Question 1

How does training for robotic radical prostatectomy work, and is prostatectomy for benign prostate disease also done transurethrally with the robot?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Transurethral procedures such as bipolar enucleation, bipolar resection, TURP, or HoLEP are all for benign prostate enlargement. Radical prostatectomy is a different operation for cancer of the prostate, done robotically. There is also a robotic option for very large benign glands: whenever the prostate is bigger than 200 to 250 grams, a robotic simple prostatectomy is performed instead of a transurethral procedure.

Question 2

Most patients' biggest concern before agreeing to prostatectomy is how well and how quickly they will return to normal erectile function - how should that be addressed?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

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.

Question 3

How long does it typically take for erectile function to return to normal after prostatectomy?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

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.

Question 4

For patients with early-stage, non-locally-advanced prostate cancer, what is the role of ablative or focal therapy such as HIFU (high-intensity focused ultrasound)?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

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.

Question 5

Is there evidence of better nerve sparing with robotic surgery compared with open surgery, particularly in locally advanced disease?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

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.

Question 6

Is robotic radical prostatectomy safer than open surgery specifically from the perspective of preserving erectile function?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

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.

Question 7

In Ethiopia, prostate disease is mainly managed with orchidectomy rather than radical prostatectomy, diagnosed by PSA alone without routine biopsy or metastatic work-up, since robotic surgery and pelvic exposure aren't available - how should localised cases be approached in that setting?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Orchidectomy should not be the answer for localised prostate cancer, it causes more harm than benefit, leaves the patient without erections, and the disease may still, over time, develop bone or other metastasis. Since MRI is available in Ethiopia even without bone or PET scans, an MRI of the lumbar spine and pelvis can screen for bony metastasis; orchidectomy is justified only if metastasis is found. Otherwise, patients with early-stage disease should be told clearly that the correct treatment, excision of the diseased organ rather than the testes, isn't currently available locally, and encouraged to pursue it overseas, including with help arranging financial support and other resources.

Question 8

A 45-year-old woman presented with haematuria and right flank pain, found to have a renal mass (likely renal cell carcinoma) with liver and lung metastases and a thrombus extending from the renal vein into the IVC. Since renal cell carcinoma is chemo-resistant, how should this be managed?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Ideally a kidney biopsy would first establish the histological subtype (clear cell, chromophobe, papillary, or another type) to guide systemic treatment, immunotherapies such as nivolumab, or TKIs such as sunitinib or pazopanib if immunotherapy isn't available. These agents are distinct from chemotherapy, and immunotherapy is increasingly recommended in guidelines for advanced and metastatic disease. This particular patient, with liver metastases, is not a surgical candidate, and a realistic prognosis should be given. Nephrectomy with IVC thrombectomy is appropriate when disease is still localised or locally advanced, since a kidney tumour extending through the IVC is still considered as such, but once there are multiple metastases in the liver and elsewhere, surgery is not the right approach.

Question 9

What are the best currently available anti-cancer therapies in India for advanced prostate cancer, and what role do targeted gene therapy and immunotherapy play?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

The backbone remains continuous ADT, agents like degarelix or leuprolide, combined with newer anti-androgens such as abiraterone or enzalutamide, known as ARPIs (androgen receptor pathway inhibitors), plus genetic testing, where a BRCA mutation supports adding a PARP inhibitor such as olaparib, with many patients now on doublet, triplet or even quadruplet combinations rather than ADT alone. Oligometastatic (limited stage 4) disease confined mainly to the prostate and pelvis can still be surgically debulked alongside roughly one to one-and-a-half years of ADT; widespread stage 4 disease has no surgical indication. When these lines of treatment fail, options include immunotherapy, docetaxel- or paclitaxel-based chemotherapy, and lutetium (PSMA) radioligand therapy, which tags rapidly-dividing, PSMA-expressing tumour cells for targeted internal radiotherapy, plus other immunotherapies such as pembrolizumab. Targeted gene therapy itself isn't yet in commercial clinical use, what is used is genetic testing to select the most effective molecule for a given patient's mutation profile, such as PARP inhibitors for BRCA2-positive cancer.

Question 10

How should counselling be framed for patients with very advanced prostate cancer?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

The patient needs a realistic sense of hope appropriate to their stage. A PSA above 1000 indicates metastatic disease, and in that setting the approach shifts from surgical cure to bringing the cancer under control with ADT and other systemic molecules.

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