Radical prostatectomy is typically offered to patients with clinically localized prostate cancer (stage T1 to T3 disease) with a life expectancy > 10 years. The operation involves total removal of the prostate, seminal vesicles and ampullae of vas deferens. Radical prostatectomy may be performed using perineal, retropubic, or laparoscopic approaches. The three goals (“trifecta”) common to all approaches are: oncologic control, urinary continence, and preserved erectile function. While key differences in technique influence optimum patient selection and expected perioperative morbidity, level I evidence is lacking comparing available surgical approaches with regard to outcomes. A comparison with other treatment options for clinically localized prostate cancer (e.g. “watchful waiting” and radiation therapy) is beyond the scope of this chapter.

All surgical approaches can be effectively combined with nerve-sparing techniques whereby one or both neurovascular bundles alongside the prostate are spared to preserve erectile function and urinary continence. However, nerve-sparing should not be performed at the expense of oncologic control. Staging pelvic lymphadenectomy, once routinely combined with radical prostatectomy, is now more selectively performed based on nomograms that allow predictions of disease stage and pelvic lymph node involvement based on prostate specific antigen (PSA), clinical stage, and Gleason pathologic score. Unlike other approaches, the perineal approach does not permit lymphadenectomy, however it can be combined with laparoscopic lymphadenectomy. Lymphadenectomy risks pelvic lymphocele formation; however, this does not commonly require further intervention.