Robotic Radical Prostatectomy

Outcomes vary by patient. In one case, a patient in his early sixties found to have a Gleason 4+4 tumour during routine follow-up for an unrelated condition could not be kept on active surveillance despite being young and sexually active. Given a realistic estimate of about an 80% chance of good erections afterward, he was started on tadalafil to prime the tissue before robotic surgery; within about four weeks of catheter removal he reported a full return of intimacy with his wife. Preservation depends on how sexually active and physically strong the patient was beforehand and on the tumour stage: early-stage tumours allow both neurovascular bundles to be spared, with tadalafil and, if needed, self-stimulation techniques or intracavernosal injections used during rehabilitation; in advanced cases where nerves cannot be spared, a penile implant remains an option. Cancer cure always comes first, since the patient must survive before sexual function can be addressed.

It varies by surgery, patient and condition, recovery can be as early as 4 to 6 weeks, sometimes 3 months, sometimes a year, and it may or may not return at all, depending on multiple contributing factors. In the prostate cancer trifecta used to counsel patients, cancer control comes first, urinary control second, and sexual control third.

Prostate cancer is usually multifocal, so focal therapy only suits a small subset of patients, about 2 to 5% of the whole pool, where a complete systematic biopsy confirms one localised, well-circumscribed nodule with the rest of the gland genuinely tumour-free; this treatment is available in India when that scenario applies. Because most prostate cancer is multifocal, robotic surgery remains the treatment of choice, with a time-proven cure rate of roughly 95%. Focal therapy treats one spot, but a new nodule can appear elsewhere later, and prior radiotherapy or focal therapy makes a subsequent robotic surgery more difficult and reduces the chance of preserving nerves and sexual function, so focal therapy is not an alternative to robotic surgery, just a different treatment for a different kind of patient.

Open prostate surgery today has almost no role. Robotic surgery achieves better surgical margins even in locally advanced disease. Having practised through the open, laparoscopic and now exclusively robotic eras, and never having converted a robotic case to open surgery, the real question in locally advanced disease is whether surgery is appropriate at all, not which technique to use. If disease is essentially metastatic, surgery offers no benefit and should not be done, but there is no patient suitable for robotic surgery who would somehow do better with an open approach instead.

Yes, robotic surgery preserves sexual function better than laparoscopic or open surgery, because the neurovascular bundles are more easily identified, the dissection is more precise, and the magnification is far better; hydrodissection of the neurovascular tissue is sometimes used to help preserve the plane. Robotic surgery scores over other options on preservation of sexual function.

Early diagnosis in uro-oncology, a locally advanced prostate cancer case, the step-by-step technique of robotic radical prostatectomy, erectile function recovery, focal therapy, robotic partial nephrectomy, and systemic treatment for advanced prostate cancer.

Director, Urology, Uro-Oncology, Andrology and Kidney Transplant at BLK-Max Super Speciality Hospital, New Delhi.