Robotic Radical Prostatectomy: Step by Step and Recovery

Robotic radical prostatectomy removes the prostate through a few small abdominal ports, with the surgeon operating from a console that magnifies the tissue more than ten times. Step by step, the operation runs from docking and bladder-neck dissection through the nerve-sparing decision and apical dissection to the join between bladder and urethra. The catheter then stays for 7 days.

Dr. Shafiq Ahmed, Senior Director - Urology, Andrology & Renal Transplant, BLK-Max Super Speciality Hospital, New Delhi, India, sets three objectives for every man he treats for prostate cancer. First, clear the cancer, with clear surgical margins. Second, return him to continence early. Third, protect his erections. Where robotic surgery allows him to meet all three, he recommends it over any other treatment, and he counsels every suitable candidate towards robotic radical prostatectomy, whether the cancer is early, locally advanced or oligometastatic.

Over the last decade, most of his patients diagnosed with prostate cancer have chosen the robot. This article follows the operation as he performs it, the technical decisions that determine cancer control and continence, and what recovery looks like afterwards. Why he extends surgery to locally advanced and selected metastatic disease is explained in the complete guide to the diagnosis and management of prostate cancer.

Who is a candidate for robotic radical prostatectomy?

Radical prostatectomy is chosen for a man with an expected lifespan of more than 10 years who is fit for surgery, and whose disease is organ-confined, locally advanced or oligometastatic. Men with widespread metastasis to the lymph nodes or bones are not candidates; their disease is controlled with androgen deprivation instead. Whether the cancer has breached the capsule, which shapes the nerve-sparing decision, is assessed before surgery with multiparametric MRI, as described in the PSA test and prostate cancer staging article.

How the robotic system works

The robotic system has two main components: the patient cart, which carries the robotic arms, and the surgeon console, from which the surgeon operates. The approach is laparoscopic in principle, performed through a few small ports in the abdomen, with the robot holding and moving the instruments.

What the console gives the surgeon is vision. The high-definition camera magnifies the tissue more than ten times, and every layer can be seen and divided precisely. Dr. Ahmad's point is that this level of dissection is very difficult in laparoscopy and impossible in open surgery, where the layers cannot be seen with the naked eye. The small nerve fibres that control erection are the clearest example: protecting them depends on seeing them.

Robotic radical prostatectomy step by step

The operation proceeds in seven stages:

1. positioning, access and docking;
2. dropping the bladder;
3. opening the endopelvic fascia and ligating the dorsal venous complex;
4. opening the bladder neck and dissecting the seminal vesicles;
5. dividing the pedicles and making the nerve-sparing decision;
6. apical dissection and division of the urethra;
7. reconstruction with the Rocco stitch and the anastomosis.

The video Dr. Ahmad presented was a robotic radical prostatectomy he performed some years ago, for a man with locally advanced disease. Because the cancer was breaching the capsule, it was largely a non-nerve-sparing operation. The sequence below follows that case.

Positioning, access and docking

The patient is placed in a steep head-down position, an exaggerated Trendelenburg position. A pneumoperitoneum is created, inflating the abdomen with gas to make working space, the ports are placed and the robot is docked. The whole process takes around 30 minutes before the operation itself begins.

Dropping the bladder

There are two ways to begin. The bladder can be dropped from the front, or the surgeon can approach from behind and dissect the seminal vesicles first. Dr. Ahmad's preference is the anterior approach, because it leads him directly into the retropubic space.

The first task there is to clear all the fat lying over the front of the prostate. He gives two reasons. With the fat cleared, it does not come into the sucker whenever there is bleeding. And anteriorly located tumours can spread into this fat, so it must be removed with the specimen.

Endopelvic fascia and the dorsal venous complex

Next, the endopelvic fascia is opened and the sphincter muscle is separated from the prostate. The dorsal venous complex, the cluster of veins over the front of the prostate, is ligated at this early stage. The purpose is to keep the field clear later, when the surgeon reaches the apex of the prostate, where precision matters most.

Bladder neck and seminal vesicles

The bladder neck is opened and the surgeon checks for an enlarged median lobe, for which there are several techniques. The posterior bladder wall is then opened to reach the seminal vesicles. Once behind the bladder, the seminal vesicles and vasa deferentia are held, lifted and dissected. The artery to the vas is identified, and Denonvilliers' fascia is seen clearly as the plane behind the prostate.

The pedicles and the nerve-sparing decision

The prostatic pedicles, which carry the blood supply to each side of the gland, are then divided. This is where the nerve-sparing decision is made.

In the case shown, the pedicles were divided with hot shears, because the nerves were not being spared. In a nerve-sparing operation, Dr. Ahmad divides the pedicles with absolutely cold scissors, avoiding thermal energy near the nerves.

The choice is dictated by the cancer. Here, the neurovascular bundle, the nerves and vessels running alongside the prostate that control erection, was swept laterally, and as much of it as could be saved with a safe margin was preserved, with the rest divided. The result was a partial nerve sparing, not a complete one. Sparing the nerves fully in a disease breaching the capsule would have risked a positive surgical margin, which would defeat the first objective of the operation.

The apex and the urethra

With the posterior and lateral dissection complete, attention returns to the front. The previously ligated dorsal venous complex is divided, and the apical dissection begins.

This is the stage that decides continence. The continence mechanism consists of small fibres around the junction of prostate and urethra, and each contributes to control of urine. Dr. Ahmad's instruction is to avoid using much heat here, to be clean and meticulous, and to release the fibres slowly. The aim is to preserve a good length of urethra, since urethral length determines the man's continence. Only then is the urethra divided, with cold scissors, and the prostate rotated and delivered from beneath the pubic bone.

Reconstruction: the Rocco stitch and the anastomosis

Reconstruction restores support behind the bladder neck and then joins the bladder to the urethra, two steps that support early continence and guard against scarring.

The Rocco stitch

Before the anastomosis, a Rocco stitch is placed. It reconstructs the posterior support behind the bladder neck and urethra. In Dr. Ahmad's account, it adds strength to the anastomosis and helps men achieve continence early.

The anastomosis

The anastomosis is the join between the bladder neck and the urethra. The bladder neck is joined to the urethra with a double-armed V-Loc barbed suture, run from right to left to complete the anastomosis. In his current practice Dr. Ahmad uses a much smaller needle than the one seen in the older video.

The principle is to approximate mucosa to mucosa. A poorly constructed anastomosis forms scar, and in Dr. Ahmad's view the most distressing complication of the anastomosis is a bladder neck contracture, a scar that narrows the outlet once the catheter is removed. Each bite should therefore be taken with time and care, with the mucosa everted before the suture is placed.

Before the knot is tied, the bladder is flushed so that any clot comes out, and the anastomosis is checked for leaks. That completes the operation.

Recovery after robotic prostatectomy: catheter, continence and erections

Recovery is quick for most men: the catheter stays for 7 days, and in Dr. Ahmad's series early continence returns within about two weeks. When the catheter is removed, the man is given a trial of voiding.

Many men need no pads or diapers at all. He is careful to add that this does not hold for every patient. Each man behaves differently, although the majority respond very well.

Erectile function depends on how much of the neurovascular bundle the cancer allowed the surgeon to keep. A full nerve-sparing operation, with cold dissection along the bundles, gives the best chance of preserved erections. A partial or non-nerve-sparing operation, as in the locally advanced case shown, trades some of that function for a clear margin.

Robotic versus open prostatectomy

Compared with open surgery, robotic prostatectomy offers clear practical advantages, while randomised trials show similar functional and early cancer outcomes. The robotic operation offers:

• very little pain;
• minimal blood loss;
• a short hospital stay;
• a lower risk of infection;
• a catheter needed for only 7 days, where open surgery has traditionally required it for longer.

On the figures Dr. Ahmad presented, bladder neck contracture occurs in as few as 2 per cent of men, and mortality is negligible.

On cancer control, outcomes after radical prostatectomy for localised disease are excellent, with disease-specific survival above 95 per cent at ten years. Randomised comparisons of robotic and open prostatectomy have found similar urinary and sexual function at two years, and similar early cancer outcomes, with the robot's clearest advantages lying in blood loss and length of stay.

For the men Dr. Ahmad treats, robotic radical prostatectomy also widens who can be operated on. Locally advanced and selected oligometastatic disease are now regularly taken for robotic radical prostatectomy in his practice, with the same three objectives: clear the cancer, restore continence early and preserve erections.