Question 1

Is robotic prostatectomy performed transurethrally, and how does it relate to transurethral prostate surgery?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Transurethral procedures, such as bipolar enucleation, bipolar resection and TURP, are all for benign prostate enlargement. Radical prostatectomy is a different operation, performed for cancer of the prostate, and is done robotically. There is also a robotic option for benign disease: when the prostate is very large, bigger than about 80 to 100 grams, a robotic simple prostatectomy is one of the options, alongside enucleation.

Question 2

Most patients' main concern before agreeing to prostatectomy is how well and how easily they will return to normal erectile function. How should this be addressed?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Erectile function after prostatectomy is highly variable. One patient in his early sixties, under routine follow-up for an unrelated urological condition, was found to have a raised PSA and a Gleason 4+4 tumour on biopsy, which ruled out active surveillance. He was sexually active and his priority was regaining sexual function. He was given a guided estimate of about an 80% chance of good erections afterwards, started on tadalafil to prime the tissue, and underwent robotic surgery; about four weeks after catheter removal he reported full return of sexual function. Outcomes depend on how sexually active and physically strong the patient was before surgery and on the tumour stage. In early tumours the nerves can be fully preserved, tadalafil is given up front and during rehabilitation, and patients are taught self-stimulation after catheter removal; if that is not enough, intracavernosal injections can be used once pain has settled after a few weeks. In advanced cases with a very high PSA, where the nerves cannot be spared, a penile implant remains an option. Cancer cure comes first: 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 with the surgery, the patient and the condition. Recovery can come as early as 4 to 6 weeks, sometimes at 3 months, sometimes at a year, and it may not return at all, depending on multiple factors. In the prostate cancer trifecta used to counsel patients, cancer control comes first, urinary control second and sexual function 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 surgical margins at least as good as open surgery even in locally advanced disease, with less blood loss and a shorter stay. 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

Robotic surgery offers real advantages for preserving sexual function: 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. Large series favour robotic surgery, although the randomised trial comparing robotic with open surgery found similar sexual function at two years, so the surgeon's experience matters as much as the technique.

Question 7

In Ethiopia, prostate cancer is managed with surgical castration (orchidectomy) at any stage, diagnosed on PSA alone without biopsy or routine metastatic work-up (above 20 is treated as cancer, above 35 as advanced), and robotic surgery is not available while open pelvic exposure is very difficult. How should localised cases be approached?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Orchidectomy is not the solution for localised prostate cancer: it does more harm than good, leaves the patient without erections, and the disease may later spread to bone. Treatment has to be individualised. MRI is widely available in Ethiopia even where bone scans and PET scans are not, so an MRI of the lumbar spine and pelvis can screen for bony metastasis. If metastasis is found, orchidectomy is justified. Otherwise, patients should be told clearly that this is early disease, that the correct treatment is excision of the prostate rather than the testes, and that it is not currently available locally, so they should seek treatment overseas, where help with finances and other arrangements can be provided. Patients who arrange this will be grateful in the long run.

Question 8

A woman in her forties presented with haematuria and right flank pain and was 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 should first establish the histological type (clear cell, chromophobe, papillary or another malignancy) to guide systemic treatment: immunotherapies such as nivolumab, or, if these are not available, TKIs such as sunitinib or pazopanib. These are not chemotherapies. Immunotherapy works well in renal cell carcinoma, is increasingly recommended in guidelines for advanced and metastatic disease, and its benefit has been seen in practice. This patient, with metastatic liver disease, is not a candidate for surgery, and should be given a guided prognosis. Nephrectomy with IVC thrombectomy is appropriate when the disease is localised or locally advanced, since a kidney tumour extending into the IVC is still considered locally advanced. Once there are multiple metastases in the liver and elsewhere, patients do not do well after surgery.

Question 9

What are the best anti-cancer therapies currently available in India for advanced prostate cancer?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Advanced prostate cancer is treated with continuous androgen deprivation therapy (ADT), such as degarelix or leuprolide, combined with abiraterone or enzalutamide. These are androgen receptor pathway inhibitors (ARPIs), newer hormonal agents. Genetic testing is also done: if a BRCA mutation is present, PARP inhibitors such as olaparib are given. Treatment for advanced prostate cancer is no longer ADT alone; patients now receive doublet and triplet combinations.

Question 10

What is the role of surgery in advanced prostate cancer, and when is it combined with systemic therapy such as chemotherapy, immunotherapy or radiotherapy?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

It depends on the stage. Oligometastatic disease is limited stage 4 disease, where the cancer is consolidated in the prostate and pelvis: in low-volume metastatic disease, radiotherapy to the prostate together with ADT and an ARPI is the standard, and surgery to the prostate in this setting is done mainly within clinical trials. When there is widespread stage 4 disease with significant metastases, there is no indication for surgery. In localised and locally advanced disease, surgery is a mainstay of treatment, with radiotherapy as the alternative, and androgen deprivation is added after surgery only when the pathology shows high-risk features such as positive lymph nodes. Treatment decisions must be individualised to the stage.

Question 11

What is the role of targeted gene therapy and immunotherapy in prostate cancer?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Once the standard lines of treatment fail, patients move to further options. Chemotherapy is effective in prostate cancer, using docetaxel-based regimens and also cabazitaxel. If the disease still progresses, lutetium therapy is used, and many patients do reasonably well on it: a lutetium-tagged radioligand, targeting the same PSMA protein seen on a PSMA PET CT, is taken up by tumour cells that express PSMA, entering and killing those cells, much like internal radiotherapy at the cellular level. Immunotherapies such as pembrolizumab are also used in the small subset with mismatch repair deficient tumours. Targeted gene therapy is not yet in commercial use. What is used is genetic testing, to select the molecules that work best for a given subset of patients, for example PARP inhibitors in BRCA2 mutation-positive cancer.

Question 12

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.

Live Discussion with Dr. Yajvender Pratap Singh Rana