Robotic Radical Prostatectomy: How the Procedure Works

This is a sign of chronic prostatitis — patients with chronic infection in the prostate get calcium deposited in the glandular secretions over time, which is the mechanism behind the calcification. If the patient is asymptomatic and PSA is normal, I would not worry. If symptomatic, try medical management first, and only if that fails should you consider a surgical procedure. Prostatic calcification itself does not cause any harm — it is simply a telltale sign of chronic infection in the prostate.

In our country this facility is not widespread and is not yet widely accepted by the urology community here, though it is practised in the West by urologists, medical oncologists, and interventional radiologists. I would add that prostate cancer is usually slow-growing, but the prostate also has BPH growing alongside it, and patients with even locally advanced or oligometastatic disease often die from the obstructive mass effect of the prostate on the bladder neck and ureters rather than from the cancer itself — which is why, as a surgeon, I usually still consult even locally advanced or oligometastatic candidates for robotic radical prostatectomy, aiming for clear margins, early continence, and preserved erectile function.

There is no real comparison — they serve different purposes. Orchidectomy is chosen for metastatic (stage 4) disease, such as a patient with multiple spinal metastases who cannot walk. Radical prostatectomy is chosen for patients whose expected lifespan is more than 10 years, who are fit for surgery, and who have organ-confined, locally advanced, or oligometastatic disease (one or two spots on PSMA PET). Orchidectomy is simply a form of androgen deprivation — nowadays we hardly do it routinely because injectable or oral androgen deprivation therapy is available; it's now used mainly for stage 4 disease.

On Doppler ultrasound, chronic prostatitis typically shows uniformly increased vascularity across the whole prostate, whereas prostate cancer shows increased vascularity at one specific point, such as a nodule. However, we don't rely on ultrasound alone to distinguish the two — it comes down to clinical judgement, PSA value, and age, since chronic prostatitis is a disease of younger, sexually active men in their 40s to early 50s, while prostate cancer is a disease of old age; I would be hesitant to diagnose chronic prostatitis in a 60-65 year old with a PSA of 10 and urinary symptoms — that points toward BPH with a suspicion of prostate cancer to rule out. On tumour lysis syndrome: yes, it can happen with any treatment — radiotherapy or chemotherapy — in any tumour, most often solid tumours; it is not specific to prostate cancer.

Yes, that's correct. Orchidectomy is a cost-effective, one-time procedure, and increasingly patients in developing countries are also getting health insurance that covers the ongoing medications, so when it comes to overall treatment, orchidectomy can even be considered superior in efficacy compared to injectable treatment, and there's no harm in doing it. However, losing a testicle is a point of real psychological impact for a man, so if a patient can afford it or the treatment is available, I would suggest androgen deprivation therapy via injections or medication as preferable — orchidectomy remains a well-suited procedure specifically for patients with stage 4 disease.

The procedure begins with robot docking after positioning the patient in an exaggerated head-low position, followed by dissection to drop the bladder, open the endopelvic fascia, and divide the pedicles and neurovascular bundles while preserving as much nerve tissue as safely possible.

High-definition, magnified imaging allows the surgeon to identify tissue layers that are far harder to distinguish during open or laparoscopic surgery.

The objectives are threefold: clearing the cancer with adequate margins, achieving early continence, and protecting erectile function where possible, all of which robotic assistance makes more feasible to achieve together.

A urinary catheter is typically kept in place for around seven days after surgery, and many patients become free of the need for pads or diapers within about two weeks, though individual recovery varies.