Robotic Prostatectomy

Who May Benefit

Robotic radical prostatectomy may be appropriate if you:

• Have localised prostate cancer confined to the prostate, and are fit for surgery
• Have intermediate- or high-risk disease where surgery offers the best chance of cure
• Have low-risk disease that has progressed while on active surveillance
• Have a reasonable life expectancy such that treating the cancer is likely to benefit you
• Prefer surgery to radiotherapy after discussing both, and want definitive pathology of the whole prostate
• Have locally advanced disease where surgery forms part of a planned multimodal approach

When This May Not Be the Right Option

• Metastatic disease, where systemic therapy takes precedence
• Significant heart or lung disease making prolonged anaesthesia unsafe
• Low-risk cancer well suited to active surveillance, where surgery may cause more harm than the cancer would
• Patients who would prefer to avoid any risk to continence and are suitable candidates for radiotherapy

The Procedure and the Alternatives

What the Operation Involves

Surgery is performed under general anaesthesia and typically takes two to three hours. The prostate and seminal vesicles are removed, the bladder is rejoined to the urethra, and a catheter is left in place. Pelvic lymph nodes are removed in the same operation where indicated. Most patients stay in hospital for one to two days, with the catheter removed after about a week.

Retzius-Sparing Approach

An approach that preserves the anterior structures around the bladder, associated in published series with earlier return of urinary continence. Suitability depends on tumour location and prostate anatomy.

Alternatives to Surgery

• Radiotherapy — external beam or brachytherapy, with comparable cancer control in many risk groups and a different side-effect profile
• Active surveillance — for low-risk and selected favourable intermediate-risk disease
• Focal therapy or HIFU — for selected localised, unilateral tumours
• Hormonal therapy — usually combined with radiotherapy rather than used alone in localised disease

Investigations Usually Required

• PSA — with previous values where available, to understand the trend
• Multiparametric MRI of the prostate — PI-RADS reported; assesses tumour location, capsular contact and seminal vesicle involvement, which directly informs nerve-sparing planning
• Prostate biopsy histopathology — Gleason score and Grade Group, number and location of positive cores
• PSMA PET-CT or bone scan with CT — staging for intermediate- and high-risk disease
• Pre-anaesthetic assessment — blood counts, kidney and liver function, blood sugar, ECG, chest imaging, and cardiology review where indicated
• Baseline continence and erectile function assessment — documented before surgery so that recovery can be measured honestly against your own starting point

Important Limitations and Risks

• Urinary incontinence. Some leakage is usual immediately after catheter removal. Most men improve substantially over three to twelve months, but a minority have persistent leakage requiring pads or further intervention.
• Erectile dysfunction. Even with bilateral nerve-sparing, erections take months to recover and may not return to their previous level. Where nerve-sparing is not oncologically safe, erectile dysfunction is likely to be permanent. Age and pre-operative function are the strongest predictors.
• Loss of ejaculation is permanent in all cases, and fertility is affected. Sperm banking should be discussed before surgery if this matters to you.
• Positive surgical margins occur in a proportion of cases, particularly with locally advanced disease, and may lead to a recommendation for additional radiotherapy.
• Biochemical recurrence — PSA can rise again after surgery. Surgery is not a guarantee of cure, and further treatment may be needed.
• Surgical risks — bleeding, infection, injury to adjacent structures, lymphocele after node dissection, venous thromboembolism, and rarely conversion to open surgery.
• Robotic assistance does not change the cancer. It is a means of performing the operation with less trauma; it does not by itself improve the chance of cure over well-performed open surgery.

What a Consultation Involves

A surgical consultation usually takes 30 to 45 minutes and covers:

• Review of your diagnosis — PSA, MRI and biopsy, and what your risk category means
• Whether surgery is the right choice for you — including an honest comparison with radiotherapy and, where relevant, surveillance
• Nerve-sparing planning — what is realistic in your case, based on where the tumour sits
• Expected recovery — hospital stay, catheter duration, return to work and activity, and the realistic timeline for continence and potency
• Your baseline function — documented so that recovery can be tracked against it
• Fitness for surgery — and any pre-operative optimisation needed
• Your questions — with time to consider before committing to a date

Bringing your partner is encouraged, particularly for the discussion about sexual function.