Robotic prostatectomy

Who it suits

Robotic prostatectomy is an option when surgery has been chosen for localised or locally advanced prostate cancer that is expected to be curable by removing the prostate. Common situations include:

• intermediate- or high-risk localised prostate cancer (ISUP grade group ≥ 2 on biopsy);
• selected low-risk disease where active surveillance has not been chosen;
• some locally advanced cases as part of a multi-modal plan.

It is not an automatic choice - active surveillance, external beam radiotherapy and brachytherapy remain valid alternatives depending on disease and patient factors.

What the operation involves

The operation is performed under general anaesthesia through five or six small port incisions. Steps (simplified):

1. Ports placed; CO2 insufflation; robot docked.
2. Access to the space behind the pubic bone. The bladder neck is separated from the prostate.
3. Seminal vesicles and vas deferens are dissected free.
4. The lateral attachments of the prostate are freed. Where appropriate, the neurovascular bundles responsible for erectile function are preserved using a nerve-sparing technique.
5. The apex of the prostate is divided from the urethra. The prostate and seminal vesicles are placed in a specimen bag.
6. The bladder is reconnected to the urethra (vesicourethral anastomosis). A catheter is left in for approximately one to two weeks.
7. Pelvic lymph node dissection is added in intermediate- and high-risk disease.
8. Specimen removed through one of the incisions; port sites closed.

Technique refinements

Dr Kooner has contributed to technique refinements that affect patient outcomes:

• Retrograde nerve sparing - dissecting the neurovascular bundles from a different direction to reduce traction and thermal injury.²
• Pelvic floor reconstruction - restoring the anterior and posterior supports of the urethra to improve early return of urinary continence.²
• Extended pelvic lymph node dissection where indicated by nomogram-estimated risk.

Hospital stay and catheter

A typical hospital stay is one to two nights. A urinary catheter stays in place for one to two weeks to protect the anastomosis while it heals. After the catheter is removed, the return of urinary control is gradual over weeks to months.

Expected outcomes

Published series of contemporary robotic prostatectomy consistently show:

• lower estimated blood loss and lower transfusion rates than equivalent open series;^4,5
• shorter length of stay;
• earlier return to work;
• similar oncologic outcomes (positive surgical margin rates, biochemical recurrence) to contemporary open series;
• similar or better return of urinary continence and erectile function depending on nerve-sparing technique.

Individual results depend on disease factors (grade, volume, extraprostatic extension) and patient factors (age, baseline continence, baseline erectile function). The published learning-curve literature suggests that the dominant driver of outcomes is surgeon case volume, not brand of robot, with a plateau reached beyond approximately 200 cases.⁵

Potential complications

Major complications of robotic prostatectomy are uncommon but real:

• urinary leak from the anastomosis (usually resolves with longer catheter drainage);
• lymphocoele after node dissection;
• bleeding requiring transfusion (uncommon);
• injury to the rectum, ureters or other adjacent structures (uncommon);
• venous thromboembolism (reduced by intra-operative calf compression and post-operative mobilisation);
• urinary incontinence - usually stress incontinence, usually transient, occasionally persistent;
• erectile dysfunction - common, influenced heavily by nerve-sparing status and baseline function;
• biochemical recurrence of prostate cancer - monitored lifelong with PSA.

Alternatives

• Active surveillance - monitoring rather than treating, usually for low-risk disease.
• External beam radiotherapy (with or without hormonal therapy).
• Brachytherapy in selected cases.
• Focal therapy (HIFU, NanoKnife, cryotherapy) in selected cases - see focaltherapy.au.
• Open radical prostatectomy - still performed in some centres.

Resources