Robotic radical prostatectomy (RRP) is a minimally invasive surgical procedure used to treat prostate cancer by removing the prostate gland and surrounding tissues. Performed with the assistance of advanced robotic systems, this technique offers enhanced precision, smaller incisions, reduced blood loss, and faster recovery compared to traditional open surgery. It is a common and effective option for patients with localized prostate cancer, aiming to eliminate cancer while preserving urinary and sexual function as much as possible.

What is robotic radical prostatectomy?

Robotic Radical Prostatectomy for Prostate Cancer is a minimally invasive surgical procedure used to remove the prostate gland in men diagnosed with localized prostate cancer (cancer that has not spread beyond the prostate).

• “Radical Prostatectomy” means removing the entire prostate gland, and often some surrounding tissues, including the seminal vesicles.
• “Robotic” refers to the use of a robotic surgical system, most commonly the da Vinci® Surgical System, which allows the surgeon to operate through small incisions using robotic arms controlled from a console.
• The robotic system offers enhanced precision, 3D visualization, and greater dexterity, which helps the surgeon perform delicate tasks more accurately than with traditional open or laparoscopic surgery.

How to do robotic radical prostatectomy?

RRP for prostate cancer is a highly specialized surgical procedure that involves the removal of the prostate gland using a robotic surgical system, most commonly the da Vinci® robotic system. Below is a simplified step-by-step overview of how the procedure is performed:

Preoperative Preparation

1. Patient Evaluation: Confirm prostate cancer diagnosis, assess cancer stage, PSA levels, imaging (MRI, CT), and patient’s overall health.
2. Anesthesia: General anesthesia is administered.
3. Positioning: The patient is placed in the steep Trendelenburg position (head-down, feet-up) to move abdominal organs away from the pelvis.

Surgical Steps

1. Trocar Placement:
   • Several small incisions (usually 5–6) are made in the abdomen.
   • Robotic arms and instruments are inserted through trocars (ports).
   • A camera port provides a 3D high-definition view.
2. Docking the Robot:
   • The robotic system is positioned and connected to the instruments inserted into the patient.
3. Dissection of Prostate:
   • The surgeon dissects around the prostate gland, carefully preserving:
     • Neurovascular bundles (important for erectile function)
     • Bladder neck
   • Seminal vesicles are also removed.
4. Control of Vessels:
   • Dorsal venous complex (DVC) is ligated to minimize bleeding.
   • Vas deferens is clipped and divided.
5. Urethra and Bladder Neck Dissection:
   • The prostate is detached from the urethra.
   • A tension-free anastomosis (connection) is made between the bladder neck and urethra.
6. Specimen Removal:
   • The prostate is placed in a specimen retrieval bag and removed through one of the port sites.
7. Drain Placement (if needed) and port closure.

Postoperative care

Patients have a more comfortable recovery period after RRP.

• Hospital stay: Typically 1–2 days.
• Catheter: A Foley catheter is left in place for 5–10 days.
• Recovery: Most patients return to normal activities within 2–4 weeks.
• Follow-up: Monitor PSA levels, urinary continence, and erectile function.

Indications for RRP

RRP is indicated in patients who are diagnosed with localized or locally advanced prostate cancer and are suitable candidates for surgery. Here are the main clinical indications:

Localized Prostate Cancer (T1–T2)

• T1 stage: Cancer is not palpable or visible on imaging, found via biopsy (e.g., due to elevated PSA).
• T2 stage: Cancer is confined within the prostate on digital rectal exam (DRE) or imaging.
• Suitable for patients with:
  • Life expectancy ≥10 years
  • Gleason score ≤7 or select 8
  • PSA <20 ng/mL (or higher in selected cases)

Select Locally Advanced Prostate Cancer (T3)

• T3a (extracapsular extension): Tumor extends outside the prostate capsule.
• T3b (seminal vesicle invasion): May be considered if part of a multimodal approach (e.g., with radiation and/or hormone therapy).

High-Risk Prostate Cancer (select cases)

• High PSA (>20 ng/mL), Gleason score 8–10, or T3 disease.
• Often as part of multimodal treatment (surgery followed by adjuvant radiation or androgen deprivation therapy).

Patient Preferences and Suitability

• Men who prefer surgical treatment over radiation or active surveillance.
• Fit for general anesthesia and major surgery.
• Good baseline urinary and sexual function may guide decision-making.

Not Typically Indicated When:

• Cancer has metastasized (Stage IV or N1/M1 disease)
• Life expectancy <10 years or significant comorbidities
• Patient is not a surgical candidate (due to poor functional status or comorbidities)

Complications of RRP

Here is a detailed list of complications associated with RRP for prostate cancer. While the robotic approach reduces many risks compared to open surgery, complications can still occur.

Common Complications

1. Urinary Incontinence

• Most common early complication
• Often temporary; improves over months
• Persistent incontinence (<10% long term in experienced hands)

2. Erectile Dysfunction

• Due to nerve damage (neurovascular bundle injury)
• Depends on:
  • Nerve-sparing technique
  • Preoperative erectile function
  • Patient age

3. Bladder Neck Contracture (Stricture)

• Scar tissue at the bladder-urethra connection
• Can cause obstructive urinary symptoms
• May require dilation or endoscopic intervention

4. Bleeding

• Less common in robotic surgery than open
• May require transfusion (rare)

5. Infection

• At incision sites or urinary tract
• Prevented with sterile technique and prophylactic antibiotics

6. Anastomotic Leak

• Leakage of urine from the bladder-urethra connection
• Often managed conservatively with prolonged catheterization

7. Injury to Adjacent Organs

• Rare but serious: Rectal injury, ureteral injury, bowel injury

8. Lymphocele (if lymph node dissection is done)

• Fluid collection in the pelvis
• May resolve spontaneously or need drainage

9. Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE)

• Risk reduced with early mobilization and prophylaxis

10. Chronic Pelvic Pain

• Uncommon but can persist long-term in some patients

Rare Complications

• Hernia at port site
• Port-site metastasis (extremely rare)
• Long-term psychological impact due to sexual or urinary dysfunction

Advantages of RRP

Here are the key advantages of RRP for prostate cancer, especially when compared to traditional open or laparoscopic surgery:

Advantages of Robotic Radical Prostatectomy

1. Enhanced Surgical Precision

• Robotic instruments offer greater dexterity and range of motion than the human hand.
• Allows for precise dissection around delicate structures like nerves and blood vessels.

2. Improved Visualization

• 3D, high-definition magnified view of the surgical field.
• Enhances the surgeon’s ability to identify and preserve critical anatomy (e.g., neurovascular bundles).

3. Minimally Invasive Approach

• Small incisions (typically 5–6) rather than a large open cut.
• Leads to:
  • Less postoperative pain
  • Reduced blood loss
  • Lower risk of wound infection

4. Faster Recovery

• Shorter hospital stay (usually 1–2 days)
• Quicker return to normal daily activities (typically 2–4 weeks)

 5. Less Blood Loss and Fewer Transfusions

• Robotic technique provides better control of small blood vessels, reducing intraoperative bleeding.

6. Better Functional Outcomes

• Improved rates of urinary continence and erectile function recovery, especially when nerve-sparing techniques are used.

 7. Shorter Hospitalization

• Most patients are discharged within 24–48 hours.
• Less need for postoperative narcotics and supportive care.

8. Comparable or Improved Oncologic Outcomes

• Cancer control (based on margin status, PSA levels, and long-term survival) is at least equal, and often superior, to open surgery in experienced hands.

Surgical outcomes of RRP

Robotic radical prostatectomy has become the most common surgical approach for localized prostate cancer due to its favorable oncologic, functional, and perioperative outcomes. Here’s a comprehensive overview:

1. Oncologic Outcomes

• Cancer Control: Excellent for localized (T1–T2) and selected locally advanced (T3a) cases.
• Positive Surgical Margin (PSM) Rates:
  • T2 tumors: ~10%
  • T3 tumors: 20–40% (depends on extent)
• Biochemical Recurrence (BCR):
  • PSA recurrence-free survival at 5 years: 85–90%
• Long-Term Survival:
  • Comparable to open surgery
  • High cancer-specific survival (>95% at 10 years for localized disease)

2. Urinary Continence Outcomes

• Early incontinence is common but usually improves over time.
• Recovery Timeline:
  • ~60–80% continent by 3–6 months
  • ~90–95% continent by 12 months (with or without pads)
• Best results with nerve-sparing and bladder neck preservation techniques.

3. Erectile Function Outcomes

• Highly variable, depends on:
  • Age
  • Preoperative sexual function
  • Nerve-sparing status
• Potency rates:
  • With bilateral nerve-sparing: ~50–70% recover function by 1 year
  • Partial or no nerve-sparing: much lower

4. Perioperative Outcomes

Summary

Robotic radical prostatectomy offers:

• Excellent cancer control
• High rates of continence recovery
• Good potential for erectile function preservation in selected patients
• Lower blood loss, shorter hospitalization, and faster return to normal activities

Comparison with open surgery

RRP has some advantages compared to open RP. We can summarize these as follows:

Robotic radical prostatectomy is a minimally invasive surgical procedure used to treat localized prostate cancer by removing the entire prostate gland with the assistance of a robotic system, typically the da Vinci® robot. This technique offers enhanced precision, 3D visualization, and improved control, resulting in less blood loss, reduced pain, shorter hospital stays, and faster recovery compared to traditional surgery. It also provides good cancer control and favorable outcomes for urinary continence and sexual function, especially when nerve-sparing techniques are used.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul – TURKIYE