1. My Clinical Approach to Robotic Radical Prostatectomy
Many patients arrive having read that robotic surgery is “flawless” or guarantees full preservation of continence and erections. The reality is more nuanced: robotic radical prostatectomy is an excellent precision tool, but the outcome depends equally on the stage of disease, each patient’s anatomy, and the experience of the surgical team.
My role is to explain, based on the European Association of Urology (EAU) guidelines, what the procedure can realistically offer a specific patient — without exaggeration and without hiding possible complications.
In practice, I always:
- Obtain full staging (PSA, Gleason/ISUP grade, mpMRI, clinical stage) before any discussion of treatment.
- Present all treatment alternatives — active surveillance, radiotherapy, surgery — with their real-world data.
- Give clear information about the factors affecting continence and erectile function, without promises.
- Individualise the decision on nerve-sparing technique and lymph node dissection based on oncological risk.
This guide is based on the EAU guidelines on prostate cancer and published clinical literature — not on marketing material.
2. What Is Robotic Radical Prostatectomy
Radical prostatectomy is the complete surgical removal of the prostate together with the seminal vesicles, aiming for oncological eradication of the disease while preserving pelvic organ function where feasible. This is followed by reconnection of the bladder to the urethra (vesicourethral anastomosis).
In the robotic variant (RARP – Robot-Assisted Radical Prostatectomy), the procedure is performed laparoscopically using a robotically guided system, through small incisions in the abdomen.
- Removal of the prostate and seminal vesicles.
- Reconnection of the bladder to the urethra (anastomosis).
- Possible pelvic lymph node dissection, depending on oncological risk — not in every case.
3. Is It Really a “Robotic” Procedure?
A robotically guided system is indeed used, but this does not mean autonomous surgery.
The robot does not perform the operation autonomously. Every movement is controlled by the surgeon through the surgical console.
The surgeon sits at a dedicated console and controls every movement of the robotic arms in real time — the system makes no treatment decisions on its own.
4. When It Is Indicated
The decision for radical prostatectomy is individualised, based on:
Clinical stage (DRE & imaging)
PSA level
Gleason score / ISUP Grade Group
mpMRI findings
Prostate biopsy result
Age & life expectancy
Comorbidities
Patient preference
Localized Prostate Cancer
Radical prostatectomy is an established option for patients with sufficient life expectancy (generally over 10 years).
Selected Locally Advanced Cases
In selected patients, surgery may be part of multimodal treatment, potentially combined with adjuvant therapy.
Pelvic Lymph Node Dissection
Extended pelvic lymph node dissection is mainly recommended for patients with intermediate or high oncological risk, for more accurate staging — not routinely for low-risk disease.
Radical Prostatectomy Is Not the Only Option
For prostate cancer, treatment choice is individualised. In low-risk disease, active surveillance may be the first option. Radiotherapy is also an effective, well-documented treatment for selected patients.
5. Pre-operative Evaluation
Imaging & Staging
mpMRI of the prostate for local staging. Additional imaging (e.g. bone scan, CT, or PSMA-PET/CT) is considered in intermediate/high-risk patients, not in every case.
General Pre-operative Assessment
Urological and anaesthetic assessment, blood tests, cardiovascular risk evaluation where needed.
Anticoagulant Therapy
Management of anticoagulant/antiplatelet medication is individualised, in consultation with the treating physician — patients should not stop these medications on their own.
Nerve-Sparing Discussion
Depending on stage, MRI anatomy, and pre-operative erectile function, the possibility of unilateral or bilateral nerve-sparing technique is discussed.
6. How the Procedure Works
General Anaesthesia
The procedure is performed under general anaesthesia, with the patient in a specific position.
Small Incisions
4–6 small incisions in the abdomen, through which the robotic instruments are introduced.
Da Vinci System Docking
The robotic arms are connected to the access ports. The surgeon moves to the control console.
Dissection & Removal of the Prostate
The prostate is freed from the bladder, urethra, and seminal vesicles, with precision aided by 3D magnification.
Nerve-Sparing, Where Indicated
When oncologically safe, preservation of the neurovascular bundles is attempted.
Lymph Node Removal, If Required
In intermediate/high-risk patients, pelvic lymph nodes are removed for staging.
Vesicourethral Anastomosis
The urethra is sutured to the bladder, aiming for a sealed, tension-free anastomosis.
Catheter Placement
A urethral catheter is placed for the period needed to allow the anastomosis to heal.
Completion
The robotic instruments are removed and the small incisions closed.
The exact course varies per patient, depending on anatomy and the surgical finding.
7. What Nerve-Sparing Prostatectomy Means
The neurovascular bundles associated with erectile function lie in very close proximity to the prostate. In appropriately selected patients, and when considered oncologically safe, the following may be attempted:
Unilateral Nerve-Sparing
Preservation of the neurovascular bundle on one side only, when there is evidence of disease on the other side.
Bilateral Nerve-Sparing
Preservation of both bundles, when anatomy and stage allow this safely.
The feasibility of nerve-sparing depends on tumour location and extent (based on MRI and biopsy), pre-operative erectile function, age, and above all, oncological safety. In higher-risk disease, nerve-sparing technique may be limited or not possible.
No one can promise preservation of erections in advance — nerve-sparing technique increases the likelihood, without guaranteeing it.
8. The Da Vinci Technology
The Da Vinci system consists of a surgeon console, robotic arms, and an imaging system. It offers:
- Three-dimensional, magnified visualisation of the surgical field.
- Articulated instruments (EndoWrist) with a greater range of motion than the human hand.
- Filtering of the surgeon’s natural hand tremor.
- The ability for meticulous dissection around the urethra and neurovascular bundles.
The robot does not perform the operation autonomously. Every movement is controlled by the surgeon through the surgical console.
9. Robotic vs Open/Laparoscopic Prostatectomy
| Feature | Robotic (RARP) | Open / Laparoscopic |
|---|---|---|
| Access | 4–5 small incisions (≤1 cm) | Single lower-abdominal incision ~10–15 cm |
| Blood loss | Usually lower | Usually higher |
| Visualisation | Three-dimensional, magnified | Direct surgeon vision |
| Hospital stay | Often shorter | Often longer |
| Oncological outcomes | Depend mainly on stage & surgeon experience | Depend mainly on stage & surgeon experience |
| Early continence recovery | Faster in some series in the first months | Often slower in the first months |
Long-term oncological outcomes depend mainly on the stage of disease, tumour biology, and the quality of the surgery — not solely on the surgical approach. 3D laparoscopic prostatectomy is also a valid alternative in experienced hands.
10. Urinary Continence After Radical Prostatectomy
After catheter removal, some degree of temporary incontinence (leakage on effort or movement) is common. Recovery is usually gradual, over a period of months.
- Pelvic floor exercises (Kegel exercises) are recommended and can start early, often even before surgery.
- Most patients notice gradual improvement in the first months after catheter removal.
- Factors such as age, membranous urethral length, and anastomotic technique can affect the speed of recovery.
No absolute recovery rates are given here — the course varies significantly by patient, and in rare cases further management of persistent incontinence may be needed.
11. Erectile Function After Prostatectomy
Even with nerve-sparing technique, a period of neuropraxia (temporary nerve dysfunction due to surgical trauma) is common, with gradual recovery of function over months, where it occurs.
- Age and pre-operative erectile function are among the most important prognostic factors.
- Bilateral nerve-sparing is associated with a higher chance of recovery compared with non-nerve-sparing technique.
- “Penile rehabilitation” — e.g. early use of PDE5 inhibitors after medical advice — is considered in selected patients.
For patients who do not achieve satisfactory recovery, further options exist: PDE5 inhibitors, a vacuum erection device, intracavernosal injections, and, in selected cases, a penile prosthesis.
12. Possible Complications
As with any surgical procedure, robotic radical prostatectomy carries possible complications, which are always discussed before surgery:
- Bleeding, rarely requiring transfusion.
- Infection.
- Deep vein thrombosis (DVT) — reduced with anticoagulant prophylaxis and early mobilisation.
- Leakage from the urethrovesical anastomosis.
- Anastomotic or bladder neck stricture, rarely, at a later stage.
- Temporary, or more rarely persistent, urinary incontinence.
- Erectile dysfunction, with variable chance of recovery.
- Lymphocele after pelvic lymph node dissection, if performed.
- Possible need for additional treatment (e.g. radiotherapy) in some patients, depending on the pathology result.
13. Hospital Stay and Recovery
There is no single universal timeline for hospital stay or catheter removal that applies to every patient \u2014 the course is individualised by the surgeon.
14. What Happens After Surgery
The removed prostate is always sent for pathological examination, which determines:
Final Gleason score / ISUP Grade Group
Surgical margin status (positive/negative)
Pathological stage (pT)
Lymph node status, if removed
The first post-operative PSA check follows, aiming for an undetectable value, followed by regular monitoring. In selected patients with unfavourable findings (e.g. positive margins, extracapsular extension, or a higher ISUP grade), the following may be discussed:
- Adjuvant or salvage radiotherapy
- Hormone therapy, in specific high-risk cases
- Closer PSA monitoring
15. The Doctor
Dr. Marinos Vasilas, Urologist – Andrologist
Dr. Marinos Vasilas specialises in robotic surgery and 3D-4K laparoscopic surgery, with a clinical focus on urological oncology (prostate, kidney, bladder). His training is linked to the Urology Department of the University Hospital of Patras, following the guidelines of the European Association of Urology (EAU).
Meet the Doctor16. Surgical Team
Robotic radical prostatectomy is performed in collaboration with a specialised surgical centre and urology team, ensuring access to modern robotic infrastructure.
Meet Our Team17. Frequently Asked Questions (FAQ)
What is robotic radical prostatectomy?
It is the complete surgical removal of the prostate and seminal vesicles to treat localized prostate cancer, using the Da Vinci robotic system. The surgeon controls the system from a console throughout the entire procedure.
How long does the procedure take?
Duration varies depending on anatomy, prostate size, and whether pelvic lymph node dissection is needed. There is no single duration that applies to every patient — the surgeon can give a more specific estimate after the pre-operative work-up.
How many days of hospitalization are needed?
Length of hospital stay varies by patient and by surgical centre, depending on the post-operative course and the clinical protocol.
When is the catheter removed?
The urethral catheter remains in place until healing of the urethrovesical anastomosis is confirmed, either clinically or with a cystogram. The exact duration is individualised and not the same for every patient.
Will I have incontinence after the surgery?
Some degree of temporary incontinence after catheter removal is common and usually improves gradually over the following months, especially with pelvic floor physiotherapy. Full recovery is not guaranteed for every patient and depends on several factors.
Will erectile function return after radical prostatectomy?
This depends mainly on whether — and to what extent — nerve-sparing technique was possible, as well as age and pre-operative erectile function. Recovery, when it happens, is gradual over months — no one can promise preservation of erections in advance.
What is the nerve-sparing technique?
It is the attempt to preserve the neurovascular bundles that lie in close proximity to the prostate and are associated with erectile function, provided this is oncologically safe based on the stage and location of the tumour.
Is lymph node removal always needed?
No. Extended pelvic lymph node dissection is mainly recommended for patients with intermediate or high oncological risk, not for every case of localized prostate cancer.
When is PSA checked after the surgery?
The first PSA check is usually performed a few weeks after surgery, aiming for an undetectable value. Regular follow-up continues at set intervals, as determined by the treating surgeon.
Might radiotherapy be needed after the surgery?
In selected patients with unfavourable pathology findings (e.g. positive surgical margins, extracapsular extension, or a higher ISUP grade), adjuvant or salvage radiotherapy may be discussed, depending on PSA behaviour and in consultation with a radiation oncologist.
Related Topics
3D laparoscopic radical prostatectomy and prostate biopsy are discussed for comparison purposes throughout this article; dedicated English-language pages for these specific procedures are not yet available.
Book a Consultation in Rhodes
Newly diagnosed with prostate cancer and looking for personalised advice on treatment options? Complete evaluation with PSA, mpMRI, Gleason/ISUP grade, and staging at our urology practice in Rhodes.
References & Sources
- EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer 2026 — uroweb.org
- Ficarra V, et al. Systematic Review and Meta-analysis of Studies Reporting Urinary Continence Recovery after Robot-assisted Radical Prostatectomy. Eur Urol 2012;62:405–417.
- Coughlin GD, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled study. Lancet Oncol 2018;19:1051–1060.
Medical Review
Dr. Marinos Vasilas, Urologist – Andrologist
Dr. Marinos Vasilas applies modern techniques for the surgical treatment of prostate cancer, including robotic radical prostatectomy with the Da Vinci system, following EAU guidelines.
Full profileThe content on this page is for informational purposes only and does not replace an individualised urological/oncological evaluation. Treatment choice for prostate cancer depends on stage, Gleason/ISUP grade, age, comorbidities, and each patient\u2019s priorities.
