Open radical prostatectomy

Surgery through one cut in the lower belly to remove the whole prostate and the seminal vesicles, and often nearby lymph nodes, to treat prostate cancer that has not spread.

Also called Radical retropubic prostatectomy, RRP, Open prostatectomy, Retropubic prostatectomy, Radical perineal prostatectomy, Anatomic radical prostatectomy, Nerve-sparing radical prostatectomy, Remove my prostate

Where: Hospital operating room
Anesthesia: General anesthesia, or a spinal or epidural anesthetic with sedation
Time in the room: About 2 to 4 hours
Hospital stay: Usually 1 to 3 nights
Going home with: Urinary catheter for about 1 to 2 weeks; often a small drain for 1 to 3 days
Back to normal: About 6 to 8 weeks
Back to work: Desk work in about 3 to 4 weeks; heavy physical work in about 6 to 8 weeks

See the steps

BladderProstateTumorSphincter muscleErection nerves

Where it happens. The highlighted part is what this procedure treats.

Overview

An open radical prostatectomy removes the whole prostate and the seminal vesicles through a single cut, usually a vertical incision in the lower belly between the belly button and the pubic bone. This is the operation on which modern nerve-sparing prostate surgery was first developed in the early 1980s, and it remains a sound choice in experienced hands.

Your surgeon works directly with hands and instruments. The prostate is reached through the space in front of the bladder, so the inner lining of the belly, where the bowels sit, is usually not opened. After the prostate is out, the bladder is sewn down to the urethra, the tube that carries urine out, over a catheter.

Compared with robotic surgery, open surgery usually means more blood loss, more pain in the first weeks, and a slightly longer hospital stay. A large randomized trial that compared the two found similar urinary and sexual function at 3 months and at 2 years. The surgeon's experience matters more than the approach.

A less common version, the perineal prostatectomy, removes the prostate through a cut in the perineum, the area between the scrotum and the anus. It avoids a belly incision, but lymph nodes cannot be removed through the same cut.

The parts of your body involved

The prostate is a walnut-sized gland below the bladder and in front of the rectum, tucked behind the pubic bone. The urethra runs through its middle, so after the prostate is removed the bladder must be joined to the urethra below. Just below the prostate is the urinary sphincter, the muscle that keeps you dry, and along its sides run the thin nerve bundles that control erections.

Prostate
A gland about the size of a walnut that adds fluid to semen. Most prostate cancers start in its back and outer part.
Seminal vesicles
Two small glands behind the prostate that make much of the fluid in semen. They are removed with the prostate.
Urethra and urinary sphincter
The urethra carries urine out through the penis. The sphincter muscle around it, just below the prostate, holds urine in. Protecting it is the key to urinary control.
Erection nerves
Thin sheets of nerves and blood vessels (neurovascular bundles) along the sides of the prostate. They are needed for natural erections but not for feeling or orgasm.
Pelvic lymph nodes
Small filters along the large blood vessels of the pelvis, where prostate cancer often spreads first.

Why it’s done

The goals are the same as for robotic surgery: to cure cancer that has not spread and to give a complete picture of the cancer. Open surgery may be chosen because of your health, your past surgeries, or the experience of the surgeon you trust most.

To cure cancer inside the prostate
Removing the whole prostate offers a long-term cure for most men with cancer that has not spread, especially intermediate-risk and many high-risk cancers.
A complete report on the cancer
The whole prostate goes to the pathologist, who reports the exact grade, the stage, the margins and the lymph nodes. This guides any next step.
When the steep head-down tilt is not safe
Robotic surgery needs you to lie steeply head-down for hours with gas in the belly. Some men with certain eye, brain, heart or lung conditions are safer with open surgery, which needs only a slight tilt and no gas.
After certain past surgeries
Heavy scarring from earlier belly or pelvic operations, or some types of hernia mesh, can make keyhole access difficult. The open approach works outside the belly lining.
Simple PSA follow-up and radiation in reserve
After surgery the PSA should be undetectable, and radiation remains available if the cancer comes back.

Other options

Robotic radical prostatectomy
The same operation through about six small keyhole cuts. Less blood loss and a faster early recovery, with similar long-term results in experienced hands.
Active surveillance
For low-risk and some favorable intermediate-risk cancers, regular PSA tests, MRI scans and repeat biopsies watch the cancer, with treatment only if it changes.
External beam radiation
Radiation from outside the body over about 1 to 9 weeks, often with hormone therapy for higher-risk cancers. Cure rates for many cancers are similar to surgery, with a different pattern of side effects.
Seed implant (brachytherapy)
Tiny radioactive seeds placed in the prostate in one outpatient procedure.
Focal therapy
Treating only the part of the prostate with cancer, for example with focused ultrasound. Fewer side effects, but long-term cancer control is less certain.
Watchful waiting
For older men or those with serious other health problems, treating only if the cancer causes symptoms.

In the operating room, step by step

Press play or pick a step. Each drawing shows what your surgeon is doing at that moment. Your team may do some steps differently.

YouSurgeonAnesthesia team

1 / 12

1. Going to sleep and positioning

You are put fully to sleep, or given a spinal or epidural anesthetic with sedation. You lie on your back, and the table is bent slightly to open the space between your belly button and pubic bone. A catheter is placed in your bladder, and your belly is cleaned and covered with sterile drapes.

More detail

Your surgeon stands at the table with an assistant across from them and a scrub nurse beside the instrument table. The slight bend in the table brings the pelvis up toward the surgeon, so a steep head-down tilt is not needed.

You are put fully to sleep, or given a spinal or epidural anesthetic with sedation. You lie on your back, and the table is bent slightly to open the space between your belly button and pubic bone. A catheter is placed in your bladder, and your belly is cleaned and covered with sterile drapes.
More detail
Your surgeon stands at the table with an assistant across from them and a scrub nurse beside the instrument table. The slight bend in the table brings the pelvis up toward the surgeon, so a steep head-down tilt is not needed.
Your surgeon makes a vertical cut in the lower belly, from below the belly button toward the pubic bone, usually about 3 to 5 inches (8 to 12 centimeters) long. The two long belly muscles are spread apart at the midline without cutting across them. A metal frame (retractor) holds the wound open.
More detail
This approach is called retropubic because the surgeon works in the space behind the pubic bone and in front of the bladder. The bowels stay inside their lining and are not handled, which helps them wake up sooner after surgery.
Your surgeon gently moves the bladder back, opening the space between it and the pubic bone. The fat on the front of the prostate is cleared so its surface can be seen.
More detail
This is the space of Retzius. Because the belly lining is not opened, the surgeon works in a closed pocket that holds the bowel safely out of the way.
If your cancer has a meaningful chance of spreading, the lymph nodes along the large blood vessels on each side of the pelvis are removed, often at this stage. They go to the lab separately.
More detail
This is a pelvic lymph node dissection. It is usually advised for intermediate-risk and high-risk cancers. The obturator nerve, which moves the thigh inward, runs through this area and is kept intact.
The thin sheet of tissue on each side of the prostate is opened. The cluster of veins over the top of the prostate is tied with stitches and divided. This is often the step with the most bleeding in open surgery, so it is done with great care.
More detail
The vein cluster is called the dorsal venous complex. Learning to control it reliably was one of the advances that made modern prostatectomy safer. Small ligaments tethering the prostate to the pubic bone may also be divided here.
In open surgery the prostate is usually freed from the bottom up. Your surgeon cuts across the urethra at the lowest tip of the prostate (the apex), staying close to the prostate to protect the sphincter muscle just below. Stitches for the later reconnection may be placed in the urethra now.
More detail
Keeping urethral length and sphincter muscle helps urinary control. The apex is also a common place for cancer to reach the edge, so the surgeon balances a clear margin against keeping tissue.
Your surgeon lifts the prostate up and away from the rectum, opening the thin layer between them. When the cancer allows, the sheets carrying the erection nerves are released from the sides of the prostate and left in place. This can be done on both sides, one side, or neither.
More detail
Surgeons often wear magnifying glasses (loupes) for this part and use fine instruments with little or no heat, because heat and stretching can stun the nerves for months. Cancer control comes first, so more tissue may be taken on a side where the cancer is close to the edge.
The blood vessels entering the sides of the prostate are tied or clipped and divided. The vas deferens tubes, which carry sperm, are cut, and the seminal vesicles are freed so they come out with the prostate.
More detail
Near the tips of the seminal vesicles the nerves are close again, so surgeons work carefully and avoid heat. The seminal vesicles are checked by the pathologist for cancer spread.
Last, the prostate is separated from the bottom of the bladder (the bladder neck) and lifted out through the incision. No bag is needed. Your surgeon checks the openings where the ureters, the tubes from the kidneys, drain into the bladder to make sure they are safe.
More detail
If the bladder opening is wide, it is narrowed with stitches to match the size of the urethra, sometimes called a tennis-racket closure. The lining of the bladder neck may be turned outward with a few fine stitches so it heals smoothly.
With the prostate and seminal vesicles gone, there is a gap between the bladder neck and the cut end of the urethra. The sphincter muscle sits just below the urethral end. The next step brings these two ends together.
More detail
The prostate goes to the pathology lab, where it is inked, sliced thin and examined. The full report usually takes about 1 to 2 weeks.
A new catheter is passed through the penis into the bladder. The stitches placed in the urethra are passed through the bladder neck and tied, bringing the bladder down to meet the urethra over the catheter. The bladder may be filled with salt water to check for leaks, and a thin drain is often placed nearby.
More detail
Open surgeons usually use about 4 to 6 separate stitches for this join (the anastomosis), while robotic surgeons often use one running stitch. Both heal well. The catheter holds the join steady while it heals.
The muscle layer is closed with strong stitches, and the skin with staples or dissolving stitches. If a drain was placed, it comes out through a small separate opening in the skin and empties into a soft bulb.
More detail
Long-acting numbing medicine may be injected into the wound edges to ease pain when you wake. The drain usually comes out after 1 to 3 days, once very little fluid is coming out.

After the operation

In the hospital

Waking up
You wake in the recovery room with a catheter, a dressing on your belly, and perhaps a drain. If you have an epidural, your belly and legs may feel numb or heavy for a while.
Pain control
Pain is controlled with an epidural, a pain pump you press yourself, or pills, then switched to pills alone. Acetaminophen on a schedule and an anti-inflammatory medicine, if allowed, reduce the need for opioids.
Getting up
Nurses help you sit up and walk the evening of surgery or the next morning. Hugging a pillow against the incision makes getting up and coughing easier.
Eating
You start with liquids and move to light food as your bowels wake up, often by the first or second day.
Catheter and drain care
A nurse teaches you to use the leg bag and the night bag. The drain is usually removed before you go home.
Going home
Most men go home after 1 to 3 nights, once they are walking, eating and comfortable on pills. Some go home with blood thinner shots for a few weeks.

At home

Pain
The incision is sore for 1 to 2 weeks and tender for several more. Take acetaminophen on a schedule as directed and opioids only for strong pain. Hug a pillow when you cough, sneeze or laugh.
Wound and showering
You can usually shower after 24 to 48 hours; pat the incision dry. Staples, if used, are removed at a clinic visit in about 7 to 14 days. Avoid baths and swimming until the wound is healed and the catheter is out.
Catheter care
Keep the bag below your bladder, wash the tip of the penis daily, and use a little lubricant where the tube enters. Pink urine and small clots are common, especially after activity or a bowel movement.
Bowels
Take a stool softener and avoid straining. Do not use enemas or suppositories unless your surgeon says so, because the rectum lies next to the new join.
Diet and fluids
Eat normal food as your appetite returns and drink enough to keep your urine light yellow.
Activity and lifting
Walk several times a day. Avoid lifting more than about 10 to 15 pounds (4.5 to 7 kilograms), sit-ups, hard exercise and bicycle riding for about 6 weeks, to let the incision and the deep join heal.
Driving
Do not drive while the catheter is in or while taking opioids. Most men drive again about 2 to 3 weeks after surgery, once they can brake hard without pain.
Work
Desk work is often possible after 3 to 4 weeks. Physical jobs usually need about 6 to 8 weeks.
Sex and erections
Sexual activity can resume when you feel ready after the catheter is out. Your team may start an erection pill or vacuum device as part of a recovery plan.

Recovery timeline

Day 0
Surgery day
Surgery takes about 2 to 4 hours. You wake with a catheter, a belly dressing, and often a drain.
Days 1 to 3
In the hospital
You walk more each day, start eating, and switch to pain pills. Most men go home after 1 to 3 nights.
Weeks 1 to 2
Catheter out and pathology
The catheter is usually removed about 7 to 14 days after surgery. Expect leakage at first and start Kegel exercises. Your surgeon reviews the pathology report.
Weeks 2 to 4
Gaining strength
Incision pain eases and energy returns. Many men drive again and do light work from home.
Weeks 6 to 8
Back to most activities
Most men return to full activity, heavier lifting and exercise.
Weeks 6 to 12
First PSA test
Your first PSA after surgery should be undetectable.
3 to 12 months
Control returns
Urinary control improves steadily, and most men reach their final level by about a year. Erection recovery is slower.
1 to 2 years and beyond
Long-term follow-up
Erections can keep improving for 2 years or more. PSA tests continue, often every 3 to 6 months at first and then yearly.

What it feels like

Men who have open surgery often say the first week is the hardest part: the incision is sore and getting in and out of bed takes effort. After that, the experience is much like robotic surgery, with the catheter, the leaking, and the waiting for results.

Waking up
Grogginess, a sore throat if you had a breathing tube, and a deep ache in the lower belly. With an epidural, your legs may feel heavy or tingly. The catheter makes you feel you need to pee.
What helpsTell the nurse about pain early and use the pain plan as offered. The urge from the catheter usually fades within a day.
The first time you get up
Sitting up pulls on the incision and can feel daunting. Many men are surprised how tired a short walk makes them.
What helpsRoll onto your side first, then push up with your arms. Hug a pillow against your belly. Walk a little several times a day rather than once a lot.
The catheter days
The tip of the penis gets sore, the tube tugs, and urine or blood can leak around it, especially with bowel movements. Many men feel embarrassed and stay home.
What helpsStrap the tube to your thigh with some slack, use lubricant where it enters, and use the large bag at night. It is temporary.
Bladder spasms
Sudden cramps low in the belly or at the tip of the penis with an urgent need to pee and urine squirting around the catheter.
What helpsCheck for kinks, avoid constipation, and ask for a spasm medicine if they are frequent. They usually stop when the catheter comes out.
The day the catheter comes out
Relief, then often frustration at leaking with standing, coughing, lifting or walking, often more by evening.
What helpsBring pads and a change of clothes. Start Kegels as taught, limit caffeine and alcohol, and see a pelvic floor physical therapist if progress is slow. Judge progress over weeks.
Erections and intimacy
Erections are usually weak or absent at first. Orgasm still happens but is dry. Many men feel a quiet sense of loss, and partners may not know how to raise it.
What helpsAsk for a penile recovery plan, which may include pills, a vacuum device or injections. Talk openly with your partner; closeness and pleasure do not depend on erections alone.
Waiting for results
Waiting for the pathology report and the first PSA can bring back the fear of diagnosis.
What helpsKnow when results are due and how your team will contact you. Ask ahead what an undetectable PSA looks like on the report.

How well it works

Success means clear margins, an undetectable PSA, and over the following year a return of urinary control and as much sexual function as possible.

The pathology report
It gives the grade group, stage, margins, seminal vesicle findings and lymph node results. Together these predict the chance of the cancer coming back.
PSA after surgery
The PSA should be undetectable by 6 to 12 weeks. A PSA that rises to 0.2 ng/mL or higher, confirmed on a second test, usually means cancer has come back, and radiation can still cure many men when given early.
Urinary control
Most men improve over 3 to 12 months, and most use no pad or one light safety pad by a year. A male sling or artificial urinary sphincter helps men with lasting leakage.
Sexual function
Erections recover slowly, often over 1 to 2 years, and depend most on age, function before surgery and nerve sparing. Pills, devices, injections or an implant help if needed.

Risks

Every operation has risks. These are the ones people ask about most, with honest odds where good numbers exist. Your surgeon’s own results matter more than averages.

Common

Urine leakageNearly everyone at first; most men are dry or nearly dry by 1 year

Leakage after the catheter comes out is expected and improves over months.

Erection problemsMost men at first

Erections weaken or stop, at least for a while. Recovery depends on age, function before surgery and nerve sparing.

No semen and no natural fertilityEveryone

Orgasm still happens, but it is dry, and you cannot father a child naturally. This is permanent.

Incision pain

The incision is sore for 1 to 2 weeks and can stay tender or numb around its edges for months.

Bladder spasms

Cramps and urges while the catheter is in are common and stop after it is removed.

Less common

Bleeding needing a transfusion

Blood loss is usually higher with open surgery than with robotic surgery, and a transfusion is needed more often, though most men still do not need one.

Wound problems

Infection, fluid under the skin, or the wound edges opening are more likely with a larger incision, especially with diabetes, smoking or heavy weight.

Scar narrowing at the join

Scar tissue can narrow the bladder-urethra join (bladder neck contracture), causing a weak stream months later. It is usually treated with a short scope procedure.

Lymph fluid collection (lymphocele)

Fluid can collect in the pelvis after lymph node removal. Large ones may need draining.

Hernia

A bulge can form in the incision (incisional hernia) or in the groin (inguinal hernia) in the years after surgery. Either can be repaired.

Blood clots

Clots in the leg veins or lungs are uncommon. Walking, leg sleeves and blood thinner shots lower the risk.

Rare

Rectal injuryFewer than 1 in 100

A small tear in the rectum is rare and usually repaired during surgery. A lasting fistula between bowel and urinary tract is very rare.

Injury to a ureter, nerve or large blood vessel

These structures lie close by. Injury is rare and is usually repaired right away.

Serious heart or lung problems

Heart attack, pneumonia or other serious medical problems after surgery are rare, and more likely in men with existing heart or lung disease.

Call your care team or go to the emergency room if

Fever of 101°F (38.3°C) or higher, or shaking chills.
No urine draining into the bag for more than 1 to 2 hours, especially with lower belly pain. Check for kinks, then call right away.
The catheter falls out or slips. Call your surgeon right away, and do not let anyone put in a new one without speaking to your surgeon first.
Thick blood or clots in the urine that do not clear, or that block the catheter.
Redness spreading from the incision, pus, a wound that opens, or fluid pouring from it.
Swelling, pain or warmth in one calf or thigh. Call 911 for sudden shortness of breath or chest pain.
Belly pain that keeps getting worse, a swollen belly, or repeated vomiting.
After the catheter is out: you cannot pass urine at all.

Questions to ask your surgeon

Why do you recommend open surgery for me rather than robotic surgery?
How many prostatectomies do you do each year, and what are your results for leakage and erections?
Can you spare the nerves on one or both sides?
Will you remove my lymph nodes?
What will you do for pain control, and will I have an epidural?
How many nights will I stay, and how long will I have the catheter?
Will I need blood thinner shots at home?
Should I see a pelvic floor physical therapist before or after surgery?
What is your plan for erection recovery?
When will I get my pathology results and my first PSA?

Words you may hear

Radical retropubic prostatectomy: Removal of the whole prostate through a lower belly incision, working behind the pubic bone.
Perineal prostatectomy: Removal of the prostate through a cut between the scrotum and the anus.
Seminal vesicles: Two small glands behind the prostate that make fluid for semen.
Urinary sphincter: The ring of muscle below the prostate that holds urine in.
Bladder neck: The bottom opening of the bladder, where it joins the prostate.
Anastomosis: The new join between the bladder and the urethra.
Dorsal venous complex: A cluster of veins over the top of the prostate that is tied off during surgery.
Nerve sparing: Keeping the thin nerve sheets that control erections when the prostate is removed.
Epidural: A thin tube placed in the back that delivers numbing medicine to control pain.
Pelvic lymph node dissection: Removal of lymph nodes from the pelvis to check for cancer spread.
Surgical margin: The cut edge of the removed prostate; a positive margin means cancer touches it.
PSA: A blood test for a protein made by prostate tissue. After prostate removal it should be undetectable.

Common questions

Is open surgery worse than robotic surgery?

For cancer control and long-term urinary and sexual function, studies show similar results in experienced hands. Open surgery usually means more blood loss, more early pain and a slightly longer stay.

How big will the scar be?

Usually about 3 to 5 inches (8 to 12 centimeters), running from below the belly button toward the pubic bone. It fades over a year or so.

Will I be able to have an orgasm?

Yes. Orgasm uses different nerves from erections, so most men can still have one. It will be dry, with no semen.

Why is the catheter sometimes left in longer after open surgery?

The join is made with separate stitches, and many surgeons prefer a little more healing time before removing the catheter. Practice varies from about 1 to 2 weeks.

Can I have radiation later if I need it?

Yes. If the PSA rises after surgery, radiation to the area where the prostate was can still be given and cures many men.

Sources this page draws on

American Urological Association and American Society for Radiation Oncology, Clinically Localized Prostate Cancer: AUA/ASTRO Guideline (2022)
American Urological Association and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, Incontinence after Prostate Treatment: AUA/SUFU Guideline (2019)
European Association of Urology, EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer
The Lancet, Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study (2016)
American Cancer Society, Surgery for Prostate Cancer

Written November 2026. This page explains what usually happens. It is not medical advice and does not replace a conversation with your own surgeon, whose plan for you comes first.

Open radical prostatectomy

Overview

The parts of your body involved

Why it’s done

Other options

Getting ready

Weeks before

The week before

The day before

The morning of surgery

In the operating room, step by step

1. Going to sleep and positioning

After the operation

In the hospital

At home

Recovery timeline

What it feels like

Waking up

The first time you get up

The catheter days

Bladder spasms

The day the catheter comes out

Erections and intimacy

Waiting for results