For a man diagnosed with prostate cancer, the first question is often the same: While getting rid of the cancer, how well can urinary continence and sexual function be preserved? Robotic prostate cancer surgery is the minimally invasive surgical method at the center of these questions, aiming at the precise removal of the prostate gland and, when necessary, surrounding tissues. However, the presence of a robotic system alone is not a guarantee of results. The right approach is determined by evaluating together the characteristics of the tumor, the patient's overall health, life expectancy, urinary and sexual function, and surgical experience.
What is robotic prostate cancer surgery?
The medical name of this operation is robot-assisted radical prostatectomy. The surgeon removes the prostate gland using special instruments inserted through small incisions in the abdominal wall and a high-resolution, three-dimensional imaging system. The robot does not perform the procedure on its own; all movements are controlled by the surgeon from the console.
After the prostate is removed, the bladder and urethra are reconnected. Depending on the risk of cancer spread, the PSA value, magnetic resonance imaging findings and the biopsy result, removal of the pelvic lymph nodes may also be added to the operation. This decision is not made the same way in every patient.
Compared with open surgery, the robotic approach may have potential advantages such as small incisions, more detailed imaging, less blood loss and, in some patients, a faster return to daily life. On the other hand, it should not be assumed that every patient is suitable for the robotic method or that the same results will be achieved at every center. The surgeon's experience, the hospital's infrastructure and correct patient selection are decisive.
Who may be a candidate for robotic surgery?
Robotic radical prostatectomy is considered especially in prostate cancer thought to be confined to the prostate, or in some selected cases of locally advanced prostate cancer. The aim is to remove the cancerous tissue with clear surgical margins and to achieve control of the disease in suitable patients.
The decision is not made only because cancer was seen on biopsy. The PSA level, the digital rectal examination finding, prostate MRI, the Gleason score or ISUP grade group on biopsy, how many foci the tumor is found in and, when needed, PET imaging results are evaluated. Age is also important, but not decisive on its own. An older patient in good general health, with sufficient life expectancy and expected to benefit from treatment, can also be a candidate for surgery.
For some patients, active surveillance, radiotherapy, hormone therapy or combinations of these treatments may be more suitable options. In low-risk prostate cancer, it may not be necessary to rush into a decision to operate. On the other hand, in clinically significant cancer, delaying treatment more than necessary is not correct either. For this reason, treatment should be based not on a single test result but on an individualized risk assessment.
Why is pre-operative planning important?
The detailed consultation before surgery is as valuable as the technical part of the operation. The blood thinners the patient uses, heart and lung conditions, previous abdominal surgery, urinary complaints and current erectile function are asked about. If necessary, an anesthesia assessment, blood tests and additional imaging are carried out.
Two critical topics should be discussed openly in this consultation: the risk of urinary incontinence and the possibility of changes in erectile function. In patients with an active sex life in particular, nerve-sparing surgery can be planned if the location of the tumor is suitable. Because the nerve bundles responsible for erection run right alongside the prostate, it is assessed before surgery whether these structures can be preserved without compromising cancer control.
Nerve sparing is not always possible. In areas where the tumor is suspected of extending beyond the capsule, oncological safety takes priority. Transparent planning helps the patient both set realistic expectations and take an active part in the treatment decision.
What is done during robotic prostate cancer surgery?
The procedure is performed under general anesthesia. Usually a few small access points are opened in the abdomen. The surgeon carefully separates the prostate from the surrounding tissues, removes the lymph nodes if deemed necessary and then sutures the bladder neck to the urethra. The duration of the operation may vary according to the patient's anatomy, previous surgery, body build, whether lymph node dissection is needed and the extent of the tumor.
At the end of the operation, a catheter is placed to support healing of the urinary tract. The catheter is usually removed within a short time after the surgeon's check. The length of the hospital stay is also planned according to the patient's pain control, mobilization, bowel movements and general well-being.
In robotic surgery, the high-magnification image provides the surgeon with an important technical advantage, particularly in distinguishing fine vascular and nerve structures. Still, surgical risks such as bleeding, infection, clot formation, urine leakage, anastomotic stricture and injury to surrounding tissues do not disappear completely. The patient should be informed in detail about their own risks.
When does urinary continence improve?
One of the issues that causes the most concern after surgery is urinary incontinence. After the catheter is removed, pads may be needed in the first days. The recovery process varies from person to person; some patients regain control within a short time, while in others recovery may take months.
Urinary function before surgery, age, the structure of the prostate, the surgical technique and the strength of the pelvic floor muscles affect this process. Pelvic floor exercises, when started before surgery in suitable patients and continued regularly afterwards, can contribute to bladder control. It is important that the exercises target the correct muscle group and are performed regularly.
If incontinence persists or significantly affects quality of life, further evaluation is carried out. Physical therapy approaches, medications or, in selected advanced cases, surgical options may come into consideration. Rather than waiting, it is necessary to communicate openly with the follow-up team.
How are sexual functions affected?
Preservation of erectile function is closely related to the stage of the cancer and whether nerve-sparing surgery can be performed. The potential for recovery may be higher in younger patients with good erection quality before surgery and whose nerve bundles can be preserved. However, this recovery usually takes place over months rather than days; in some patients the process may exceed a year.
After surgery, erectile rehabilitation is planned individually. Oral medications, vacuum devices, injection treatments or, for patients who need them, other approaches may be considered. The aim is to support not only sexual activity but also the health and blood flow of penile tissue. The sensation of orgasm may continue in most patients, but because the prostate and seminal vesicles are removed, no semen is expected to come out. This must be discussed before surgery, especially with patients who plan to have children.
The pathology result and post-operative follow-up
Pathological examination of the prostate tissue removed at surgery plays a key role in determining the next steps. The final pathology shows the true extent of the tumor, the surgical margin status, its grade and whether the lymph nodes are involved. Although pre-operative imaging is very valuable, the final staging is sometimes clarified by pathology.
The PSA test is used in follow-up. Because the prostate is completely removed, PSA is expected to be very low, often at undetectable levels. A rise in PSA again during follow-up may require further evaluation. In that case, radiotherapy or other treatments may be considered in some patients. Such a possibility does not automatically mean that the operation has failed; the aim in prostate cancer treatment is to plan the right additional treatment at the right time.
In the approach of Assoc. Prof. Dr. Uygar Miçooğulları, the oncological evaluation before the operation and the follow-up of urinary and sexual function after surgery are treated as parts of the same treatment plan. The patient being able to get accessible answers to their questions and not being left alone during the process is as important as the technical surgery.
Which questions should you ask when choosing a surgeon?
Before the brand of the robotic system, the experience and treatment approach of the surgeon leading the procedure should be evaluated. It is appropriate for the patient to ask about their own tumor risk group, why lymph node removal is or is not necessary, the possibility of nerve sparing and their personal functional risks. In addition, the post-operative catheter period, the team to contact in an emergency, the pathology result consultation and the PSA follow-up plan should be clarified from the outset.
The right decision is not simply about turning to the newest technology. It is about planning with an experienced team that knows the characteristics of your cancer, honestly explains the treatment alternatives and follows you during recovery. Preparing for this consultation with your biopsy, PSA and imaging results makes it easier to determine the safest path for you.
