Robotic Radical Prostatectomy

Robotic radical prostatectomy is the surgical removal of the whole prostate, with the seminal vesicles and, where needed, the pelvic lymph nodes, performed through small incisions with a surgical robot. For Dr. Yajvender Pratap Singh Rana, it is the treatment of choice for prostate cancer confined to the pelvis, because the disease is usually multifocal and the operation is time-proven, with a cure rate he put at almost 95%.

Dr. Yajvender Pratap Singh Rana is Senior Director - Urology, Uro-Oncology, Andrology and Kidney Transplant at BLK-Max Super Speciality Hospital, New Delhi, India. He has practised through all three eras of prostate surgery: he performed open prostatectomy, then laparoscopic prostatectomy, and for many years now has operated only with the robot. His Jivo Masterclass for international doctors opened with a message of confidence: urological cancers are becoming more common, but better imaging and technology mean cure rates are rising too. A patient who arrives with a suspicion of cancer has, in his words, a fair chance of survival and a fair chance of cure.

This guide covers how prostate cancer is suspected and confirmed, who is a candidate for robotic surgery today, how surgery compares with the alternatives, and what recovery looks like. Three companion articles go deeper: the surgical technique of robotic prostatectomy for locally advanced prostate cancer, with robotic partial nephrectomy; erectile function and continence after robotic prostatectomy; and advanced prostate cancer treatment.

Prostate cancer warning signs and early referral

The warning signs Dr. Rana named are haematuria, lower urinary tract symptoms (LUTS) that do not settle, unexplained weight loss or fever, and an abnormal lump. Modern urology is full of lasers, scopes and robots, but he was clear that none of it helps a patient who is referred late. The decisive step is early suspicion and early referral, and that rests on history taking. A clinician with a pen, paper and a careful history can reach most diagnoses. Staging comes later, so the absence of a PET scanner is no reason to delay.

Each warning sign should prompt investigation:

• Haematuria at any age. In a young patient blood in the urine may come from a stone or an infection, but in a middle-aged or elderly patient it can lead to a diagnosis of prostate, bladder or kidney cancer. It should never be ignored.
• LUTS that do not settle with initial management. LUTS are problems with storing or passing urine, such as a weak stream or frequent urination. Persistence is the moment to investigate further.
• Unexplained weight loss or unexplained fever.
• An abnormal lump in the scrotum or anywhere in the abdomen.

Each of these, in his phrasing, signals that a significant problem may be developing inside the body.

The diagnostic work-up for suspected prostate cancer

Three basic tests give the first picture: a routine urine examination, an ultrasound of the abdomen and a serum prostate-specific antigen (PSA), a blood marker produced by prostate tissue. Together they show whether everything is under control or whether there is a problem to pursue.

Dr. Rana's sequence for a raised PSA is methodical:

1. PSA above 4. Repeat the test after any urinary infection has been treated, since infection can raise PSA on its own.
2. PSA still high or rising after infection control. Proceed to multiparametric MRI of the prostate, then biopsy.
3. Digital rectal examination. Urologists always examine the prostate. A hard, abnormal gland together with a high PSA makes the diagnosis of cancer almost certain.

What multiparametric MRI adds

Multiparametric MRI (mpMRI) combines several MRI sequences to show both the anatomy of the prostate and the behaviour of tissue within it. Dr. Rana called it very good imaging where a centre can offer it. Its value is clearest in the grey zone, with a PSA between 4 and 10 and a prostate that feels benign: MRI can locate a tumour the examining finger cannot. The radiologist reads the T2-weighted images, diffusion-weighted imaging (DWI) and the apparent diffusion coefficient (ADC) map, and assigns a PI-RADS score, a five-point scale of suspicion. A score of 3 is equivocal; scores of 4 and 5 indicate that clinically significant cancer is likely. The final answer, he stressed, always comes from a prostate biopsy, usually taken through a transrectal ultrasound (TRUS) probe.

When bladder cancer is suspected, typically in a patient with haematuria, a flexible cystoscopy, a camera passed through the urethra into the bladder, is the next step. Readers who want more on PSA thresholds and biopsy decisions will find them in Dr. Nitin Shrivastava's guide to age-adjusted PSA, PSA density and PSA velocity.

How to stage prostate cancer without a PET scan

PSA, MRI and a bone scan together can stage prostate cancer well, in Dr. Rana's advice to doctors who work without a PET scanner. Staging decides whether surgery can cure the patient. PSMA PET CT, which images a protein expressed on prostate cancer cells, is the most sensitive tool, but many hospitals across Africa do not have it.

The question staging answers is whether cancer has spread widely into bone. If it has, the patient needs long-term androgen deprivation therapy (ADT), hormone treatment that lowers testosterone, rather than an operation. Where neither a bone scan nor PET is available, he suggested MRI of the lumbar spine and pelvis, which can show bony metastases. The article on advanced disease sets out how that finding changes the plan.

Who is a candidate for robotic radical prostatectomy

In Dr. Rana's practice, men with localised, locally advanced or oligometastatic prostate cancer can all be candidates for robotic radical prostatectomy; men with widely metastatic disease are not. The most important shift he described is that surgery is no longer limited to cancers caught with a PSA between 4 and 10. The indications for radical prostatectomy have widened to three groups:

For widely metastatic disease he does not operate: there is no benefit from surgery, and ADT with other systemic drugs controls the cancer. International guidelines, including those of the European Association of Urology, still regard surgery for metastatic prostate cancer as investigational outside clinical trials, so this indication is a matter for careful selection by an experienced team.

Three treatment options for locally advanced disease

For a man whose cancer has just breached the capsule, Dr. Rana set out three treatment paths, and he favours the third:

• ADT alone. He does not regard this as good treatment on its own, because long courses of hormone therapy carry long-term side effects.
• Radiotherapy with ADT. Radiotherapy has its own drawbacks, including effects on the bladder and rectum, and bleeding such as haematuria.
• Radical prostatectomy. The best chance of cure, delivered by a minimally invasive operation.

The technique article follows one such patient, a man of 67 with a PSA of 62, from neoadjuvant hormone therapy through to surgery.

Robotic prostatectomy vs focal therapy (HIFU) and open surgery

Dr. Rana considers focal therapy suitable for only 2 to 5% of men with prostate cancer and regards open prostatectomy as becoming obsolete, so robotic surgery remains his operation of choice. Both alternatives come up in almost every consultation: focal therapy, which treats only the visible tumour, and conventional open surgery.

Who is suitable for focal therapy

Focal therapy uses an energy source, such as high-intensity focused ultrasound (HIFU), to destroy one area of the prostate while leaving the rest of the gland untouched. Dr. Rana offers it, but only to a narrow group: men with a single, well-circumscribed nodule, where a complete systematic biopsy confirms that no other part of the gland contains cancer. He estimated these patients at 2 to 5% of all men with prostate cancer.

His reasons for treating it as a different tool, not an alternative to surgery, are specific:

• Prostate cancer is usually multifocal. Treating one nodule offers no advantage when tumour is present elsewhere in the gland.
• New nodules appear. After a few years another area may need focal treatment again, or the patient may need robotic surgery after all.
• Prior treatment makes later surgery harder. After focal therapy or radiotherapy, robotic prostatectomy becomes technically difficult, nerve preservation becomes difficult, and so does preserving sexual function.

Robotic surgery, by contrast, has stood the test of time, with many years of robust patient data behind it.

Robotic vs open prostatectomy

Asked whether robotic surgery spares nerves better than open surgery in locally advanced disease, Dr. Rana answered that open prostatectomy now has hardly any role and is becoming obsolete. Robotic surgery achieves surgical margin rates comparable to open surgery, with less blood loss and a shorter hospital stay. A patient is either a suitable candidate for surgery or not; he does not believe there is any patient who cannot have robotic surgery but would benefit from open surgery. In his own career he has never converted a robotic prostatectomy to an open operation. A wider comparison of the three approaches appears in Dr. Amit Goel's article on robotic, laparoscopic and open prostatectomy.

The robot's advantage is easiest to see deep in the pelvis. Placing a haemostatic stitch on the dorsal venous complex, the cluster of veins in front of the urethra, at that angle and depth was a difficult task by laparoscopy. With the robot's wristed instruments and magnified view the stitch can be taken conveniently.

Recovery after robotic radical prostatectomy

Because the operation is minimally invasive, recovery is short. Dr. Rana's patients typically go home after three days. They keep a urinary catheter for two weeks, and at most 20 days. When the join between bladder and urethra is tested at the end of surgery and shown to be watertight, he removes the catheter with confidence after 7 to 10 days.

He frames the outcome around the prostate cancer trifecta, in order of priority:

1. Cancer control.
2. Urinary control (continence).
3. Sexual function.

Continence after robotic surgery is, in his experience, quite acceptable. Erectile function depends on the stage of the tumour and on whether the nerves can be preserved, a subject covered in detail in the article on erectile function and continence. His summary for counselling is blunt: the cancer cure comes first, because a man has to survive before he can enjoy sex.

Robotic simple prostatectomy for very large benign glands

Dr. Rana uses the robot for benign prostate enlargement in one situation: a very large gland, above 200 to 250 grams, which he treats with robotic simple prostatectomy, removing only the obstructing inner part of the gland. Radical prostatectomy is reserved for malignancy. Other benign enlargement is treated with transurethral operations, performed through the urethra without any incision, including bipolar enucleation, bipolar resection and transurethral resection of the prostate (TURP). European Association of Urology guidance considers simple prostatectomy, open or robotic, for glands larger than about 80 ml.

When robotic surgery is not available locally

Dr. Rana advises against orchidectomy for localised prostate cancer and reserves it for disease that imaging shows has spread. Several doctors in the session practise where neither robotic surgery nor routine pelvic cancer surgery is available. A surgeon from Ethiopia described a setting in which prostate cancer at every stage is treated with bilateral orchidectomy, surgical removal of the testes to lower testosterone. Dr. Rana's view was that orchidectomy should not be done for localised prostate cancer: it does more harm than good, costing the patient his erections without removing the organ that holds the cancer. Treatment, he said, has to be individualised to the stage of the tumour. If MRI shows metastases, orchidectomy is justified. If it does not, he advised telling the patient plainly that this is early disease, that the right treatment is removal of the prostate rather than the testes, and that it is worth seeking treatment abroad where it is not available at home. The full discussion, with every question from the session, is on the Live Discussion page.

The approximate cost of the operation for international patients is listed on the robotic radical prostatectomy cost page. Dr. Rana's earlier masterclass on robotic surgery across urology covers the wider range of urology procedures performed robotically, and Dr. Shafiq Ahmad's step-by-step account of robotic radical prostatectomy offers a second surgeon's perspective.