Advantages of surgery:

• If the cancer is confined within the prostate the operation should be curative.  The chances of cure relate directly to the PSA, tumour stage, and Gleason grade which indicate the likelihood of microscopic spread outside the prostate - the main cause of cancer recurrence after surgery.  The expected success rate therefore varies from person to person and your specific circumstances should be discussed in detail with your urologist.
• The prostate is examined under the microscope to determine the true nature and extent of the cancer.  Many people are surprised to learn that the prostate biopsies that diagnosed the cancer are not always an accurate reflection of the amount and grade of cancer they have.  This is because they are only a very small and essentially random sample of the prostate and can be difficult to interpret or can miss significant areas of cancer, underestimating the volume or grade of the disease.   Surgery allows thorough examination of the prostate and this then gives a better idea of how likely it is that the cancer has been cured.
• The PSA drops to undetectable levels immediately.  Following surgery, the PSA falls to zero, or ‘undetectable levels’ within 6-8 weeks.  This gives reassurance that there is no evidence of remaining cancer cells.  PSA levels are then monitored over the next 10 years, and as long as it remains undetectable, the patient can be reassured of treatment success.
• Radiotherapy may be offered for cancer recurrence.  If there is a recurrence of the cancer in the area where the prostate was removed, radiotherapy may be given to treat this. 
• Surgery treats outlet obstruction. In addition to removing the cancer, in men with an enlarged prostate a prostatectomy also removes this cause of urinary obstruction, treating symptoms such as difficulty starting and poor flow.

Disadvantages of surgery:

• Wound discomfort.    The laparoscopic approach causes minimal discomfort, hence its appeal.  Wound problems are therefore rare and post-operative pain can be effectively controlled by simple painkillers
• Urinary incontinence.  Leakage of urine on coughing, straining or physical activity may initially occur following removal of the catheter (the tube in the penis draining urine into a bag).  This is because re-joining the urethra (tube you urinate through) and bladder during a radical prostatectomy causes bruising, swelling, and impaired function of the muscle that keeps the urethra closed (the urinary ‘sphincter’).  Fortunately permanent damage to the sphincter is uncommon, and the younger, fitter, and slimmer the patient, the faster the continence returns.  This healing process is sped up by performing regular pelvic floor exercises to strengthen the continence muscles.  Long term continence rates differ amongst surgeons.
• The small number of patients who are still not pad-free at 12 months may require a further procedure to restore their continence.
• Impotence.  The nerves that supply the penis for erections pass along either side of the prostate and are therefore removed with the prostate in a ‘non-nerve sparing’ radical prostatectomy.  This approach is general recommended in patients with PSA over 10, Gleason score >7, or locally advanced tumours, in whom the cancer can spread microscopically along nerve fibres and may not be completely removed if the nerves are left behind.  This allows the widest possible margin of tissue around the prostate to be removed to avoid the risk of leaving cancer cells behind, however leads to loss of normal spontaneous erections.  While oral medication to restore erections will not work with damaged nerves, there are multiple other options to achieve erections and it is important to remember that all men can be made artificially potent after radical prostatectomy somehow.  Those patients with normal erections and lower risk disease may be candidates for a ‘nerve-sparing’ radical prostatectomy in which the nerves are dissected from the side of the prostate and left intact.  This gives the greatest chance of return of potency, and the younger and fitter the patient, the faster erections return, although it can take up to 1-2 years in some patients.

Summary: