Retrograde neuro-sparing robotic prostatectomy: what you need to know

Prostate cancer treatment has seen remarkable advancements, particularly with the introduction of robotic surgery techniques. For patients with organ-confined prostate cancer, robotic radical prostatectomy offers a minimally invasive option with precision that enhances outcomes. Techniques such as retrograde nerve sparing allow surgeons to better preserve erectile function and urinary control while minimising recovery time.

Consultant urological and robotic prostate surgeon Mr Jonathan Noël explores the benefits of robotic surgery, the unique retrograde nerve-sparing approach, and what patients can expect during their recovery journey.

Retrograde neuro-sparing robotic prostatectomy. What is it?

Retrograde neuro-sparing robotic prostatectomy is a minimally invasive approach to treating prostate cancer by removing the entire prostate gland. Robotics allows the use of precise keyhole instruments controlled by a robotic system. However, prostate removal can impact a man’s ability to maintain strong erections, which depends on the nerve-sparing technique used. A retrograde nerve spare involves removing nerves from the bottom to the top of the prostate, unlike the more common anti-grade approach, performed from top to bottom. Retrograde nerve sparing is a complex technique mastered by only a few surgeons.

For prostate cancer confined to the gland, typically on one or both sides without spread, treatment options for the entire gland include radical radiotherapy—such as external radiotherapy or brachytherapy (radiotherapy seeds)—or surgical removal of the prostate. Surgery offers the advantage of lowering PSA levels to undetectable levels for easier monitoring. It is essential to choose an experienced surgeon who employs advanced techniques and tracks their outcomes.

What are the benefits of choosing a retrograde nerve spare robotic radical prostatectomy? What is the recovery like?

Prostatectomy is an excellent treatment option for those fit for general anaesthesia. While it demands a lot from your body initially, recovery is quick—most patients go home within a day or two. Unlike radiotherapy or brachytherapy, prostatectomy removes the gland entirely, eliminating concerns about residual cancer in the prostate.

The retrograde nerve-sparing robotic radical prostatectomy offers unique advantages. By releasing the nerves early and leaving them in their natural state without stretching, traction, or heat, their recovery is significantly improved. I use cold clips to control blood supply rather than heat, as preserving the nerves' integrity is crucial for faster recovery. This approach contrasts with the clipless technique, which applies heat, potentially compromising the benefits of nerve-sparing.

Preserving erectile function relies not just on sparing nerves but on how they are handled. Based on my experience, including time at the Global Robotics Institute, retrograde nerve-sparing minimises nerve disruption for better outcomes. Additionally, sparing nerves aids in faster urinary continence recovery, as shown in studies. Other factors, such as patient weight, prostate size, and the extent of surgical repair, also influence continence, but nerve preservation provides a clear advantage.

Who is an ideal candidate for retrograde nerve spare robotic radical prostatectomy?

The ideal candidates for a retrograde nerve-sparing robotic radical prostatectomy are patients with prostate cancer confined to the prostate gland, without spread to nearby organs, lymph nodes, or tissues. Patients with organ-confined cancer can have the nerves spared during surgery. However, if cancer has spread outside the gland on one side, nerves on that side may need to be sacrificed, while sparing those on the unaffected side. Our goal is to ensure a good recovery with satisfactory erectile and continence function.

After surgery, a catheter will remain in place to allow the bladder and urethra to heal. To ease bowel movements during this time, stay hydrated and eat plenty of fruits and vegetables. Once bowel function normalises, bladder function typically improves. After the catheter is removed, medications like tadalafil (Cialis) or sildenafil (Viagra) promote blood flow and aid rehabilitation. With both nerves spared, erectile function often returns within two months, as does urinary control, which is supported by pelvic floor exercises.

How do these advances in robotic technology help?

Advances in robotic technology have greatly enhanced surgical precision. The robot's 30-degree angled camera can be easily toggled up or down with the press of a button. During a retrograde nerve spare, this allows me to adjust the view and release the nerves early in their natural position, promoting better healing. Another key feature is the robot's ability to assess blood flow using medications administered during surgery, displayed through an enhanced visual field. This helps preserve more nerve tissue and optimise outcomes.

If you would like to book a consultation with Mr Noël, do not hesitate to do so by visiting his Top Doctors profile today.