Robotic Prostatectomy: What Actually Matters for Outcomes
This article forms part of Dr Deanne Soares’ urologic cancer education series, providing evidence-based guidance on the diagnosis, treatment and recovery pathways for urological cancers.
There is a lot written about robotic prostatectomy as though the robot itself is the story. It isn’t.
For patients and families, the real questions are more specific and more human:
Will the cancer be properly treated?
Will I be dry?
Will erections come back?
How long will this take to feel like “me” again?
And how do I weigh the trade-offs without regretting the decision?
For referring GPs, the question is often a version of the same thing: Who is going to make the right calls for this patient — not just execute a technically neat operation?
This piece focuses on what actually drives outcomes after prostate cancer surgery in Australia: oncological control (especially margins), nerve sparing judgement, surgeon experience that goes beyond numbers, and recovery realism. Not hype. Not absolutes. Just the parts that matter.
The decision before the operation is already shaping your outcome
By the time a patient is booked for robotic prostate cancer surgery, a large part of the “outcome” is already in motion. Not because the surgery is predetermined, but because:
the biology of the tumour is what it is,
the MRI and biopsy have already set the risk frame,
the baseline urinary and sexual function matters enormously,
and the plan (including what we are prepared to sacrifice, and what we are not) is established before the first incision.
There is a temptation — completely understandable — to look for certainty. “Will you spare the nerves?” “Will I be continent?” “Will the margins be clear?” The honest answer is that these are not yes/no questions at consultation. They are probabilities, and they are conditional on what we find and what we prioritise.
Good outcomes are not created by optimism. They are created by clear goals, sensible expectations, and careful judgement when the anatomy and the cancer don’t behave as neatly as the diagrams.
Surgical margins: what they are, why they matter, and what people misunderstand
What is a “margin”, in practical terms?
After a prostate is removed, a pathologist inks the outer surface and examines whether cancer cells are present at the cut edge. If cancer reaches that inked edge, it’s called a positive surgical margin.
A margin is not a moral judgement on the operation. It is a description of the relationship between the tumour and the boundary of what was removed.
Why margins matter
Margins matter because they correlate with the chance of biochemical recurrence (a PSA rise after surgery). Not every positive margin leads to recurrence, and not every recurrence is caused by a margin — but margins are one of the variables we can influence.
Where it becomes clinically relevant is what happens after surgery: PSA monitoring, the need for adjuvant or salvage radiotherapy in selected cases, and the anxiety that comes with uncertain risk. A clean, undetectable PSA after surgery is what most people want to see, and margin status helps us interpret risk when we plan follow-up.
What patients often misunderstand about “clear margins”
Misunderstanding #1: “Clear margins” means the cancer is cured.
Clear margins are reassuring, but they are not a guarantee. Cancer biology and staging still matter. If a tumour has already escaped microscopically beyond the prostate capsule, it may not be captured by margins alone.
Misunderstanding #2: A positive margin means “the surgeon left cancer behind.”
Sometimes a positive margin reflects true residual local disease. Sometimes it reflects the reality that the tumour is abutting the capsule in a way that makes a wider excision the only path to a negative margin — and a wider excision may come at a predictable functional cost.
There is also nuance in the pathology report: length of margin, location, grade at the margin, and whether there is extraprostatic extension. Those details matter. A small focal margin in a favourable context is not the same as an extensive margin in a high-grade setting.
Misunderstanding #3: Margin status is purely a technical issue.
Technique is part of it, yes. But margins are heavily influenced by pre-operative staging accuracy and intra-operative judgement: where the tumour is likely to be, how close it is to the neurovascular bundles, and when “a little more tissue” is the difference between good cancer control and a lifelong functional deficit.
The trade-off that sits underneath: margins vs nerve sparing
This is the part people often sense but don’t always have explained clearly.
In selected men, the cancer is peripheral and close to the capsule. The nerves that support erections run adjacent to the prostate. If we chase a wider margin aggressively in every case, more men will lose erections and some will struggle more with continence. If we spare nerves in a way that is oncologically unsafe, the risk of positive margins and recurrence rises.
So the key question is not, “Do you always spare nerves?”
It is, “Can you spare nerves safely for this cancer in this patient?”
That decision is dynamic. MRI helps, but MRI is not perfect. Biopsy helps, but biopsy samples. The surgeon’s job is to integrate all of it — and then adjust based on real intra-operative findings.
Nerve sparing: when it is possible, when it is unsafe, and why results vary
What nerve sparing actually means
Nerve sparing describes preserving the neurovascular bundles that contribute to erections. It is not a single uniform manoeuvre. There are degrees of nerve sparing. The plane of dissection matters. The tension on tissues matters. The thermal energy used matters.
Even in experienced hands, nerve sparing is not a guaranteed “switch” that brings function back. It is an attempt to preserve the best possible substrate for recovery.
When nerve sparing is possible
Nerve sparing is more feasible when:
MRI suggests organ-confined disease without extracapsular extension at the relevant side,
biopsy grade and pattern do not suggest aggressive peripheral spread,
the tumour location is away from the neurovascular bundles,
and the patient’s baseline erectile function is strong enough that preservation has meaningful upside.
When nerve sparing is unsafe
There are situations where nerve sparing becomes a poor bargain. Examples include:
clear or highly suspicious extracapsular extension on MRI adjacent to the bundle,
high-grade, high-volume disease with concerning pattern distribution,
tumours with features that behave aggressively beyond the capsule,
or intra-operative findings that don’t match the hopeful pre-operative picture.
In those moments, the surgeon is making a decision with a long time horizon. Saving a millimetre of tissue that preserves a chance of erections is not a win if it increases the likelihood of needing early radiotherapy, which then compromises sexual function anyway. That is not a scare tactic — it is simply the reality of sequencing and cumulative impact.
Why outcomes vary between patients (even with “the same operation”)
Patients often talk to one another. The stories can be confusing: one man is dry in weeks, another needs pads at six months. One man regains erections at four months, another is still struggling at eighteen.
Some of that is surgical. A lot of it is patient factors:
Baseline erectile function and vascular health: diabetes, smoking history, cardiovascular disease, and certain medications can shift recovery.
Age: not because older men “can’t” recover, but because nerve recovery and vascular response are typically slower.
Pre-operative urinary function: men with urgency or overactive bladder symptoms beforehand may have different postoperative experiences even if the sphincter is intact.
Pelvic floor strength and engagement with rehab: the “work” after surgery matters.
Cancer factors dictating resection extent: if cancer control requires wider excision, function may be affected despite best technique.
Two men can both have robotic prostatectomy and both have an excellent operation. Their recovery trajectories can still look quite different.
Erectile function recovery: timelines, and what I wish more patients were told
Here is the reality most men appreciate hearing early, even if it is uncomfortable:
Erectile recovery is often measured in months, not weeks.
For some men it is closer to 12–24 months, particularly if one or both sides cannot be fully spared.
The first erections that return may not look like the erections you remember. They often improve gradually with time, rehabilitation, and sometimes medication or devices.
Early on, there can be a period of “nothing happens” that feels like failure. It usually isn’t. It is often nerve shock and recovery biology.
A calm plan helps: penile rehabilitation strategies (where appropriate), realistic timeframes, and a clear understanding that recovery is not linear. Some men have a stepwise improvement. Some plateau and need escalation. That is not unusual.
Partners matter in this conversation too. Not because sex should be “performative”, but because the emotional and relational impact of erectile changes can be profound. Addressing it early, in a contained and practical way, reduces distress later.
Surgeon experience and judgement: why “robotic” is not standardised
Volume matters — but it isn’t the whole story
Patients understandably ask, “How many have you done?” It is a reasonable question. Repetition improves technical efficiency. It improves complication recognition. It builds muscle memory.
But there are two traps with volume as the only metric.
First: not all volume is equivalent. The complexity of cases, the surgeon’s training pathway, ongoing audit, and how outcomes are tracked matter. A surgeon who does a high number of straightforward cases may not have the same decision-making depth as someone who routinely manages high-risk, locally advanced disease and has a structured approach to balancing oncological and functional outcomes.
Second: surgery is not only about doing the same thing repeatedly. Prostate cancer is variable. Anatomy is variable. Prior pelvic surgery, body habitus, bleeding tendency, prostate size, and tumour location all add layers.
Experience should translate into composure and good decisions when the case is not “textbook”.
Why robotic surgery is not standardised
People sometimes assume that because a robot is involved, the operation is uniform — as though every surgeon is pressing the same sequence of buttons.
Robotic technology provides instruments, vision, and ergonomics. It does not provide judgement.
Key parts of the operation involve choices:
the dissection plane for nerve sparing on each side,
how widely to excise where cancer risk is highest,
how to manage anatomic variations and bleeding,
how to reconstruct and support continence mechanisms,
when to take lymph nodes and how extensively,
and what to do when pre-operative assumptions don’t hold in theatre.
These choices are where outcomes are shaped. They are also the hardest parts to summarise in a brochure.
The importance of case selection
Not every person with prostate cancer benefits equally from surgery, and not every cancer is best treated with surgery alone. In Australia, men and people mwith prostates often move between public and private settings, with varying wait times, access to multidisciplinary meetings, and different local pathways.
The role of the subspecialist surgeon is not simply to operate. It is to advise: is surgery the right treatment for this cancer in this patient, at this point in time, and with what expectations?
Sometimes the best surgical decision is to slow down and stage further. Sometimes it is to involve radiation oncology early for a balanced discussion. Sometimes it is to be honest about what surgery can and cannot preserve.
This is where patients feel the difference between a “robotic surgeon” and a robotic prostate cancer surgeon with subspecialist judgement.
Recovery realism: continence, sexual function, and the parts people underestimate
Urinary continence timelines: what is typical, and what is not
Continence after prostate cancer surgery is often described too casually. Patients are told they will “leak a bit” and then be fine. That framing can be minimising when a person is standing in the supermarket trying to work out whether their pad is visible.
A more realistic approach:
Many men have early leakage after catheter removal, especially with coughing, standing, lifting, or at the end of the day.
Improvement is typically progressive over the first weeks to months, with many men seeing meaningful gains by 3 months.
Continued improvement can occur up to 12 months (and sometimes beyond), particularly with pelvic floor physiotherapy and persistent training.
However, outcomes vary, and it is not helpful to pretend otherwise. Age, baseline urinary function, pelvic floor strength, extent of dissection, and any postoperative complications all play a role.
The goal is not to frighten patients. It is to set an expectation that early leakage is common, that structured rehab improves odds, and that if continence is not improving along an expected trajectory, there are steps we can take.
Sexual function recovery: the mental weight is often heavier than expected
Most men intellectually understand that erections may take time. Fewer are prepared for what that uncertainty does to identity and mood.
There can be grief. Frustration. A sense of “I did everything right — why isn’t this back yet?” Some men avoid intimacy altogether for fear of disappointment. Others push too hard and interpret variability as failure.
A better framing is that recovery after prostatectomy is not only physical. It is also psychological. A surgeon’s job includes naming that early, normalising it, and offering a plan rather than leaving men to quietly spiral.
Psychological adjustment: the aftershocks
Even when cancer control is good, the period after surgery can be emotionally strange.
The weeks of decision-making are intense.
Surgery happens, the prostate is out, and suddenly people expect you to be relieved.
Yet you might be managing a catheter, pads, fatigue, altered sleep, and changes in intimacy — all while waiting on final pathology.
It can feel anticlimactic and confronting at the same time.
For some men, there is also the shift from “I am being treated” to “I am being monitored”. PSA surveillance is reassuring, but it can also provoke anxiety before each test. These are normal reactions. They deserve to be addressed directly rather than brushed aside.
What patients often underestimate
A few recurring themes:
Fatigue: not dramatic, but persistent, and often underestimated — especially by men used to functioning at full capacity.
The inconvenience of early recovery: catheter management, sleep disruption, learning pad routines, planning outings differently.
The time horizon: people plan for a few weeks off work, but the broader recovery after prostatectomy can take months to truly settle.
The relationship impact: partners are often supportive, but they may also feel anxious, uncertain about how to help, or quietly affected by the change in intimacy and the fear of cancer recurrence.
Clear pre-operative counselling doesn’t make recovery easy. It makes it less surprising. Surprise is often what turns normal recovery into distress.
What to focus on when you are choosing surgery and planning recovery
If I had to reduce this to a few practical priorities:
For patients and partners
Ask about cancer control strategy: what drives the plan for margins and the likelihood of needing additional treatment.
Ask what nerve sparing is realistically possible for your tumour, not in theory.
Discuss your baseline urinary and sexual function openly. It changes the risk-benefit calculation.
Plan for recovery as a process, not an event: pelvic floor physiotherapy, sexual rehabilitation where appropriate, and psychological support if needed.
For referring GPs
Consider early alignment of expectations: PSA trajectory, pathology nuance, the possibility of salvage pathways, and support for sexual health discussions.
Encourage patients to choose a surgeon who demonstrates judgement, not just technical confidence.
Support the partner as part of the care unit; it improves coping and adherence to rehab.
Conclusion: good outcomes are built on judgement and realism
Robotic prostatectomy can be an excellent treatment for prostate cancer in the right patient. But the meaningful differences in outcomes rarely come down to the robot.
They come down to:
how the cancer is staged and understood before surgery,
how margins are balanced against functional preservation,
whether nerve sparing is chosen wisely — and avoided when it is unsafe,
the surgeon’s experience translating into sound intra-operative decisions,
and the quality of recovery support and expectation-setting afterwards.
This is not about fear, and it is not about perfection. It is about clarity.
If you are considering robotic prostate cancer surgery, aim to make an informed decision based on your individual cancer, your baseline function, and your priorities. Ask the questions that feel uncomfortable. They are usually the important ones. With a thoughtful plan and realistic expectations, most men move through recovery steadily — and many do very well.
Subspecialist judgement is not a slogan. It is the quiet work of tailoring the operation and the pathway to the person in front of you. That is what ultimately protects outcomes — oncological, functional, and emotional — long after the theatre lights are off.
About the author: Dr Deanne Soares is a Melbourne-based urologist with a subspecialty focus in robotic prostate, kidney and bladder cancer surgery, offering advanced minimally invasive cancer care.
