Robotic Versus Open Prostatectomy: Comparing the Outcomes

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.

What you're describing is the androgen depletion syndrome — you have abolished testosterone, so the patient develops post-menopausal-type symptoms. In our practice, for patients who have undergone androgen deprivation, we educate them not to panic, start gabapentin and sometimes an anti-anxiety medication, and for central obesity and related issues advise calcium and vitamin D supplements, a high-protein, low-fat diet, regular exercise, and sunlight exposure, since bones become fragile and there is increased risk of coronary artery disease and hypertension. We sometimes also use denosumab if the patient is very incapacitated by hot flashes and sweating. You did the right thing for your patient — surgical castration is the most practical option where injectable androgen analogues or antagonists aren't reliably available.

PSA becomes non-detectable, indicating successful cancer clearance, in 86 percent of open prostatectomy cases compared with 97 percent of robotic prostatectomy cases, with disease-specific survival after robotic surgery exceeding 95 percent over 10 years.

Continence at six months is achieved in around 60 percent of open prostatectomy patients, compared with 96 percent of robotic prostatectomy patients.

Around 97 percent of patients retain erections at one year after robotic surgery, while potency outcomes are notably poorer after open prostatectomy, since it is difficult for the naked eye to protect the fine nerve fibres involved.

Robotic prostatectomy involves less pain, less blood loss, a shorter hospital stay, lower infection risk and a shorter catheter duration than open surgery.