxiety and depression, and there is evidence that successful surgery improves both. One study found that quality-of-life scores rose substantially in the first month after surgery, and measures of anxiety and depression both dropped by roughly 40 to 45 percent from their preoperative levels.³¹ This makes intuitive sense: the cancer has been physically removed, the uncertainty of “what now” has been resolved, and the patient has a clear pathology result and a follow-up plan. That said, the urinary and sexual side effects discussed above impose their own psychological burden over the months that follow, and some men experience a delayed emotional dip when the initial relief of surgery fades and the reality of functional recovery sets in.

How Genomic Testing Is Changing Post-Surgery Decisions

After surgery, the pathology report tells you the cancer’s grade, stage, and margin status. Increasingly, genomic classifier tests performed on the removed tissue can add another layer of information. These tests analyze patterns of gene activity to estimate the risk that the cancer will spread, which can meaningfully change what happens next. In one study, knowledge of genomic classifier results shifted treatment recommendations: observation increased by 20 percent for patients the test classified as low risk for metastasis, while treatment recommendations increased by 16 percent for those classified as high risk.³² RNA expression tests are gaining particular traction, enabling more personalized decisions about whether to add radiation or hormone therapy after surgery.³³ Challenges remain around implementation and clinician confidence in interpreting these tools, but the direction is clear: the post-surgery conversation is becoming more individualized than “your margins were positive, so let’s add radiation.”³⁴