Who can undergo a robotic assisted radical prostatectomy (RARP)?

There are 2 factors to be considered for RARP – patient factors and tumour factors.

Patient factors – The operation requires the patient to be under anaesthesia and mechanical ventilation, and surgery in general takes 3-4 hours. Hence the patient must be physically fit. Patients with severe cardiopulmonary diseases, morbid obesity and glaucoma may not be suitable.

Tumour factor / prostate cancer – If the cancer is found to be metastatic (cancer spread to distant sites beyond the prostate organ), the RARP option becomes irrelevant and other treatment methods need to be pursued. Localised tumour (cancer confined to the prostate gland) and locally advanced cancers (cancer extending outside the prostate and even the nearby lymph nodes) are suitable to undergo RARP. During the RARP procedure, the prostate gland and seminal vesicles (organs which store the sperms) are removed. Sometimes the nearby lymph nodes are also removed. The size and location of the tumour are critical factors to be considered if the patients want a nerve sparing RARP to try and preserveqtheir erections.

What tests are done?

Nowadays the standard sequence of testing to diagnose prostate cancer is firstly a PSA (Prostate-specific antigen) and a DRE (digital rectal examination) followed by a multiparametric MRI (mpMRI) and finally a prostate biopsy.

Once the cancer has been confirmed the doctor may order a CT scan and a bone scan. These tests if needed have nowadays been replaced by a single test, the PSMA PET scan (PSMA stands for prostate specific membrane antigen while PET means positron emission tomography).

These test results (rectal examination, PSA, Gleason score and Grade Group from the biopsy, PMSA PET scan or CT and bone scan) will determine the seriousness or risk of the prostate cancer. Based on these results the patient will be assigned to one of 3 risk groups – low risk, intermediate risk and high risk. Depending on the risk group, the urologist will discuss with the patient the various treatment options.

Treatment and Risks

The 2 main treatments for prostate cancer which has not metastasised are surgery and radiotherapy. Radiotherapy treatment can be divided into conventional radiotherapy which takes 6 weeks, and SBRT (Stereotactic body radiation) which takes 1 week.

Surgery can be divided into open surgery and robotic surgery. The risks of surgery are incontinence and erectile dysfunction (ED). To minimize incontinence, it is advisable that the person prior to surgery maintain a healthy lifestyle (healthy weight, regular exercise) and perform pelvic floor
exercises or Kegel exercises. Kegel exercises should be continued after the operation.

The risks of erectile dysfunction are very high after the surgery. If the surgeon is able to perform a nerve sparing operation, then about 50-60% of patients may be able to recovery their erections in 1-2 years. The recovery from incontinence and erectile dysfunction are both dependent on tumour factors, patient factors and also on the experience of the surgeon.

Nowadays robotic surgery is preferred as compared to open operation because robotic surgery offers lower rates of perioperative complications, adverse events, shorter hospital stay, quicker recovery and reduced rate of readmissions. There are 2 types of robotic RARP – the standard conventional procedure and the Retzius-sparing procedure.

The advantage of the Retzius sparing procedure is that it has a quicker recovery of urinary continence compared to the conventional procedure. The disadvantage of the Retzius sparing procedure is that it is a more difficult procedure and takes a longer time to learn this technique. The standard conventional approach still remain the most common robotic technique worldwide.

Post RARP

There are no immediate treatments or medications after surgery. The only requirement is to monitor the PSA regularly. A safe level is PSA test result below 0.20 (ng/mL). In general, this PSA test and urologist consultation is repeated every 3 months for the next 24 months. If the PSA results remain below 0.20, the PSA test frequency and urologist visit is revised to once every 6 months.