Robotic prostatectomy

Robot-assisted radical prostatectomy is an operation to remove the prostate and seminal vesicles. In selected cases, pelvic lymph nodes may also be removed.

It is usually considered for men with localised or locally advanced prostate cancer when surgery offers a realistic chance of cancer control.

The operation is performed using robotic instruments controlled by the surgeon. The robot does not operate on its own. The technology provides magnified vision, precise movement and access to deep pelvic anatomy.

1

What is it?

Robot-assisted radical prostatectomy is an operation to remove the prostate and seminal vesicles for prostate cancer.

In some men, pelvic lymph nodes are also removed. The operation is performed using robotic instruments controlled by the surgeon. The robot does not operate by itself.

The operation is usually performed through the abdomen using several small keyhole ports. This is called transabdominal multi-port robotic surgery.

2

Who is it for?

Surgery may suit men with localised or locally advanced prostate cancer where removing the prostate offers a realistic chance of cancer control.

Suitability depends on:

PSA level
MRI findings (PSMA scan might also be helpful)
Biopsy grade
Cancer stage
Prostate size
General health
Urinary function
Erectile function
Patient preference

Surgery is not right for every man. Some men are better suited to active surveillance, radiotherapy, focal therapy or systemic treatment.

3

Benefits

The main benefit is removal of the prostate, usually including all of the cancer.

Surgery also gives a full pathology report. This can show the final cancer grade, tumour extent, margin status, seminal vesicle involvement and lymph node status if nodes are removed.

After prostate removal, PSA should usually fall to an undetectable or very low level. This can make follow-up clearer.

If further treatment is needed later, the PSA pattern and pathology report help guide the next steps.

What surgery aims to do

The main aim is to remove the cancer completely. A second aim is to preserve urinary control and sexual function where it is safe and technically possible.

These aims sometimes compete. If cancer is close to the edge of the prostate, near the continence structures or near the nerves involved in erections, cancer control may need to take priority over preservation.

Good prostate cancer surgery is not one fixed operation done the same way every time. The operation is planned around the MRI, biopsy findings, anatomy, baseline urinary and sexual function, and what is found during surgery.

Continence-sparing surgery

Continence recovery depends on several factors.

The length of the urethra below the prostate varies between men and can influence the likelihood and speed of continence recovery. Tumour location also matters.

In selected cases, specialised techniques such as hood-sparing or related continence-preserving approaches may be possible. These techniques aim to preserve important supporting structures around the bladder neck, urethra and continence mechanism. In some men, this may help support earlier urinary control.

These approaches are not suitable for every patient. The decision depends on anatomy, MRI findings, tumour position and cancer safety.

Nerve-sparing surgery

The nerves involved in erections run very close to the prostate.

In some men, one or both nerve bundles can be preserved. In others, nerve-sparing may not be safe because of tumour position, MRI stage, biopsy findings or suspected spread beyond the prostate.

Nerve-sparing decisions should be based on MRI, biopsy findings, clinical staging, baseline erectile function and intra-operative judgement.

The key question is not simply “can the nerves be spared?”
The key question is “can the nerves be spared safely?”

 

4

Risks

Bleeding causing a heamatoma (blood clot in pelvis)
Infection causing a urine infection, or catheter related problem
Blood clots in the legs (DVT), or lung (PE, potentially very serious)
Urine leak (from the new join between the urethra and bladder)
Catheter problems (displacement, falling out, blocking)
Urinary leakage from around the catheter known as bypassing
Erectile dysfunction which may be permanent
Penile shortening (1-3cm)
Bladder neck narrowing or urethral scarring
Positive surgical margin
Cancer recurrence
Need for further treatment

A technically good operation can still have a difficult outcome because surgery is affected by tumour biology, anatomy, age, baseline urinary and sexual function, obesity, diabetes, smoking and other health factors.

 

5

Before treatment

Before surgery, the usual assessment includes review of:

PSA and PSA trend
MRI scan, bone scan or PSMA scans
Biopsy results
Gleason score / Grade Group
Cancer stage
Prostate size
Urinary symptoms
Erectile function
General health
Medication, including blood thinners

Some men need additional scans, lymph node assessment or multidisciplinary team review.

Pre-operative assessment checks fitness for anaesthetic and surgery. This may include blood tests, urine testing, ECG, blood pressure check, medication review and planning around blood thinners.

Pelvic floor exercises are usually recommended before surgery so that patients understand the muscles involved in urinary control before the catheter is removed.

 

6

During treatment

Robot-assisted radical prostatectomy is usually performed through the abdomen using several small keyhole ports. This is called transabdominal multi-port robotic surgery.

The robotic instruments are placed through these ports and controlled by the surgeon from the console. The robot does not perform the operation by itself. It allows magnified vision, fine instrument control and precise dissection deep within the pelvis.

My average robotic operating time is usually around 1–2 hours, although this can vary depending on anatomy, prostate size, previous surgery, inflammation, obesity, tumour position, lymph node removal and surgical complexity.

During the operation, the prostate and seminal vesicles are removed. Pelvic lymph nodes may also be removed if indicated by the cancer risk.

The operation can involve both anterior and posterior dissection around the prostate. The exact approach is tailored to the patient’s anatomy, MRI findings and tumour location.

Where possible and safe, I may use a modified Retzius-sparing approach or other continence-preserving techniques. These aim to preserve important supporting structures around the bladder neck, urethra and continence mechanism. This may help early urinary control in selected patients, but it is not suitable for every case.

The priority remains cancer control. If the tumour is close to the edge of the prostate, near the nerves, or in a position where preservation would risk leaving cancer behind, a wider excision may be safer.

The bladder is then joined back to the urethra with stitches. A catheter is left in place to drain urine while this join heals.

7

After treatment

Most men go home with a catheter for a short period after surgery.

A blood thinning injection may be recommended for 28 days

You will receive instructions about catheter care, wound care, pain relief, activity, bowel function and warning signs.

Continence recovery usually improves over weeks and months. Some men regain control quickly. Others need more time and may need pads during recovery.

Erectile function recovery is more variable. It depends on age, baseline erections, general health, diabetes, vascular health, smoking, whether nerve-sparing was possible and healing after surgery.

After the prostate is removed, PSA should usually fall to an undetectable or very low level. PSA monitoring is then used to check for recurrence.

8

Has it worked?

The first signs come from the pathology report and the PSA result after surgery.

The pathology report shows:

Final Grade Group / Gleason score
Tumour stage
Whether the cancer was contained within the prostate
Margin status
Seminal vesicle involvement
Lymph node status if nodes were removed

The PSA should usually become undetectable or very low after surgery.

Long-term follow-up is based on PSA monitoring. If PSA remains detectable or rises later, further assessment or treatment may be needed.

9

Questions to ask

What robotic platform is used?

I use the da Vinci Xi robotic surgical system.

The da Vinci Xi is widely used for multi-port robotic surgery, including prostate cancer surgery. It is currently the platform with the greatest worldwide experience behind it and is widely used across urology and other surgical specialties.

For patients, the important point is that the robot is not experimental and it does not operate by itself. It is a surgical platform controlled by the surgeon.

A useful analogy is flying an aircraft or driving a car. The machine matters. You want a platform that is reliable, familiar, well-supported and tried and tested. But the machine does not fly the plane or drive the car on its own. The operator, training, judgement, team and conditions still matter.

The da Vinci Xi provides magnified 3D vision, precise instrument movement, tremor filtration and access deep within the pelvis. These features can help the surgeon perform careful dissection around the prostate, bladder neck, urethra, continence structures and nerves.

The platform is important, but it is only one part of good surgery. The outcome still depends on patient factors, cancer anatomy, surgical planning, theatre team experience, technical judgement and recovery support.

Are there other robotic platforms?

Yes. Several robotic surgical platforms are now used or being evaluated in the UK.

These include other da Vinci systems and newer platforms such as Versius, Hugo, Senhance and other robotic systems.

I do not currently use these other platforms for prostatectomy. My practice uses the da Vinci Xi.

As far as we know, prostatectomy outcomes are not determined by the machine alone. Results depend on patient selection, cancer anatomy, surgeon experience, theatre team familiarity, operative planning, technique, recovery support and follow-up.

That said, the da Vinci Xi has the greatest worldwide experience behind it for multi-port robotic surgery and remains the most established robotic platform for prostatectomy.

For most robotic prostatectomy operations, I consider the da Vinci Xi the most appropriate platform because it is established, familiar to experienced robotic teams, widely supported and tried and tested.

The analogy is like flying a plane or driving a car. You want a reliable platform that is well understood, but the platform alone does not determine the journey. The operator, team, planning, conditions and judgement still matter.

Questions to ask

Is surgery suitable for my cancer?
Is my cancer likely to be contained within the prostate?
Is nerve-sparing safe in my case?
Am I suitable for hood-sparing or continence-preserving techniques?
Would a modified Retzius-sparing approach be appropriate?
Do I need lymph node removal?
What is my risk of urinary leakage?
What is my chance of erectile function recovery?
How long will I need a catheter?
What happens if the margin is positive?
How will PSA be monitored afterwards?
What are the alternatives to surgery?

 

10

Useful UK based links

11

Need further help?

Private consultations with Mr Anthony Bates are available through Prostatology for raised PSA, MRI review, biopsy results, robotic prostatectomy planning and second opinions.

Book through Prostatology:
https://www.prostatology.co.uk/consultations

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