The prostate is removed through a surgical procedure called a radical prostatectomy, which takes out the entire prostate gland along with the seminal vesicles and, in some cases, nearby lymph nodes. There are three main approaches: open surgery through a single large incision, laparoscopic surgery through several small incisions, and robotic-assisted surgery where a surgeon controls robotic arms through small incisions. The robotic approach is now the most common method at major medical centers. Regardless of the approach, the core steps are similar: the prostate is separated from the bladder above and the urethra below, then the bladder is stitched directly to the urethra to restore the urinary tract.
Three Surgical Approaches
In an open prostatectomy, the surgeon makes a single incision either in the lower abdomen (from the belly button to the pubic bone) or in the perineum, the area between the scrotum and the anus. The abdominal approach is more common because it gives better access to the lymph nodes nearby. Open surgery involves more blood loss and a longer recovery than the other two methods, but it remains a valid option, particularly at centers where minimally invasive equipment or expertise is limited.
Laparoscopic prostatectomy uses several small incisions in the abdomen instead of one large one. The surgeon inserts long, thin instruments and a small camera to view the surgical area on a screen. This approach typically results in less pain, less blood loss, a shorter hospital stay, and faster recovery compared to open surgery.
Robotic-assisted prostatectomy is a refinement of the laparoscopic technique. The surgeon sits at a console and controls robotic arms that hold the camera and instruments. The robot doesn’t operate on its own. It translates the surgeon’s hand movements into smaller, more precise motions inside the body. This added precision is especially valuable when working around the delicate nerves responsible for erections and the muscles that control urination.
What Happens During the Operation
Although the specific order can vary by surgeon, the major steps of a robotic or laparoscopic prostatectomy follow a general sequence. First, small incisions (typically five or six, each about the width of a fingertip) are made in the abdomen. Carbon dioxide gas is pumped in to inflate the space and give the surgeon room to work.
The surgeon begins by separating the seminal vesicles and the vas deferens from behind the prostate. Then the bladder is moved away from the front of the prostate. If lymph node removal is planned, the nodes on both sides of the pelvis are taken out at this stage. The bladder neck, where the bladder connects to the top of the prostate, is identified and cut through. A cluster of blood vessels running along the front of the prostate is tied off to control bleeding. The prostate is then carefully freed from the surrounding tissue on all sides and separated from the urethra at its base.
Once the prostate is fully detached, it’s placed in a small bag and pulled out through one of the port incisions. The final and arguably most critical step is reconnecting the bladder directly to the urethra. This is done with a continuous running stitch that circles the full connection point. A catheter is threaded through the penis into the bladder before the last stitches are placed, and the connection is tested by filling the bladder with saline to check for leaks.
Nerve-Sparing Technique
Two bundles of nerves run along each side of the prostate and control the ability to get an erection. During a nerve-sparing prostatectomy, the surgeon carefully peels these bundles away from the prostate rather than cutting through them. Whether both bundles, one, or neither can be saved depends on where the cancer is located and how aggressive it appears. Surgeons use preoperative imaging and biopsy results to make this decision before the operation begins.
Even when the nerves are successfully preserved, erections don’t return immediately. The nerves go through a period of “shock” from being stretched, handled, and exposed to the heat of surgical instruments used to stop bleeding. Recovery of erectile function can take anywhere from several months to two years. In cases where the nerves must be cut to ensure all the cancer is removed, nerve grafting is sometimes possible to try to reestablish the connection, though results vary.
When Lymph Nodes Are Removed
For men with intermediate or high-risk prostate cancer, the surgeon typically removes lymph nodes from the pelvis during the same operation. European guidelines recommend this step when the estimated risk of cancer in the nodes exceeds 5%, while U.S. guidelines set the threshold at 2% or higher. The nodes are sent to a pathologist who examines them for cancer cells, which helps determine whether additional treatment is needed after surgery. In extended dissections, the median number of nodes removed is around 23.
Preparing Before Surgery
One of the most useful things you can do before a prostatectomy is start pelvic floor exercises as soon as the surgery is scheduled. These exercises strengthen the muscles that help control urination, and starting early gives you better muscle tone going into surgery, which improves continence recovery afterward.
The routine involves two types of contractions. Slow holds mean tightening the pelvic floor and holding for up to 10 seconds, then relaxing for 4 seconds, repeated up to 10 times. Fast holds mean squeezing as hard as possible for one second, then relaxing, also up to 10 repetitions. The goal is to work up to doing both sets three to six times a day. Start lying down, then progress to sitting and standing as control improves.
Recovery After Surgery
Most people go home one to two days after a robotic or laparoscopic prostatectomy. Open surgery may require a slightly longer stay. You’ll leave the hospital with a urinary catheter in place, which stays in for 7 to 14 days while the connection between the bladder and urethra heals.
Urinary leakage after the catheter comes out is normal and expected. The prostate used to sit between the bladder and the urethra, providing structural support, and the muscles need time to compensate for its absence. About 90% of men who have robotic-assisted surgery regain full urinary control within six months. By 12 months, that number reaches 94%, and very little additional improvement occurs after that point. Continuing pelvic floor exercises after surgery is the single most effective way to speed up this recovery.
Other risks to be aware of include blood clots in the legs (the most significant non-surgical complication of any major pelvic operation), rectal injury during the dissection, and temporary slowing of bowel function. Serious complications are uncommon, particularly with experienced surgical teams.
Monitoring After Prostate Removal
After the prostate is removed, PSA levels in the blood should drop to essentially zero, since the prostate is the primary source of PSA. Your doctor will check PSA levels every 6 to 12 months for the first five years and once a year after that. Any detectable rise in PSA after it has reached zero signals that prostate cancer cells may still be present somewhere in the body and that additional evaluation or treatment may be needed. This simple blood test is the main tool used to catch a recurrence early.