Robotic Prostatectomy 👉 RARP

The short version

Robotic prostatectomy is the surgical removal of the whole prostate — plus the seminal vesicles, plus (often) nearby pelvic lymph nodes — performed through several small abdominal incisions while the surgeon operates a da Vinci robotic console. For localized prostate cancer at Grade Group 2 with adverse features, it's one of the two primary treatment options. The other is radiation. Long-term cancer control between the two is broadly equivalent. The differences are everything else.

How the procedure actually works

Under general anesthesia, the surgical team makes five to six small (~1cm) incisions across the lower abdomen. CO₂ is used to inflate the abdominal cavity so there's room to work. The robot's instrument arms enter through ports placed in those incisions; a camera arm enters through one of them and projects a magnified 3D view to the console.

The surgeon sits at the console a few feet from the operating table. Hand movements at the console get scaled down and tremor-filtered before the instrument tips inside the body actually move — micro-movements at millimeter scale. The robot doesn't operate autonomously. It's a precision-translation interface between the surgeon's hands and the surgical field.

Operating time runs roughly two to four hours. Typical hospital stay is one night. The catheter that drains urine while the bladder-to-urethra reconnection heals stays in for about a week.

What gets removed; what gets preserved

Removed: the entire prostate, the seminal vesicles attached behind it, and — if there's any meaningful risk of nodal involvement — a sampling of the nearby pelvic lymph nodes. The bladder gets reconnected directly to the urethra after the prostate comes out.

Preserved (if possible): the neurovascular bundles — two small bundles of nerves and blood vessels that run along the outer surface of the prostate, one on each side. They're what carry the signals that produce erections. Sparing them where the cancer allows is the single biggest determinant of erectile function after surgery.

The sparing decision is made per side based on where the cancer is and how close it sits to the prostate's outer wall, the capsule. If the cancer is hugging the capsule on one side, the surgeon often has to sacrifice that side's bundle to take enough surrounding tissue to be confident in a clean margin. See EPE for the longer version of that trade-off — and the Biopsy results & RARP page for how this specifically plays out given my biopsy findings.

Why surgery is on the table for me

Three things keep it in the conversation:

• The cancer appears localized. The April MRI showed nothing in the lymph nodes, seminal vesicles, or bones, and the biopsy showed no clear extension beyond the gland — and a June PSMA PET scan confirmed it, with no sign of spread anywhere in the body.
• I'm a reasonable surgical candidate. 66 with no major comorbidities. Recovery from major abdominal surgery is age-sensitive and the curve gets steeper later. Doing this now is materially easier than doing it in five years.
• Surgery yields the strongest post-procedure data. The entire prostate gets sectioned and graded by pathology. After surgery I'd know — definitively — the true grade, whether there was extra-prostatic extension, whether the margins were clean, whether the seminal vesicles were involved, and whether any sampled lymph nodes had cancer. That information either confirms the disease was contained or tells us we need to add radiation, ADT, or both.

Recovery, in the calendar sense

• Hospital: one night.
• Catheter: roughly one week — comes out at the first post-op visit.
• Desk work: ~two weeks. Many people work from home sooner. Energy is the limiter.
• No heavy lifting: ~six weeks. Anything more than ~10 lbs risks an incisional hernia until the abdominal wall fully closes.
• Continence: bladder control is initially poor and recovers in stages. Most men return to baseline (no pads) somewhere between three and twelve months; pelvic floor PT helps.
• Erectile function: the slowest to recover. Depends heavily on how much of the neurovascular bundles were spared, age, and pre-op function. Best-case curve runs six to twenty-four months, often supported by medication early on. If both bundles had to be sacrificed, natural erections don't return.

Outcomes & side-effect profile vs. radiation

For localized disease at my stage, ten- to fifteen-year cancer-control rates between surgery and radiation are comparable. The trade-offs are in which side effects, and when.

Surgery's profile

• Up-front recovery is intense but finite — weeks, not months.
• Incontinence is worst early and improves over months.
• Erectile function is the biggest variable, set largely by nerve-sparing.
• Rare but real surgical risks: bleeding, infection, anastomotic leak, bowel or ureter injury.
• Removing the prostate eliminates future risk of new prostate cancer in the gland — there's no gland left.

Radiation's profile (for comparison)

• No surgery, no catheter, no incisional recovery.
• Treatment itself stretches over weeks (external beam) or a single procedure (brachytherapy).
• Side effects skew toward bowel symptoms (urgency, irritation), late-onset erectile dysfunction (months to years), and fatigue during treatment.
• The prostate stays in place, which makes monitoring slightly more ambiguous and salvage treatment harder if cancer comes back.

What surgery doesn't do

It doesn't undo microscopic spread that's already left the prostate. If a few cells slipped through the capsule weeks or months before the operation, taking the gland out won't catch them. That's why PSA after surgery is the key follow-up signal: with no prostate, PSA should fall to undetectable. If it rises, that's the disease reasserting itself somewhere, and the response usually involves adding radiation and/or ADT.

It also doesn't fully answer the EPE question pre-operatively. My June PSMA PET showed no definite spread, but microscopic EPE sits below what a PET can resolve, so the capsule question stays a probability until the gland is sectioned. The EPE deep-dive covers the pre-op estimation tools — Partin tables, Briganti nomograms, PSMA PET — and where they fall short.

What's still feeding the decision

• Decipher: back. The Decipher genomic test came back at intermediate risk; Artera, the second genomic test, is the last input I'm waiting on.
• Done: a PSMA PET looked for spread the MRI can't see and came back clean — though it flagged a small, unconfirmed spot on the left side (detail on the Biopsy results & RARP page).
• In progress: a second pathology read at MSK — the cribriform / IDC-P findings change the stakes enough that a second opinion on the slides is worth getting.
• Done: parallel consultations with two radiation oncologists — both proposed short-course radiation, with hormone therapy contingent on the final risk grade.
• Surgeon-specific outcome data: continence and potency curves vary materially by individual surgeon volume and technique. The platform is the same; the operator isn't.