Robotic Surgery

Robotic surgery — more precisely, robot-assisted minimally invasive surgery — is an advanced surgical approach in which a surgeon controls a computerized robotic system to perform precise operations through a series of small incisions, rather than through the large incisions required in conventional open surgery. The robotic platform does not act autonomously; it translates every movement made by the surgeon at a remote control console directly into the movements of miniaturized surgical instruments inside the patient's body.

In urological surgery, robotic systems are used across a wide range of oncological and reconstructive procedures. The technology provides the operating surgeon with a high-definition, three-dimensional, magnified view of the surgical field — offering substantially greater visual detail than the naked eye or standard laparoscopy. The articulating (wristed) robotic instruments replicate and refine the natural range of motion of the human wrist within the confined spaces of the pelvis and abdomen, while simultaneously filtering out any physiological hand tremor. These capabilities are particularly valuable in urological surgery, which frequently demands precise dissection in anatomically restricted regions adjacent to critical neurovascular and sphincteric structures.

Robotic surgery is currently the most widely performed minimally invasive surgical approach for radical prostatectomy (removal of the prostate for prostate cancer) and is also used for radical and partial nephrectomy (kidney surgery), radical nephroureterectomy (for upper tract urothelial carcinoma), radical cystectomy (bladder removal), adrenalectomy, and urological reconstructive procedures.

Pre-operative evaluation

Before robotic surgery, the patient undergoes a thorough pre-operative assessment to ensure fitness for surgery under general anesthesia and to confirm that the robotic approach is appropriate for their specific condition. This evaluation includes:

• Complete medical history, physical examination, and review of all relevant imaging (CT, MRI, or PET-CT)
• Blood tests, including a complete blood count, metabolic panel, and coagulation profile
• Cardiovascular and pulmonary assessment as clinically indicated
• In prostate cancer surgery: review of PSA values, prostate biopsy results, and imaging

Patient preparation instructions

• Fasting from midnight the evening before surgery (no food or drink, including water).
• Patients taking anticoagulant or antiplatelet medications (such as aspirin, warfarin, clopidogrel, or direct oral anticoagulants) will be asked to stop these a specified number of days before surgery, as directed by the surgical team.
• For pelvic procedures (particularly prostatectomy), bowel preparation may be recommended.
• Smoking cessation before surgery reduces the risk of anesthetic complications and promotes better wound healing.
• Transportation and post-operative care arrangements should be made in advance, as most patients will not be able to drive themselves home.

On the day of surgery

• The patient arrives at the hospital several hours before the scheduled operation to allow time for admission, pre-operative checks, intravenous access, and consultation with the medical team. General anesthesia is administered, and the patient is positioned on the operating table according to the procedure being performed.

In the operating room

• The surgeon makes three to five small incisions in the abdomen or pelvis, each typically 8–12 mm in size. Carbon dioxide gas is introduced through one of these ports to inflate the abdominal cavity (pneumoperitoneum), creating the working space necessary for the robotic instruments to move freely without contact with the abdominal wall.
• The robotic patient-side cart is positioned adjacent to the patient, and robotic arms are inserted through the incisions. One arm holds a high-definition, three-dimensional endoscopic camera; the remaining arms hold the specialized surgical instruments. The operating surgeon then moves to the surgeon console — located in the same operating room — and performs the surgery while viewing a magnified, stereoscopic image of the operative field. All movements of the surgeon's hands and wrists at the console are translated, filtered, and reproduced by the robotic instruments inside the patient's body in real time.

Duration and hospital stay

• The duration of robotic surgery varies by procedure. Hospital stays are generally shorter than for equivalent open surgery.

Robotic surgery carries the general risks associated with any major surgical procedure performed under general anesthesia. Specific risks relevant to robot-assisted urological surgery include:

• Bleeding: Blood loss during robotic surgery is generally lower than in open surgery. A blood transfusion is required infrequently, but remains possible.
  
  
• Infection: Wound site infection, urinary tract infection, or, rarely, intra-abdominal infection can occur. Prophylactic antibiotics are administered routinely.
  
  
• Injury to adjacent structures: The risk of inadvertent injury to surrounding organs (bowel, blood vessels, ureter, or nerves) is present in all pelvic and abdominal surgery. The magnification and precision of robotic instruments aim to minimize this risk.
  
  
• Conversion to open surgery: In a small proportion of cases, technical difficulties, unexpected anatomy, or intraoperative complications may necessitate conversion from the minimally invasive approach to an open surgical incision. This is not a surgical failure but a clinical decision made in the patient's best interest.
  
  
• Urinary incontinence: Following robotic radical prostatectomy, temporary urinary leakage is common and expected in the early post-operative period. The majority of patients recover continence over the following weeks to months, though a minority may experience persistent stress urinary incontinence.
  
  
• Erectile dysfunction: Injury to or manipulation of the neurovascular bundles — even when nerve-sparing technique is employed — may result in temporary or permanent erectile dysfunction after prostatectomy.
  
  
• Urethral anastomotic stricture: A small proportion of patients develop narrowing at the bladder-urethra anastomosis after prostatectomy, which may require subsequent endoscopic treatment.
  
  
• Lymphocele: After lymph node dissection, lymphatic fluid may accumulate in the pelvis (lymphocele), occasionally requiring drainage.
  
  
• Procedure-specific risks: Each robotic procedure carries additional specific risks; the treating surgeon will discuss these in detail during the pre-operative consultation.

Immediate post-operative course

• After surgery, patients are monitored in the recovery area and then transferred to a ward. Urinary catheters placed during the operation remain in situ for a specified period after discharge and are removed at a post-operative clinic visit once healing is confirmed. Patients are encouraged to ambulate early to reduce the risk of thromboembolic complications.

Oncological outcomes

• For the urological cancers for which it is most commonly used — particularly prostate and kidney cancer — robotic surgery achieves oncological outcomes equivalent to those of traditional open surgery, while generally offering the advantages of reduced intraoperative blood loss, shorter hospitalization, and faster convalescence.

Functional recovery

• Urinary continence and erectile function recovery following robotic radical prostatectomy are influenced by multiple factors, including the patient's age, pre-operative functional status, surgical technique, and tumor characteristics. Pelvic floor physiotherapy — beginning before surgery — supports continence recovery.

Post-operative surveillance

• The follow-up schedule after robotic surgery for urological cancer is determined by the cancer type and pathological findings at surgery. For prostate cancer, PSA is monitored at regular intervals after prostatectomy; a detectable or rising PSA may indicate biochemical recurrence requiring further evaluation and treatment. For kidney and upper tract cancers, cross-sectional imaging and laboratory follow-up are performed according to cancer risk and stage.