10 questions to ask before robotic prostate cancer surgery

Is surgery the right treatment for my cancer, and what are my alternatives?

"What would you recommend if I were your brother, and why?"

This is the most important question, and it comes before any question about the operation. Prostate cancers vary enormously. Some grow so slowly they are best monitored with active surveillance. Others need treatment, and for those, surgery and radiotherapy give similar long-term cancer control, with different side effects and different recovery.

Your recommendation should be built on your Grade Group (Gleason score), PSA, MRI findings, the stage of the cancer, your general health and what matters most to you.

How many of these operations have you performed, and do you audit your results?

"How many robotic prostatectomies do you do each year, and can I see your outcomes?"

Robotic prostatectomy has a long learning curve. Research consistently shows that cancer control, continence and erectile function improve with a surgeon's experience. It is not rude to ask. Good surgeons expect the question and are happy to answer it.

Volume is only part of the picture. Ask how outcomes are measured: whether the surgeon records continence, erections and positive margins for every patient, and whether the results are submitted to a national audit or registry.

My answer: I have performed more than 900 robotic operations as a consultant (and over 1500 including training & fellowship). I average between 225 - 250 robotic procedures a year, and I prospectively log and audit my cases. You can see some of my audited outcomes on my About page.

Will you be able to spare the nerves, and on which side?

"Is nerve-sparing realistic for me, on one side or both?"

The nerves that control erections run in two delicate bundles along each side of the prostate. Preserving them, called nerve-sparing, gives the best chance of recovering erections, and also helps continence.

Whether they can be spared depends mostly on where the cancer is. If it sits right at the edge of the prostate on one side, the safest cancer operation may mean removing the nerves on that side, while still sparing the other. Your MRI and biopsy results guide this decision, and sometimes the final decision is made during the operation itself.

Worth knowing: cancer control always comes first. A surgeon who promises full nerve-sparing before looking closely at your MRI is giving you reassurance, not information.

Will I leak urine afterwards, and for how long?

"What proportion of your patients are dry at three months and at one year?"

Some leakage is normal when the catheter first comes out, especially when coughing, sneezing or standing up. For most men it improves steadily over the following weeks and months. Starting pelvic floor exercises before surgery and having good technique makes a real difference.

It is also worth asking about technique. A Retzius-sparing prostatectomy approaches the prostate from behind, leaving the structures in front of the bladder undisturbed, and is associated with an earlier return of continence in suitable men.

My answer: I expect most of my patients to be dry at night and using a single pad for safety by six weeks, and over 90% are continent at one year after nerve-sparing surgery. I offer both Retzius-sparing and standard nerve-sparing surgery, and choose the one that suits your cancer and anatomy.

What will happen to my erections and sex life?

"Given my age and current function, what is realistic for me, and what help is available?"

This is the side effect many men find hardest to ask about, and the one where expectations matter most. Recovery of erections is slower than continence, often taking one to two years, and depends on three things: how good your erections are before surgery, your age and general health, and whether the nerves can be spared.

A few facts are worth knowing in advance. You will still be able to have an orgasm, but it will be dry, because the glands that make semen are removed. That also means you will no longer be fertile, so if you may want children, ask about sperm banking before surgery.

I explain this in more depth in erectile dysfunction after robotic prostatectomy.

How long will I be in hospital, and where will the operation take place?

"How many nights should I expect to stay, and what happens if I need to come back?"

One of the advantages of robotic surgery is a faster recovery. The operation is done through a handful of small cuts, so pain is usually modest and most men are walking the same evening.

Ask where the operation will be done, who looks after you overnight, and who you call if there is a problem once you are home, day or night. Knowing that plan in advance is reassuring for you and your family.

My answer: most of my patients go home the morning after surgery.

How long will I have a catheter, and who will remove it?

"Will I go home with a catheter, and what support will I have with it?"

After the prostate is removed, the bladder is rejoined to the urethra. A catheter rests across that join while it heals, and is usually removed after about a week. It is often the part of recovery men worry about most, but almost everyone manages it well with a little preparation.

Ask who will teach you how to look after it, whether you will have spare bags and a night bag, and where and when it will be removed.

My 10 recovery tips after prostate removal include practical advice on living with the catheter.

When can I return to work, driving, exercise and normal life?

"What should my first six weeks look like?"

Most men are back to normal daily routines within two to four weeks. Desk-based work is often possible after a couple of weeks, while physical jobs need longer. Heavy lifting and strenuous exercise are usually avoided for around six weeks to let the deep tissues heal.

You should not drive while the catheter is in, and you need to be able to brake hard in an emergency before you get back behind the wheel. Check with your insurer too.

For a realistic timeline, see recovery after robotic prostatectomy, week by week.

What will the pathology report tell us, and what if it shows more than expected?

"When will I get my results, and what would change the plan?"

After surgery, the whole prostate is examined under the microscope. This gives the most accurate picture of your cancer: its final grade, whether it was confined to the prostate, whether any cancer reached the edge of the tissue removed (a positive margin), and, if they were removed, whether the lymph nodes were clear.

Results usually take two to three weeks. A positive margin does not necessarily mean cancer has been left behind, and many men with one never need further treatment. But it is worth knowing in advance what would prompt a discussion about additional treatment such as radiotherapy.

How will I be followed up, and what should my PSA do?

"Who will check my PSA, how often, and what number would worry you?"

Once the prostate has been removed, your PSA should fall to an undetectable level within a few weeks. From then on, regular PSA tests are the main way of checking that the cancer has not come back. They are usually every few months at first, then less often as time goes on.

If PSA starts to rise, it can usually be picked up early, while further treatment is still very effective. Ask who will arrange your tests, who will tell you the results, and who you contact with any concern about continence, erections or your PSA in the months and years ahead.