Simply put, radical prostatectomy is feasible for patients with early stage prostate cancer. It has two main indications: 1. The clinical stage of the tumor is early, i.e. organ-confined prostate cancer without metastasis to lymph nodes and bones; 2. The patient’s life expectancy is greater than 15 years. The reason for this stipulation is that radical surgery can only completely remove the tumor inside the prostate, and once the tumor metastasizes to the bones and surrounding lymph nodes, surgery is no longer able to remove these lesions; and when the patient’s life expectancy is only 10 years or less, even if he or she receives radical prostate cancer surgery, he or she cannot benefit from such surgery. This is because there is a high probability that such a patient will die from other diseases, not from prostate cancer, within 10 years even without treatment. So what is the procedure of radical prostate cancer surgery? Radical prostate cancer surgery is usually performed under general anesthesia, and the incision is made in the lower abdomen, extending from the level of the pubic bone upward, 12-15 cm long. The excised lymph nodes are immediately sent for examination, which is called “intraoperative frozen section pathology”. If the lymph nodes have significant metastases, then the patient’s prostate cancer is no longer an early organ-confined tumor and the surgery should be stopped in principle, whereas if no metastases are found in the lymph nodes, then the surgery will continue. This step is important because if the urethra is dissected too close to the prostate, it can cause residual prostate cancer cells, but if it is too far from the prostate, it can damage the urethral sphincter and cause postoperative urinary incontinence. The prostate is then removed at the neck of the bladder, and the vesicourethral glands and vas deferens are also removed on both sides. Finally, the urethra is reconstructed to connect the bladder to the transected urethra, which we call an anastomosis. After the bladder neck is anastomosed to the urethra, a catheter with a balloon is passed through the penis and into the bladder before the end of the surgery. In the final stage of the surgery, the surgeon also places a drainage tube inside the pelvic cavity, which can easily drain the blood and fluid inside the pelvic cavity to prevent postoperative infection. This is the entire procedure of radical surgery for retropubic prostate cancer, which usually takes about 3 hours. Of course, the operation time may vary according to the local anatomical characteristics of the prostate gland of different patients, and there is no direct relationship between the operation time and the result of the operation. Complications after radical prostate cancer surgery and their management There are always postoperative complications in any surgery. So, what are the complications of radical prostate cancer surgery? Urinary incontinence is one of the most dreadful complications after radical prostate cancer surgery. Most patients will not experience permanent incontinence, and even if it occurs, the degree of incontinence is mild, and it only occurs during strenuous exercise. There are three factors associated with postoperative urinary control, the first being the function of the patient’s sphincter prior to surgery and the second being the level of prostate removal versus urethral reconstruction by the surgeon. The third factor is the degree of preservation of the neurovascular plexus. The objective criterion for incontinence-free is that no pad is used at any time and is considered incontinent; the opposite is considered incontinent. 2. Sexual dysfunction For classical, non-preserved sexual nerve trans-pubic posterior prostate cancer radical surgery, the incidence of postoperative sexual dysfunction is almost 100%. However, even for radical prostate cancer surgery with preservation of the sexual nerve, sexual dysfunction occurs in 14.0 to 88.4% of cases after surgery. Erectile dysfunction after radical prostate cancer surgery may be caused by nerve and vascular injury due to surgery, and damage to the neurovascular bundle may lead to decreased oxygenation of cavernous smooth muscle, resulting in decreased or lost erectile function, and may even cause cavernous fibrosis and impaired venous closure. However, the preservation of the neurovascular bundle during surgery does not guarantee the recovery of sexual function after surgery. 3. Urethral stricture Urethral stricture is another complication that affects the normal urinary function of patients after radical prostate cancer surgery, including bladder anastomotic stricture and bladder neck contracture, the incidence of which is 0.48%~32%, generally appearing 1~6 months after surgery. The incidence of postoperative urethral stricture is significantly increased in patients who smoke, have preoperative coronary vascular disease, primary hypertension and diabetes mellitus, which may be related to their causing microangiopathy of the anastomosis, local ischemia, and scar formation during anastomotic healing. Other complications of radical prostate cancer surgery include venous thrombosis, intraoperative hemorrhage, rectal bladder injury, and bladder neck contracture. Although many complications after radical surgery have been described above, it should be understood that the incidence of these complications is not very high. With the improvement of medical treatment, their incidence will be further reduced. Moreover, even if these complications occur, doctors still have ways to deal with them. Question 1: Is there any way to treat the leakage of urine during strenuous activities after radical prostate cancer surgery? Because of the irritation of the catheter placed for a long time after surgery, urinary function will not be restored immediately after removal of the catheter. Stress urinary incontinence can be improved by lifting the anus, i.e., try to repeatedly tighten the pelvic floor muscles to tighten the urine flow while standing to urinate, which helps to strengthen the external sphincter to achieve urine control. Until urinary control is fully restored, you can use a device such as a pee pad as recommended by your doctor. There are many medications that can relieve incontinence if it does not get better day by day. If you are not able to control urination on your own after one year after surgery, surgical placement of an artificial sphincter or the use of a penile clamp are possible, all of which allow patients with urinary incontinence to carry out normal life and activities. Question 2: Is there no sexual function after radical prostate cancer surgery? After radical prostate cancer surgery, patients under 50 years of age can maintain normal erection by preserving only the unilateral plexus, while patients over 50 years of age need complete preservation of the bilateral plexus to avoid impotence. In some patients, the erectile dysfunction that occurs in the short term after surgery is due to the transient injury of the vascular nerve bundle, and some drugs with therapeutic effect can be used under the guidance of the doctor, which has a certain effect on the early recovery of sexual function. Question 3: What should I do if I have urethral stricture after surgery? Treatment of urethral stricture includes simple urethral dilatation, endourethrotomy under direct vision, endourethrotomy for transurethral stricture and, less frequently, surgical reconstruction.