Prostatectomy and sexual health: how robotic surgery can make a difference

“Prostatectomy is a surgical procedure involving the partial or total removal of the prostate, the small male gland located below the bladder and involved in the production of seminal fluid,” explains Prof. Greco.

Robotic prostatectomy can be performed in two forms, depending on the clinical indication:

• Simple prostatectomy (adenomectomy): removal of the prostatic adenoma that obstructs the urethra and urinary flow in cases of benign prostatic hyperplasia (BPH). It is generally recommended for very large prostates.
• Radical prostatectomy: performed to treat prostate cancer. This procedure involves complete removal of the prostate, seminal vesicles, and sometimes pelvic lymph nodes. After removal, the surgeon reconstructs the continuity between the bladder and the urethra to restore normal urinary flow.

The primary sexual concern following radical prostatectomy is erectile dysfunction (ED), which can result from damage to the cavernous (erectile) nerves responsible for erection.

The impact of the procedure varies based on several key factors:

• Surgical technique: advanced approaches, such as robot-assisted surgery, generally provide better outcomes.
• Patient age: younger patients tend to recover more easily, while advanced age can negatively affect nerve regeneration and overall sexual function.
• Pathology and disease extent: more extensive or aggressive tumors may require a more radical excision, increasing the risk of ED.
• Preoperative sexual function: preexisting erectile dysfunction or severe cardiovascular disease makes postoperative recovery more challenging.

Robotic surgery has revolutionized the approach to prostatectomy by offering several advantages:

• Greater precision with minimal damage to surrounding tissues
• Minimally invasive technique with reduced postoperative pain
• Less intraoperative bleeding
• Faster postoperative recovery and shorter hospital stay (typically 3–4 days)

How robotic surgery enhances nerve-sparing techniques

Thanks to magnified 3D vision and superior surgical precision, robotic prostatectomy optimizes the nerve-sparing approach, which aims to preserve the erectile nerve bundles that envelop the prostate, enabling the potential recovery of erectile function postoperatively.

Nerve-sparing techniques include:

• Unilateral nerve-sparing: preserving only one of the two nerve bundles if oncologic conditions allow. Recovery chances are lower than with bilateral preservation but still possible.
• Bilateral nerve-sparing: preserving both erectile nerve bundles for optimal functional recovery.
• Tailored (personalized) nerve-sparing: robotic surgery allows the surgeon to customize the preservation of neural structures, balancing oncologic safety with the patient’s quality of life.

For patients with preexisting erectile dysfunction who wish to regain erectile function, it is possible to perform a tricomponent penile prosthesis implant at the same time as the robotic prostatectomy.

This minimally invasive procedure of short duration allows the patient to address the oncologic problem while also restoring the possibility of a satisfying sexual life.

After a partial (simple) prostatectomy, antegrade (normal) ejaculation may still occur, although retrograde ejaculation, in which semen flows back into the bladder instead of exiting via the urethra, is common. This can reduce the volume of ejaculate while typically maintaining orgasm and sexual pleasure.

After a radical prostatectomy, antegrade ejaculation is no longer possible because the prostate and seminal vesicles, which produce semen, are completely removed. However, orgasm can still be achieved, often with preserved satisfaction, despite the absence of ejaculation.

In both cases, fertility is affected or completely lost. Men wishing to have children are advised to consider sperm cryopreservation before surgery.

“A prostatectomy should not be seen as the end of a man’s sexual life. Robot-assisted surgery and nerve-sparing techniques offer real opportunities to preserve erectile function whenever feasible. Accurate preoperative evaluation, treatment at specialized centers, and a structured postoperative rehabilitation program are all essential for optimal recovery,” concludes Prof. Greco.