A Temporary Stent for Benign Prostatic Enlargement: Temporary Treatment Without a Permanent Implant

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Benign prostatic hyperplasia or BPH is a non-cancerous enlargement of the prostate. As the prostate grows, it may compress the urethra and interfere with emptying the bladder.

Typical symptoms include:

  • A weak or interrupted urinary stream
  • Difficulty starting urination
  • Straining to pass urine
  • Urinary frequency or urgency
  • Getting up repeatedly at night
  • Dribbling after urination
  • A feeling that the bladder has not emptied completely

Medication is often the first treatment. However, tablets do not help every patient and may cause dizziness, tiredness, reduced ejaculation, erectile difficulties or reduced libido. The iTind procedure offers selected men a minimally invasive alternative to long-term medication or conventional prostate surgery.

What is iTind / Temporary Stent?

The iTind is a small temporary device made from nitinol, a flexible nickel–titanium alloy with “shape memory.”

It is sometimes called a temporary prostatic stent, although it differs from a traditional stent because it is not intended to remain permanently within the prostate. The device is left in place for only five to seven days and is then removed completely.

While in position, three expanding struts apply controlled pressure to specific areas of the prostate and bladder neck. This remodels the prostatic urethra and creates channels through which urine can flow more easily.

The procedure does not:

  • Permanently implant metal within the prostate
  • Remove prostate tissue
  • Use laser, heat or steam
  • Prevent future prostate treatments if symptoms return

Who may benefit from iTind?

iTind may be considered for men who have bothersome urinary symptoms caused by BPH and who:

  • Have obtained insufficient benefit from medication
  • Have developed side effects from BPH tablets
  • Prefer not to take daily medication indefinitely
  • Want a less invasive alternative to TURP or laser surgery
  • Wish to minimise the risk of ejaculatory or erectile side effects
  • Prefer not to have a permanent prostatic implant
  • Have prostate size and anatomy suitable for the device

The procedure is generally best suited to men with moderate-to-severe symptoms and a prostate measuring approximately 25–75 mL, without a significantly obstructing median lobe.

These measurements are a guide rather than a guarantee of suitability. The shape of the prostate, severity of obstruction and function of the bladder are as important as prostate size.

Assessment before treatment

Urinary symptoms are not always caused by an enlarged prostate. Similar problems can result from infection, urethral narrowing, bladder weakness, an overactive bladder, neurological disease, medication or, less commonly, cancer.

Assessment may therefore include:

  • Medical history and examination
  • International Prostate Symptom Score
  • Urine testing
  • PSA testing when appropriate
  • Urinary-flow measurement
  • Ultrasound measurement of residual urine
  • Prostate ultrasound or other imaging
  • Flexible cystoscopy
  • Urodynamic testing in selected patients

Any urinary infection should be treated before the procedure.

Patients taking aspirin, warfarin, clopidogrel, apixaban, rivaroxaban or other blood-thinning medication require an individual management plan. Do not stop blood thinners without instructions from your prescribing doctor and urologist.

How is the iTind procedure performed?

Insertion

The folded iTind device is passed through the urethra using a small cystoscope. It is positioned in the prostatic urethra immediately below the bladder neck and then released.

The procedure is usually performed as day surgery. Depending on the patient and treatment setting, local anaesthetic, intravenous sedation or a short general anaesthetic may be used.

A soft retrieval string remains attached to the device and passes out through the urethra. It is usually secured to the penis until the device is removed.

Most patients can return home on the same day without a urinary catheter. Occasionally, temporary catheterisation is necessary if the patient is unable to pass urine.

The treatment period

The device remains inside the prostate for five to seven days. Its struts gradually apply pressure to the prostate and bladder neck, creating three longitudinal channels within the urinary passage.

Patients remain at home during this treatment period.

Removal

The device must be removed after five to seven days. It is collapsed into a soft catheter and withdrawn in one piece, usually during a brief outpatient visit.

Local anaesthetic gel is often sufficient, although additional pain relief or sedation may be offered when appropriate. No metal or permanent implant remains inside the prostate after removal.

What should I expect while the device is in place?

The five-to-seven-day treatment period is generally the most uncomfortable part of the process. Common temporary symptoms include:

  • Pelvic or perineal pressure
  • Burning or stinging when passing urine
  • Urinary urgency and frequency
  • Discomfort at the tip of the penis
  • Bladder spasms
  • Light bleeding in the urine
  • Interrupted sleep
  • Awareness of the retrieval string
  • A temporarily weak or irregular urinary stream

These symptoms are usually mild to moderate and commonly improve soon after the device is removed.

Patients should generally avoid heavy lifting, vigorous exercise, cycling and sexual activity while the device and retrieval string are in place. Follow the particular instructions provided by your urologist.

The retrieval string should not be pulled, cut, repositioned or removed by the patient.

How can pain and discomfort be managed?

Pain varies considerably between patients. Some men experience only mild pressure, while others find urinary urgency, bladder spasm or discomfort from the retrieval string more troublesome.

A pain-management plan may include the following measures.

Paracetamol

Paracetamol is usually the first choice for mild-to-moderate discomfort. Take it according to your doctor’s instructions or the directions on the packet.

Check cold, influenza and combination pain medicines carefully, as these may also contain paracetamol. Do not exceed the recommended daily dose.

Patients with significant liver disease or heavy alcohol consumption should discuss paracetamol use with their doctor.

Anti-inflammatory medication

An anti-inflammatory medicine such as ibuprofen may help reduce pain and inflammation when medically appropriate.

These medications may not be suitable for patients with:

  • Kidney impairment
  • Stomach ulcers or gastrointestinal bleeding
  • Heart failure or certain cardiovascular conditions
  • Asthma triggered by anti-inflammatory medication
  • Bleeding disorders
  • Anticoagulant or antiplatelet treatment

Check with your urologist, general practitioner or pharmacist before taking an anti-inflammatory medication.

Medication for bladder irritation

An alpha blocker may occasionally be continued or prescribed temporarily to help urine flow. A bladder-calming medication may be considered if urgency or bladder spasms are particularly troublesome.

These medicines are not necessary for every patient and have their own potential side effects.

Practical measures

It may also help to:

  • Maintain normal hydration without forcing excessive fluids
  • Reduce coffee, tea, cola drinks, alcohol and energy drinks
  • Avoid constipation
  • Wear loose, supportive underwear
  • Avoid heavy lifting and strenuous exercise
  • Take pain relief early rather than waiting until discomfort becomes severe

Strong opioid medication is not usually required. It may worsen constipation and, in susceptible patients, contribute to difficulty emptying the bladder.

Severe or increasing pain is not considered something that should simply be tolerated. Contact the treating practice if the discomfort is not controlled by the recommended measures.

What happens after removal?

Burning, urinary urgency and light bleeding may continue briefly after the device is removed, but these symptoms should progressively improve.

Some patients notice an improvement in their stream soon after removal. For others, improvement develops more gradually over several weeks as irritation settles and the remodelled urinary channels stabilise.

Many patients return to normal daily activities within a few days. Your urologist will advise when you may resume strenuous exercise and sexual activity.

Follow-up may include:

  • Review of urinary symptoms
  • Repeat symptom scoring
  • A urinary-flow test
  • Measurement of residual urine
  • Discussion about continuing or stopping BPH medication

Do not stop established prostate medication unless advised to do so.

Side effects and possible complications

Most side effects are temporary and occur while the device is in place. Reported problems include:

  • Burning during urination
  • Urinary frequency and urgency
  • Pelvic discomfort or pain
  • Blood in the urine
  • Temporary difficulty passing urine
  • Urinary tract infection
  • Bladder spasm
  • Movement or incorrect positioning of the device
  • Temporary catheterisation
  • Failure to obtain sufficient symptom relief

Published studies report different complication rates, but most events have been mild and self-limiting. Temporary haematuria, dysuria, urgency and pelvic discomfort are the most frequently reported problems.

Acute urinary retention, urinary infection or significant bleeding are less common but important complications.

When should I seek urgent medical attention?

Contact your urologist or attend an emergency department if you:

  • Cannot pass urine
  • Develop fever, shaking or chills
  • Feel generally unwell or confused
  • Develop severe or increasing pelvic pain
  • Pass large blood clots
  • Have heavy or persistent bright-red bleeding
  • Cannot keep fluids down
  • Notice that the retrieval string or device has moved
  • Develop pain that is not controlled by the agreed treatment plan

Does iTind affect erections or ejaculation?

One of the principal attractions of iTind is its favourable sexual side-effect profile.

Clinical studies have reported preservation of erectile and ejaculatory function in most treated patients. This contrasts with tissue-removing prostate procedures, which may carry a significant risk of retrograde or absent ejaculation.

Nevertheless, no treatment can guarantee that sexual or ejaculatory function will remain unchanged in every patient.

How effective is iTind?

Studies have demonstrated average improvements in:

  • Urinary symptom scores
  • Quality of life
  • Peak urinary-flow rate
  • The patient’s perception of urinary function

The improvement may be less dramatic than that achieved with a tissue-removing operation such as TURP or laser enucleation. The advantage is that iTind is less invasive, usually requires little recovery time and has a low reported risk of sexual side effects.

It is therefore best viewed as a balance between symptom improvement and treatment invasiveness.

How long does the benefit last?

Although the implant remains in place for only five to seven days, the channels produced within the prostate may remain open for several years.

Prospective studies have demonstrated sustained benefit for more than four years in some appropriately selected patients. This does not mean that iTind is guaranteed to last for four years—or that it will provide lifelong relief.

BPH may continue to progress as a man ages. Some patients will eventually need to restart medication or undergo another procedure. Longer-term evidence for iTind remains more limited than that available for established procedures such as TURP or laser enucleation.

Because nothing is left permanently inside the prostate, iTind does not generally prevent later treatment. Options may include medication, another minimally invasive procedure, TURP, GreenLight laser treatment, HoLEP or another form of prostate surgery.

Who should not undergo iTind?

Contraindications described in the manufacturer’s information include:

  • Active urinary tract infection
  • Acute prostatitis
  • Known prostate cancer
  • Known bladder cancer
  • An artificial urinary sphincter or another implant within the urethra
  • Bladder atonia or a non-contractile bladder
  • Neurogenic bladder dysfunction
  • Urinary obstruction caused by a urethral stricture or something other than BPH

The procedure may also be unsuitable or less predictable in men with:

  • A significantly obstructing median prostatic lobe
  • A prostate outside the best-studied size range
  • Severe chronic urinary retention
  • Very high residual urine volumes
  • Recurrent urinary infections
  • Bladder stones
  • Significant ongoing haematuria
  • Advanced bladder weakness
  • A need for rapid and substantial removal of obstructing tissue
  • Anatomy that prevents safe cystoscopic access

Previous prostate surgery, urethral surgery, nickel sensitivity and blood-thinning medication require individual consideration.

Patients with obstruction causing kidney impairment, repeated retention, recurrent infections, bladder stones or significant bleeding may receive more reliable relief from a definitive tissue-removing procedure.

Advantages of iTind

Potential advantages include:

  • Minimally invasive day procedure
  • No cutting, laser, steam or thermal energy
  • No permanent implant
  • Usually no postoperative catheter
  • Rapid return to ordinary activities
  • Low reported risk of new erectile dysfunction
  • Low reported risk of ejaculatory dysfunction
  • Does not usually compromise future BPH treatment

Limitations of iTind

Potential limitations include:

  • Discomfort during the treatment week
  • A retrieval string for five to seven days
  • A second procedure to remove the device
  • Not suitable for every prostate shape or size
  • Less improvement than some tissue-removing procedures
  • Possibility of persistent or recurrent symptoms
  • Potential need for future medication or surgery
  • Less very-long-term evidence than TURP or laser enucleation

Is iTind the right treatment for me?

iTind is not simply a smaller version of TURP. It offers a different compromise: a less invasive procedure with no permanent implant and a favourable sexual side-effect profile, but generally more modest improvement and less long-term evidence than tissue-removing surgery.

The best treatment depends on:

  • The severity of your symptoms
  • The size and shape of your prostate
  • The amount of urinary obstruction
  • Bladder strength and residual urine
  • Previous treatment
  • General health and medication
  • The importance of preserving ejaculation
  • Your willingness to accept possible future retreatment

A urological assessment is essential to confirm that BPH is responsible for the symptoms and to compare iTind fairly with medication, Rezūm, UroLift, TURP, GreenLight laser, HoLEP and other appropriate treatments.

This information is intended for general education and does not replace individual medical advice. Treatment suitability, availability and costs vary. Always follow the instructions provided by your treating urologist.

References

  1. Sandhu JS, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline Amendment 2023. Journal of Urology. 2024.
  2. Chughtai B, et al. The iTind Temporarily Implanted Nitinol Device for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Multicentre, Randomised, Controlled Trial. Urology. 2021;153:270–276.
  3. Kadner G, et al. Second generation of temporary implantable nitinol device in men with lower urinary tract symptoms: two-year results of the MT-02 study. World Journal of Urology. 2020;38:3235–3244.
  4. Amparore D, et al. Three-year results following treatment with the second-generation temporary implantable nitinol device. Prostate Cancer and Prostatic Diseases. 2021;24:349–357.
  5. Amparore D, et al. Temporary implantable nitinol device for BPH-related lower urinary tract symptoms: over 48-month results. Minerva Urology and Nephrology. 2023;75:743–751.
  6. NICE: iTind for lower urinary tract symptoms caused by BPH.
  7. Olympus: iTind clinical and procedural information.

Protecting the Rectum During Prostate Radiotherapy: A Patient Guide

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Radiotherapy is an established treatment for many men with prostate cancer. Modern planning and image-guidance techniques can direct radiation accurately, but the prostate lies immediately in front of the rectum. Because the two organs are so close, part of the rectal wall may receive radiation during treatment.

Radiation teams use several methods to limit exposure to surrounding healthy tissue. For selected patients, one option is to place a temporary biodegradable material between the prostate and rectum before radiotherapy planning.

This article explains why bowel effects occur, how rectal spacing works, its possible benefits and limitations, and the questions patients should discuss with their treating team. It does not recommend a particular product, device or brand.

Why can prostate radiotherapy affect the bowel?

The front wall of the rectum normally sits very close to the back of the prostate. Radiation directed at the prostate may therefore also reach a small amount of nearby rectal tissue.

Possible bowel effects during or after radiotherapy include:

  • increased bowel frequency
  • urgency
  • loose stools or diarrhoea
  • mucus discharge
  • rectal discomfort
  • bleeding
  • inflammation known as radiation proctitis

Many bowel symptoms are mild and settle after treatment, but some develop later or persist. Risk varies with the radiation technique, dose, fractionation schedule, individual anatomy, bowel health, medicines and previous pelvic treatment.

Rectal bleeding after radiotherapy should not automatically be attributed to radiation. Other causes, including haemorrhoids, polyps, inflammatory bowel disease and bowel cancer, may require investigation.

How is the rectum protected?

Protection begins with careful radiotherapy planning rather than with a spacer alone. Strategies may include:

  • intensity-modulated or volumetric-modulated radiotherapy
  • image guidance before and during treatment
  • accurate bladder and bowel preparation
  • management of rectal gas or stool
  • individualised dose constraints
  • limiting movement of the prostate
  • selecting an appropriate radiation schedule
  • a temporary rectal spacer in selected patients

A spacer is therefore an additional planning tool, not a substitute for high-quality radiation oncology.

What is a rectal spacer?

A rectal spacer is a temporary biodegradable material placed into the tissue plane between the prostate and the anterior rectal wall. Increasing this distance may reduce the radiation dose received by the rectum.

Materials used in currently available spacer systems include:

  • polyethylene-glycol hydrogel
  • stabilised hyaluronic-acid gel

These materials have different handling and imaging characteristics. They should not be assumed to have identical evidence, contraindications or safety profiles.

A spacer does not treat prostate cancer. Its role is to alter the anatomy temporarily while radiation treats the cancer.

Do all men having prostate radiotherapy need a spacer?

No. Many patients can receive carefully planned radiotherapy without one.

Potential benefit depends on factors such as:

  • the natural distance between the prostate and rectum
  • prostate size and shape
  • tumour position and extent
  • radiation dose and treatment schedule
  • the ability to meet rectal dose constraints without a spacer
  • previous prostate or pelvic procedures
  • bowel disease
  • bleeding risk and relevant medicines
  • whether pelvic lymph nodes are also being treated
  • local expertise and access

For some patients, the predicted reduction in rectal dose may be clinically meaningful. For others, the benefit may be small, uncertain or outweighed by the insertion risk.

The decision is usually made with the radiation oncologist. A urologist or another trained proceduralist may also be involved.

What does the evidence show?

Clinical studies of biodegradable rectal spacers generally show that increasing the distance between the prostate and rectum can reduce the radiation dose delivered to parts of the rectal wall.

A multicentre randomised trial involving 201 men receiving hypofractionated prostate radiotherapy evaluated a hyaluronic-acid spacer. The study reported improved rectal dosimetry and fewer acute grade 2 or worse gastrointestinal adverse events in the spacer group than in the control group.

These findings are relevant but require context:

  • dosimetric improvement does not guarantee that an individual patient will avoid bowel symptoms
  • trial participants and treatment protocols may differ from patients treated in routine practice
  • evidence for short-term bowel outcomes is stronger than evidence for some long-term outcomes
  • results for one spacer material or insertion technique should not automatically be applied to another
  • operator experience and correct placement affect both benefit and risk

Patients should ask how the published evidence applies to their planned radiotherapy technique and personal anatomy.

How is a spacer inserted?

The procedure is generally performed before radiotherapy planning.

Under ultrasound guidance, a needle is passed through the perineum—the skin between the scrotum and anus—into the potential space between the prostate and rectum. The tissue plane is checked carefully, and the spacer material is then introduced while its position is monitored.

Depending on the patient and treating centre, the procedure may use:

  • local anaesthesia
  • sedation
  • general anaesthesia

Fiducial markers used to help target radiotherapy may sometimes be inserted during the same procedure.

The exact preparation, antibiotic policy, management of anticoagulants and post-procedure care vary. Patients should follow the instructions given by their treating team.

Why does correct placement matter?

The spacer needs to create suitable separation along the part of the rectum closest to the planned radiation target. Too little separation, marked asymmetry or injection into the wrong tissue plane may reduce the expected dosimetric benefit.

Incorrect placement may also injure the rectal wall, prostate, urethra, bladder or nearby blood vessels. Training, real-time imaging, careful patient selection and recognition of abnormal anatomy are therefore important.

Some hyaluronic-acid materials can be broken down with an enzyme if significant malposition is recognised. This does not make incorrect placement harmless or remove the need for prevention, prompt assessment and appropriate management.

Who may be unsuitable?

Suitability depends on the particular device instructions, the patient’s anatomy and the clinical situation. Reasons to avoid or reconsider insertion may include:

  • infection or inflammation near the proposed injection site
  • inability to identify a safe tissue plane
  • tumour extending into the space behind the prostate
  • extensive scarring from previous surgery or treatment
  • significant rectal or anorectal disease
  • uncorrected bleeding disorder
  • anticoagulant or antiplatelet therapy that cannot be managed safely
  • allergy or hypersensitivity relevant to the proposed material
  • significant immunosuppression
  • a situation in which the expected dosimetric benefit is minimal

The approved Australian instructions for use for the exact device should be checked by the treating clinician.

Anticoagulant and antiplatelet medicines must not be stopped without advice from the clinician who manages them. Interrupting these medicines can cause stroke, heart attack, thrombosis or other serious harm.

Possible short-term effects

Temporary effects may include:

  • perineal discomfort or bruising
  • minor bleeding
  • a sensation of rectal fullness
  • discomfort when opening the bowels
  • urinary frequency or burning
  • a weaker urinary stream
  • constipation

The pattern and duration vary. New, severe or worsening symptoms require clinical review.

Uncommon but important complications

Spacer insertion is invasive and can cause serious complications, even when performed carefully.

Reported or plausible complications include:

  • infection, prostatitis or pelvic abscess
  • bleeding or haematoma
  • urinary retention
  • significant rectal or pelvic pain
  • spacer malposition or migration
  • injection into the rectal wall, prostate or another unintended site
  • injury to the urethra, bladder, rectum or blood vessel
  • rectal ulceration or tissue necrosis
  • embolic or vascular complications
  • fistula formation
  • need for further treatment, hospital admission or surgery

Severe pain, fever, difficulty passing urine, heavy bleeding, worsening bowel symptoms or feeling systemically unwell after the procedure should be assessed promptly.

What happens to the spacer?

Biodegradable spacers are intended to remain during the radiotherapy period and then gradually break down and be absorbed.

The expected duration and degradation process depend on the material. A second operation is not normally required solely to remove an appropriately placed biodegradable spacer.

Different spacer materials

The choice should not be reduced to a promotional comparison between brand names. Relevant clinical differences may include:

Consideration Hyaluronic-acid gel Polyethylene-glycol hydrogel
Primary purpose Temporary prostate–rectum separation Temporary prostate–rectum separation
Typical placement Transperineal, image-guided Transperineal, image-guided
Biodegradable Yes Yes
Handling Deposited and shaped during injection Forms a hydrogel after delivery
Imaging Visibility depends on material and imaging method Some formulations are designed for greater CT visibility
Evidence Randomised and observational studies are available Randomised, prospective and observational studies are available
Key limitation Insertion-related risk and dependence on correct placement Insertion-related risk and dependence on correct placement

This table is descriptive, not a claim that one material is safer or more effective. Head-to-head observational comparisons may be affected by patient selection, injected volume, operator technique, learning curve and treatment planning. They cannot by themselves establish universal superiority.

What about previous surgery or salvage radiotherapy?

Previous prostate procedures, pelvic surgery, focal therapy, radiotherapy or inflammation may alter the tissue plane behind the prostate. This can make placement more difficult or unsuitable.

The evidence for spacers in salvage or re-irradiation settings is less established than for primary prostate radiotherapy. These cases require individual assessment in an experienced multidisciplinary setting.

Questions to ask before deciding

  • What bowel risks are associated with my proposed radiotherapy plan?
  • Can the required rectal dose limits be met without a spacer?
  • What additional benefit is expected in my anatomy?
  • What spacer material is proposed, and is the exact device included in the ARTG for this intended use?
  • What evidence supports it for my radiation schedule?
  • Who will perform the procedure, and what is their experience?
  • What are the recognised contraindications and complications?
  • How will my anticoagulant or antiplatelet medicines be managed?
  • What symptoms after insertion require urgent review?
  • What are the alternatives if I choose not to have a spacer?
  • Are there additional costs or gaps?

Australian regulatory considerations

The Australian Register of Therapeutic Goods (ARTG) is the public database of therapeutic goods that may be legally supplied in Australia, unless an exemption or another authorised access pathway applies. An ARTG entry records the particular sponsor and intended purpose; it is not a general recommendation that the product is best for an individual patient.

Device inclusion, instructions for use, contraindications, availability and reimbursement can change. The treating team should confirm the current ARTG entry and approved instructions for the exact device proposed.

The bottom line

The rectum lies close to the prostate and may receive some radiation during prostate-cancer treatment. Modern planning and image guidance are the foundation of rectal protection.

A biodegradable rectal spacer can create temporary separation and may reduce rectal radiation exposure in selected patients. It does not treat the cancer, cannot guarantee freedom from bowel effects and introduces procedural risks of its own.

The decision should be individualised according to anatomy, the proposed radiation plan, expected dosimetric benefit, medical history, bleeding risk and local expertise. It should be made before radiotherapy planning through an informed discussion with the treating radiation oncology team.

This article provides general disease education and does not replace individual medical advice. It does not promote or recommend a particular therapeutic device, spacer material, brand, clinician or health service.

References and further reading

 

Information Sheet: Prostatitis

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Robotic-Assisted Radical Prostatectomy: When Is a Non-Nerve-Sparing Procedure Necessary?

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Removing the prostate while putting cancer control first

Robotic-assisted radical prostatectomy is a well-established surgical treatment for localised and selected locally advanced prostate cancer. During the operation, the prostate gland and seminal vesicles are removed, and the bladder is reconnected to the urethra. In selected patients, pelvic lymph nodes may also be removed.

One of the important decisions made before and during prostate cancer surgery is whether the nerves responsible for erections can safely be preserved.

This is known as nerve-sparing prostatectomy.

Unfortunately, nerve preservation is not always appropriate. When prostate cancer is close to, involves, or is suspected of extending beyond the outer edge of the prostate near these nerves, attempting to preserve them may compromise the completeness of cancer removal.

In this situation, a partial or complete non-nerve-sparing robotic prostatectomy may be recommended.

The guiding principle is simple:

Preserve the nerves when it is oncologically safe to do so, but do not preserve them at the expense of adequately treating the prostate cancer.

What are the nerves that are being “spared”?

Running immediately alongside the prostate are delicate bundles of nerves and blood vessels known collectively as the neurovascular bundles.

These structures contain nerves that play an important role in producing erections.

They sit extremely close to the outer surface, or capsule, of the prostate. This anatomical relationship creates a challenge during prostate cancer surgery.

If the cancer is safely contained within the prostate and sufficiently distant from the neurovascular bundle, the surgeon may be able to carefully dissect the prostate away while preserving the nerves.

This is a nerve-sparing radical prostatectomy.

If cancer is suspected to extend towards or through the prostate capsule in this area, the surgeon may need to remove some or all of the neurovascular tissue together with the prostate.

This is a non-nerve-sparing prostatectomy.

Why would a surgeon deliberately remove the erectile nerves?

It may initially seem counterintuitive to remove structures that are so important for sexual function.

The reason is cancer control.

The primary purpose of radical prostatectomy is to completely remove the prostate cancer.

If a tumour is growing very close to the edge of the prostate, particularly next to a neurovascular bundle, dissecting too close to the prostate in an attempt to preserve the nerves could potentially leave cancer cells behind.

This is called a positive surgical margin.

In appropriately selected patients, taking a wider margin around the prostate may therefore provide a safer cancer operation.

The decision represents a balance between:

Cancer control

and

preservation of erectile function.

When these two goals conflict, cancer control generally takes priority.

When may a non-nerve-sparing prostatectomy be recommended?

Non-nerve-sparing surgery may be considered when there is a significant risk that prostate cancer has extended towards or into the tissues surrounding the prostate.

Examples include:

Locally advanced prostate cancer

A tumour suspected of extending through the prostate capsule, particularly clinical T3 disease, may require a wider surgical excision.

Cancer close to the neurovascular bundle on MRI

Modern multiparametric prostate MRI can provide valuable information about the location of the tumour and its relationship to the prostate capsule and neurovascular bundles.

Features suggesting extraprostatic extension may influence the decision not to preserve the nerve bundle on that side.

High-grade prostate cancer

Higher-grade cancers, including cancers with an unfavourable Gleason score or ISUP Grade Group, may have a greater likelihood of extending outside the prostate.

The biopsy result alone does not automatically determine whether the nerves can be preserved, but it forms part of the overall assessment.

Extensive cancer on prostate biopsy

Large-volume disease, particularly when concentrated along the outer portion of the prostate near a neurovascular bundle, may make nerve preservation less appropriate.

Very high PSA or other high-risk features

PSA level, PSA density, biopsy findings, MRI appearance and clinical examination are considered together when estimating the likelihood of disease extending beyond the prostate.

Cancer involving one particular side of the prostate

Importantly, nerve sparing does not necessarily have to be “all or nothing.”

If the cancer is predominantly on one side, it may sometimes be possible to preserve the neurovascular bundle on the opposite side.

This is known as unilateral nerve sparing.

Nerve sparing is not simply YES or NO

Modern robotic prostate surgery is more nuanced than dividing operations into completely nerve-sparing and completely non-nerve-sparing procedures.

Depending on the location and extent of the cancer, surgery may involve:

  • Bilateral nerve sparing
  • Unilateral nerve sparing
  • Partial nerve sparing
  • Wider excision on one side and nerve preservation on the other
  • Complete bilateral non-nerve-sparing surgery

The surgical plan can therefore be tailored to the individual patient and, importantly, to the cancer on each side of the prostate.

How does nerve-sparing surgery differ from non-nerve-sparing surgery?

During nerve-sparing surgery, the surgeon carefully separates the neurovascular bundle from the surface of the prostate while attempting to minimise traction, heat and other potential injury to these delicate nerves.

During non-nerve-sparing surgery, the dissection is deliberately performed further away from the prostate.

The neurovascular tissue is removed together with the prostate where necessary to obtain a wider cancer margin.

The robotic platform provides magnified three-dimensional vision and highly controlled instrument movement. This allows the surgeon to identify tissue planes with considerable precision.

However, robotic technology cannot make an unsafe nerve-sparing operation safe.

The biology and location of the cancer ultimately determine how close to the prostate the surgeon can safely operate.

What happens to erections after non-nerve-sparing prostatectomy?

This is one of the most important issues to discuss before surgery.

The nerves surrounding the prostate are responsible for signalling increased blood flow into the penis to produce a natural erection.

If both neurovascular bundles are completely removed, the likelihood of recovering spontaneous erections adequate for sexual intercourse is very low.

This is different from nerve-sparing surgery, where the nerves remain anatomically intact but may temporarily function poorly following surgery.

After nerve-sparing prostatectomy, erectile recovery can occur gradually over many months and sometimes over 18–24 months or longer.

After complete bilateral non-nerve-sparing surgery, however, the nerves themselves have been removed rather than temporarily stunned.

The expectations for recovery are therefore very different.

Does non-nerve-sparing surgery affect sensation or orgasm?

This is an important distinction.

The nerves responsible for penile sensation are different from the neurovascular nerves primarily responsible for erections.

Many men can therefore continue to experience penile sensation and sexual pleasure following radical prostatectomy.

Orgasm may also remain possible.

However, radical prostatectomy removes the prostate and seminal vesicles and disconnects the reproductive pathway. Consequently, there is no ejaculation of semen after surgery.

This is sometimes described as a dry orgasm.

The sensation of orgasm can also feel different after prostate surgery.

Does non-nerve-sparing prostatectomy cause infertility?

Yes.

Radical prostatectomy results in permanent infertility because the prostate and seminal vesicles are removed and sperm can no longer enter the ejaculate.

Men who may wish to father children in the future should discuss sperm banking before surgery.

This applies whether the operation is nerve sparing or non-nerve sparing.

Is a non-nerve-sparing procedure reversible?

No.

Once a neurovascular bundle has been surgically removed, it cannot simply be reattached at a later date.

This is an important difference between temporary nerve dysfunction and actual nerve removal.

After nerve-sparing surgery, the nerves may be anatomically preserved but temporarily injured or “stunned”. Recovery may therefore occur with time.

After complete non-nerve-sparing surgery, the erectile nerves have been physically removed as part of the cancer operation.

The procedure itself is therefore not reversible.

However, this does not mean that erections or sexual activity are impossible.

There are several effective treatments available for erectile dysfunction following prostatectomy.

Can erections still be achieved after non-nerve-sparing surgery?

Rarely yes, but they will usually require assistance.

Treatment options include:

PDE5 inhibitor tablets

Medications such as sildenafil or tadalafil are commonly used after prostate surgery.

They rely substantially on functioning nerve pathways and are therefore generally more effective following nerve-sparing surgery.

Their effectiveness following complete bilateral non-nerve-sparing surgery is considerably more limited.

Vacuum erection device

A vacuum erection device creates negative pressure around the penis, drawing blood into the erectile tissues.

A constriction ring can then be placed around the base of the penis to maintain the erection.

Because this technique does not depend on intact erectile nerves, it can be useful after non-nerve-sparing surgery.

Penile injection therapy

Medication can be injected directly into the erectile tissue of the penis.

These medications act directly on penile blood vessels and therefore do not require normal prostate-associated nerve signalling.

For this reason, penile injections can be highly effective even after bilateral non-nerve-sparing prostatectomy.

Penile prosthesis

For men with persistent erectile dysfunction who wish to restore reliable erections, a penile prosthesis can provide an effective long-term solution.

An inflatable penile prosthesis allows an erection to be mechanically produced when desired.

For appropriately selected men, satisfaction rates following penile prosthesis surgery are generally high.

What about penile rehabilitation?

Penile rehabilitation may be discussed following radical prostatectomy.

The objectives can include maintaining penile tissue health, encouraging regular oxygenation of the erectile tissues, minimising shortening and fibrosis, and assisting the return to sexual activity.

A rehabilitation program may involve:

  • PDE5 inhibitor medication where appropriate
  • Vacuum erection therapy
  • Penile injection therapy
  • Regular sexual stimulation
  • Early assessment and management of erectile dysfunction

The appropriate program depends heavily on whether surgery was bilateral nerve sparing, unilateral nerve sparing or completely non-nerve sparing.

It is therefore important that expectations are realistic.

After complete bilateral nerve removal, rehabilitation cannot make the removed nerves grow back. Instead, treatment focuses on maintaining penile health and providing alternative ways of achieving an erection.

Can the surgeon decide during the operation whether to spare the nerves?

Sometimes.

The intended degree of nerve sparing is usually planned before surgery using information from:

  • Prostate MRI
  • Prostate biopsy
  • PSA
  • Clinical examination
  • Location and volume of cancer
  • Gleason score and ISUP Grade Group
  • Estimated risk of extraprostatic extension
  • The patient’s existing erectile function
  • The patient’s priorities regarding cancer control and sexual function

However, the final surgical approach may occasionally need to be modified according to findings encountered during the operation.

The most important objective remains adequate removal of the cancer.

Does non-nerve-sparing surgery improve cancer cure rates?

Not every patient benefits from wider surgery.

For men with cancer safely confined within the prostate, unnecessary removal of the neurovascular bundles may produce significant functional consequences without providing additional cancer benefit.

Conversely, when cancer is suspected of extending close to or beyond the prostate capsule adjacent to a neurovascular bundle, wider excision may reduce the risk of leaving tumour at the surgical margin.

This is why the decision must be individualised.

The best operation is not automatically the operation that preserves the most nerves. It is the operation that provides appropriate cancer clearance while preserving as much normal function as can safely be preserved.

What about urinary continence?

Nerve sparing primarily relates to erectile function, rather than the urinary sphincter responsible for continence.

Urinary control after radical prostatectomy depends on several factors including:

  • Age
  • Pre-operative urinary function
  • Pelvic floor strength
  • Urethral length
  • Bladder function
  • Surgical anatomy and technique
  • Previous prostate treatments
  • Individual healing

Pelvic floor rehabilitation before and after surgery can be an important part of recovery.

Non-nerve-sparing surgery does not automatically mean that a patient will remain incontinent.

Questions worth asking before surgery

If a non-nerve-sparing robotic prostatectomy has been recommended, useful questions to discuss with your urologist include:

Why is nerve preservation considered unsafe in my particular cancer?

Is the concern on one side or both sides of the prostate?

Could unilateral or partial nerve sparing be considered?

What does my MRI show about the relationship between the cancer and neurovascular bundles?

What is my estimated chance of erectile recovery with the proposed operation?

What erectile rehabilitation options will be available after surgery?

Should I consider sperm banking before treatment?

These conversations are particularly important because the decision to remove a neurovascular bundle is generally irreversible.

The important message

A non-nerve-sparing robotic-assisted radical prostatectomy is not an inferior version of nerve-sparing surgery.

In the right patient, it is a deliberate cancer-control strategy.

When prostate cancer is close to or suspected of involving the tissues surrounding the prostate, preserving the erectile nerves too aggressively may risk leaving cancer behind.

Modern robotic surgery allows the operation to be tailored to the individual patient. Some men can undergo bilateral nerve preservation, others may benefit from preservation on only one side, while patients with more extensive disease may require a wider non-nerve-sparing excision.

The consequences for erectile function are important and should be understood before surgery.

Once the neurovascular nerves have been removed, the procedure cannot be reversed.

However, loss of spontaneous erections does not mean the end of sexual intimacy. Vacuum devices, penile injection therapy and penile prostheses can provide effective options when natural erections are no longer possible.

Ultimately, the aim is to achieve the best possible balance between two important goals:

Effective treatment of the prostate cancer and preservation of quality of life.

A note for patients

Every prostate cancer is different. MRI findings, biopsy results, PSA, cancer grade, age, general health, pre-existing erectile function and personal priorities all influence the appropriate surgical approach.

A detailed discussion with your urologist before robotic prostatectomy is essential so that you understand whether nerve sparing is appropriate, what degree of nerve preservation may be possible and what this means for cancer control, continence and sexual function.

This information is intended for general patient education and does not replace individual medical advice. Treatment recommendations should be based on your individual prostate cancer characteristics, imaging, pathology, general health and discussion with your treating urologist.

Single-Port Robotic Surgery: The Next Evolution of da Vinci Surgery in Urology

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Robotic surgery has transformed modern urology. Now, the technology is evolving again.

The da Vinci SP® (Single Port) Surgical System represents a new generation of robotic-assisted surgery designed to allow complex operations to be performed through one small surgical access point, rather than the multiple abdominal ports traditionally required for robotic surgery.

For suitable patients, this offers an exciting possibility: maintaining the precision and control associated with robotic surgery while potentially reducing the physical footprint of the operation.

What is the da Vinci SP system?

Traditional multi-port robotic surgery generally requires several small abdominal incisions. Each incision accommodates a camera, robotic instrument or assistant port.

The da Vinci SP system takes a different approach.

Through a single approximately 2.7 cm cannula, the system can deploy:

  • Three fully wristed robotic instruments
  • A flexible, articulating 3D high-definition camera
  • Instruments capable of triangulating once inside the body

The surgeon remains completely in control of the operation from the robotic console. The robot does not perform the surgery independently. Rather, it translates the surgeon’s hand movements into precise movements of the instruments inside the patient.

The system provides 360-degree anatomical access and was specifically designed to facilitate surgery within confined anatomical spaces.

Why is Single-Port surgery particularly interesting in urology?

Much of urological surgery occurs deep within relatively confined areas of the body, particularly surgery involving the prostate, bladder and kidney.

This makes urology particularly well suited to the development of single-port techniques.

The da Vinci SP platform is being used internationally for procedures including:

  • Robotic radical prostatectomy for prostate cancer
  • Robotic simple prostatectomy or prostate enucleation for very large benign prostates
  • Partial nephrectomy for selected kidney tumours
  • Radical nephrectomy
  • Pyeloplasty for pelvi-ureteric junction obstruction
  • Selected reconstructive urological procedures

Importantly, the technology also allows surgeons to explore different routes to the target organ. For prostate surgery, for example, selected procedures may potentially be performed through extraperitoneal or transvesical approaches rather than traversing a larger area of the abdominal cavity.

What are the potential advantages for patients?

The obvious attraction is fewer incisions, but the potential benefits extend beyond the cosmetic appearance of the scar.

One main access point

Instead of several robotic ports spread across the abdomen, the SP system introduces the camera and three robotic instruments through a single access site.

For the patient, this can mean a smaller overall surgical footprint.

Potentially less postoperative discomfort

Early clinical evidence comparing single-port with conventional multi-port robotic approaches has reported less postoperative pain in some procedures.

This may translate into reduced analgesic requirements and greater comfort during the first few days after surgery.

Shorter hospital stay

One of the most interesting findings emerging from early SP experience is the possibility of shorter hospitalisation for selected procedures and patients.

Some international centres have developed pathways where appropriately selected patients undergoing certain SP procedures can leave hospital considerably earlier than would traditionally have been expected.

Potentially faster recovery

Reducing the number of abdominal access points and, in selected operations, avoiding unnecessary entry into parts of the abdominal cavity may help reduce the physiological impact of surgery.

The aim is simple: perform the operation that needs to be done while disturbing as little normal anatomy as possible.

Smaller scars

For many patients, particularly younger men undergoing prostate cancer surgery, the cosmetic result also matters.

Single-port surgery concentrates access into one main incision rather than several separate robotic scars.

A smaller scar does not determine whether cancer surgery has been successful, of course. Cancer control, continence, erectile function and surgical safety remain far more important than cosmetics.

Nevertheless, if equivalent surgery can ultimately be achieved through a smaller access footprint, it represents another meaningful refinement of minimally invasive surgery.

Single-Port radical prostatectomy for prostate cancer

Robotic-assisted radical prostatectomy is already one of the established surgical treatments for localised prostate cancer.

During surgery, the prostate and seminal vesicles are removed and the bladder is reconstructed onto the urethra. Where oncologically appropriate, preservation of the nerves responsible for erectile function may also be attempted.

The da Vinci SP system provides the surgeon with magnified 3DHD vision and highly articulated instruments while allowing the operation to be approached through a single primary access point.

Early studies of SP prostatectomy have reported encouraging results, including shorter hospital stays, shorter catheterisation in some series, less postoperative pain and lower complication rates in selected comparisons, without apparent compromise of functional outcomes. However, SP remains a developing technology and longer-term comparative evidence continues to accumulate.

That distinction is important.

Single Port does not automatically mean “better” for every patient.

The best surgical approach depends upon the cancer, prostate size, previous abdominal surgery, anatomy, other medical conditions and, importantly, the experience of the surgeon and surgical team.

Single-Port surgery for very large benign prostates

Another particularly interesting application is surgery for men with very large prostates causing severe urinary obstruction.

Traditionally these men may have required open simple prostatectomy or, more recently, endoscopic laser enucleation or multi-port robotic simple prostatectomy.

The SP platform allows surgeons to perform robotic simple prostatectomy through a highly focused approach, including a transvesical approach directly through the bladder in appropriately selected patients.

Early experience suggests this may allow the durable urinary outcomes associated with simple prostatectomy while reducing some of the immediate recovery burden associated with conventional transabdominal surgery.

Is Single-Port surgery safer?

It is tempting to assume that fewer incisions automatically means safer surgery.

Medicine is rarely that cooperative.

Every operation still carries risks including bleeding, infection, injury to surrounding structures, anaesthetic complications and procedure-specific complications.

After prostate cancer surgery, additional considerations include:

  • Temporary or persistent urinary incontinence
  • Erectile dysfunction
  • Bladder-neck contracture or urethral narrowing
  • Lymphocele where lymph-node dissection is performed
  • Urinary leakage
  • Need for further treatment if prostate cancer recurs

The SP platform changes how the surgeon accesses the operation. It does not remove the fundamental risks of the operation itself.

Patient selection and surgical experience therefore remain critical.

The Gambaro Community and Prostate Cancer Care

Technological advances do not arrive in hospitals by magic. Behind the gleaming robotic arms is something much more human: patients, families, clinicians, donors and communities willing to invest in better healthcare.

The Gambaro family’s support for prostate cancer care at The Wesley Hospital is an outstanding example.

For more than a decade, the Gambaro community has supported prostate cancer care through its annual fundraising luncheon.

At the 2024 Gambaro Prostate Cancer Care Luncheon, the community raised more than $545,000, with funds directed towards enhancing future prostate cancer care services and treatment at The Wesley Hospital. This luncheon takes place next week 4 September 2026, ensure you are there to assist the Wesley to secure funding for the single port DaVinci.

This relationship has a long history. Earlier Gambaro fundraising events at The Wesley also promoted advances in prostate cancer diagnosis and minimally invasive robotic surgery, bringing together clinicians, patients and the wider Brisbane community.

Why fundraising for prostate cancer technology matters

Modern prostate cancer care extends far beyond simply purchasing a piece of equipment.

High-quality care requires an ecosystem that may include:

Advanced imaging → accurate diagnosis → multidisciplinary assessment → precision surgery → specialist nursing → rehabilitation → survivorship care

Community fundraising can help hospitals invest across this pathway, supporting technology, equipment, clinical services, education and improvements in patient care.

The Gambaro community’s longstanding commitment to prostate cancer care demonstrates what can happen when philanthropy and medicine pull in the same direction.

The future: smaller access, bigger possibilities

The evolution of robotic surgery has been remarkable.

We have moved from large open incisions to laparoscopic surgery, then to multi-port robotic surgery and now towards sophisticated single-port robotic procedures capable of operating through increasingly focused anatomical pathways.

The da Vinci SP system is another step along that journey.

Its promise is not simply that surgeons can operate through one incision. The more interesting possibility is that surgeons may increasingly tailor the surgical access route itself to the individual patient.

For patients undergoing prostate, kidney or reconstructive urological surgery, that may eventually mean less tissue disruption, less postoperative discomfort, shorter hospitalisation and a quicker return to normal life, while maintaining the fundamental goals of safe and effective surgery.

And behind advances such as these are not only surgeons and engineers.

They are also communities.

Through initiatives such as the Gambaro Prostate Cancer Care fundraising program, community support continues to help The Wesley Hospital pursue advances in prostate cancer diagnosis, treatment and patient care.

Sometimes progress in surgery comes through several small incisions.

Increasingly, it may come through just one.

Important information

The da Vinci SP system is a surgical platform rather than a treatment in itself. Not every patient or urological procedure is suitable for a single-port approach. The potential advantages and risks depend upon the particular procedure, patient anatomy, underlying condition and experience of the treating surgical team.

Patients considering robotic surgery should discuss conventional multi-port robotic surgery, single-port surgery and other appropriate alternatives with their urologist before deciding on treatment.

Robotic-Assisted Enucleation of the Large Benign Prostate / Robotic-Assisted Simple Prostatectomy RASP

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A modern surgical option for very large benign prostate enlargement

Benign prostatic hyperplasia (BPH), or benign prostate enlargement, becomes increasingly common as men age. For many men, symptoms can initially be controlled with medication or minimally invasive treatments. However, when the prostate becomes very large, simply creating a small channel through the prostate may not provide the durable result required.

Robotic-assisted simple prostatectomy (RASP), sometimes described as robotic-assisted adenoma enucleation, is designed to remove the bulk of the obstructing benign prostate tissue while leaving the outer prostate capsule behind.

Importantly, this is not the same operation as a robotic radical prostatectomy for prostate cancer. In a radical prostatectomy, the entire prostate and seminal vesicles are removed. In robotic simple prostatectomy, only the enlarged central adenoma responsible for urinary obstruction is removed.

Current guidelines recognise robotic-assisted simple prostatectomy as an established surgical option for men with large to very large prostates.

Why does a large prostate cause problems?

The prostate surrounds the urethra immediately below the bladder.

As benign prostate tissue enlarges, it can compress and distort the urethra. The bladder then has to work increasingly hard to push urine through this narrowed channel.

Symptoms may include:

  • Weak urinary stream
  • Hesitancy or difficulty starting urination
  • Straining
  • Intermittent urinary flow
  • A feeling that the bladder has not emptied properly
  • Frequent urination
  • Urgency
  • Getting up repeatedly at night to urinate
  • Acute or chronic urinary retention
  • Recurrent urinary infections
  • Bladder stones
  • Blood in the urine
  • Progressive deterioration of bladder function
  • In severe cases, obstruction affecting the kidneys

Surgery is particularly appropriate when significant symptoms persist despite conservative or medical therapy, or when BPH produces complications such as recurrent urinary retention, infection, bladder stones, recurrent bleeding or renal impairment.

When is robotic prostate enucleation considered?

Robotic-assisted enucleation is particularly attractive when the prostate is large or very large.

There is no magical prostate volume at which the robot suddenly becomes necessary. Treatment needs to be individualised according to prostate anatomy, symptoms, bladder function, other medical conditions and the surgeon’s expertise.

In practice, robotic simple prostatectomy is most commonly considered for prostates approximately 80–100 mL or larger, and can be particularly useful for extremely large glands well beyond 150–200 mL.

The EAU describes simple prostatectomy as a treatment primarily for substantially enlarged prostates, traditionally above approximately 80–100 mL.

Typical indications include:

  • Severe lower urinary tract symptoms caused by a very large prostate
  • Recurrent urinary retention
  • Dependence on an indwelling or intermittent urinary catheter
  • Failure or intolerance of BPH medications
  • Recurrent bladder infections associated with obstruction
  • Recurrent bleeding from a large vascular prostate
  • Bladder stones associated with prostate obstruction
  • Very high residual urine volumes
  • Progressive bladder dysfunction caused by obstruction
  • Upper urinary tract or renal consequences from longstanding obstruction
  • A very large median lobe protruding into the bladder
  • A very large prostate where conventional TURP would be impractical or require extensive resection

Robotic surgery can also be useful when another bladder procedure, such as removal of large bladder stones or repair of a bladder diverticulum, needs to be performed at the same operation.

How is the operation performed?

The procedure is usually performed under a general anaesthetic using a robotic surgical platform.

Several small incisions are made in the abdomen. Robotic instruments and a high-definition three-dimensional camera are introduced through these ports.

The surgeon remains completely in control of the operation. The robot does not perform the surgery independently. Rather, it translates the surgeon’s hand movements into extremely precise movements of miniature instruments inside the body.

There are several variations of robotic simple prostatectomy, including transvesical, transcapsular, extraperitoneal and newer single-port approaches.

Finding the natural plane

The principle of the operation is beautifully simple.

The enlarged prostate consists of an inner adenoma surrounded by the compressed outer prostate or surgical capsule.

The surgeon identifies the natural anatomical plane between these layers and carefully separates the adenoma from the capsule.

Think of removing the flesh of an orange while deliberately leaving the peel behind. 🍊

The obstructing prostate adenoma is progressively freed from its surrounding capsule and removed.

Bleeding points can be precisely controlled using robotic suturing and cautery. The remaining prostate cavity and bladder are then reconstructed according to the surgical technique being used.

The removed prostate tissue is sent to pathology for examination.

What happens to the prostate afterwards?

The prostate is not completely removed.

The peripheral prostate and capsule remain in the body.

This is important because:

  1. PSA does not normally fall to zero after the operation.
  2. The remaining prostate tissue can still develop prostate cancer in the future.
  3. Appropriate PSA surveillance and prostate cancer screening should therefore continue.

Occasionally, previously unsuspected prostate cancer may also be identified when the removed adenoma is examined by the pathologist.

What happens to urinary flow?

Removing the obstructing adenoma creates a very large channel between the bladder and the remaining prostatic urethra.

Most appropriately selected patients experience substantial improvements in:

  • Urinary flow
  • Bladder emptying
  • Residual urine
  • Urinary symptoms
  • Quality of life

Studies of laparoscopic and robotic simple prostatectomy demonstrate substantial improvements in urinary symptom scores and maximum urinary flow rates.

For a man who has spent years waiting for his bladder to negotiate with a very large prostate, the improvement in flow can be rather dramatic.

The urinary catheter

A urinary catheter is placed during the operation.

This allows urine to drain freely while the bladder and prostate cavity heal. Depending upon the operation and surgeon’s technique, continuous bladder irrigation may initially be used to prevent blood clots accumulating within the bladder.

How long does the catheter stay in?

Catheter duration varies considerably between surgical techniques and centres.

Following conventional robotic simple prostatectomy, a catheter commonly remains for approximately 5–10 days, although some contemporary techniques permit earlier removal.

Recent comparative studies report catheter durations around 5–11 days following RASP, although protocols vary substantially between surgeons and institutions.

Laser enucleation procedures such as HoLEP generally permit earlier catheter removal. A 2026 meta-analysis comparing robotic simple prostatectomy with laser enucleation found that catheterisation was approximately 3.5 days shorter after laser enucleation.

In some patients a cystogram may be performed before catheter removal, particularly when extensive bladder reconstruction has been performed.

What can I expect after catheter removal?

The first few days can be a little lively.

Patients may experience:

  • Urinary frequency
  • Urgency
  • Mild burning
  • Blood in the urine
  • Passing occasional small clots
  • Temporary leakage
  • A sudden improvement in urinary flow

Urinary frequency and urgency can take longer to settle if the bladder has been struggling against obstruction for many years.

Removing the obstruction fixes the prostate problem, but an ageing or overactive bladder does not necessarily receive the memo immediately.

Advantages of robotic-assisted enucleation

For appropriately selected men with very large prostates, potential advantages include:

Removal of a very large amount of obstructing tissue

Rather than simply widening the channel, the procedure anatomically removes most of the transition-zone adenoma.

Suitable for extremely large prostates

The technique is relatively independent of prostate size and can be particularly useful when the prostate is enormous.

Excellent visualisation

The robotic system provides magnified three-dimensional vision and excellent access to the bladder and prostate.

Precise control of bleeding

Robotic suturing allows individual bleeding vessels to be identified and controlled.

Lower morbidity than traditional open simple prostatectomy

Compared with open surgery, robotic simple prostatectomy generally produces less blood loss, lower transfusion rates and shorter hospitalisation, although robotic operations can take longer.

Simultaneous bladder surgery

Large bladder stones, selected bladder diverticula and other pathology can potentially be managed during the same operation.

Durable removal of obstruction

Because most of the obstructing adenoma is removed, substantial recurrent obstruction from regrowth is uncommon.

Possible complications

As with any major surgical procedure, complications can occur.

Bleeding

Some bleeding is expected because the prostate has a rich blood supply.

Blood transfusion is uncommon with modern robotic techniques but remains possible, particularly with exceptionally large glands, anticoagulant therapy or significant postoperative bleeding.

Rarely, significant bleeding may require return to theatre.

Urinary infection

A urinary infection can occur following surgery or while the catheter is present.

Symptoms can include fever, burning, cloudy urine or feeling systemically unwell.

Blood clots and catheter blockage

Bleeding can produce clots within the bladder.

Continuous bladder irrigation may therefore be used during the early postoperative period. Occasionally a catheter may require irrigation or replacement, and rarely clot evacuation under anaesthesia is necessary.

Temporary urinary incontinence

Some men experience temporary urinary leakage following catheter removal.

This generally improves as the external urinary sphincter adapts to the newly unobstructed urinary channel.

Pelvic floor exercises may assist recovery.

Persistent severe stress urinary incontinence is uncommon but remains a recognised complication.

Urinary urgency

Urgency, frequency and urge incontinence may temporarily become more noticeable after surgery.

Men who had longstanding bladder obstruction may have developed detrusor overactivity or impaired bladder function. Consequently, bladder symptoms may take weeks or months to settle and occasionally require additional treatment.

Bladder neck contracture

Scar tissue can occasionally develop around the bladder outlet.

If significant, this may require an endoscopic procedure to reopen the channel.

Urethral stricture

Scar tissue can develop within the urethra following instrumentation or catheterisation.

This is uncommon but may require dilatation, urethrotomy or, rarely, reconstructive surgery.

Injury to surrounding structures

Rare complications include injury to the:

  • Bladder
  • Ureteric openings
  • Ureter
  • Rectum
  • Bowel
  • Blood vessels

Major complications requiring additional surgery are uncommon but possible.

General surgical complications

These include:

  • Deep vein thrombosis
  • Pulmonary embolism
  • Chest infection
  • Cardiovascular complications
  • Anaesthetic complications
  • Port-site hernia
  • Wound infection

Appropriate preventative measures are used according to individual patient risk.

What happens to ejaculation?

This deserves particular emphasis.

Retrograde or absent ejaculation is very common.

During normal ejaculation, the bladder neck closes and semen travels forward through the urethra.

After removal of a large prostate adenoma, this mechanism is altered. Semen may pass backwards into the bladder or there may be very little visible ejaculate.

The sensation of orgasm usually remains, but ejaculation is frequently dry or markedly reduced.

This can significantly affect fertility and should be discussed before surgery in men who may wish to father children.

What about erections?

Robotic simple prostatectomy is different from radical prostatectomy for prostate cancer.

The prostate capsule and surrounding neurovascular structures are generally preserved.

Consequently, erectile dysfunction is not an inevitable consequence of robotic simple prostatectomy.

Temporary deterioration can occur following any major pelvic operation, particularly in older men with pre-existing vascular or erectile problems, but many men maintain their preoperative erectile function.

Will the prostate grow back?

One of the major advantages of anatomical enucleation is its durability.

The majority of the obstructing adenoma is physically removed rather than simply compressed or partially vaporised.

Some benign prostate tissue remains and can slowly enlarge over many years, so recurrent obstruction is possible, but clinically significant regrowth requiring repeat surgery appears uncommon.

Long-term RASP-specific retreatment data are less mature than data for older procedures because robotic simple prostatectomy is a newer technique. Studies nevertheless show durable functional improvement, and contemporary comparisons demonstrate similar symptom and flow improvements between RASP and anatomical endoscopic enucleation.

For perspective, long-term data for traditional open simple prostatectomy, which uses the same fundamental principle of adenoma enucleation, show endourological reintervention rates of approximately 3% at one year, 6% at five years and 8.8% at eight years. These figures should not be presented as RASP-specific recurrence rates, but they demonstrate the durability of complete adenoma enucleation.

Robotic enucleation versus HoLEP

Both procedures are excellent options for large prostates.

HoLEP removes the adenoma through the urethra using a holmium laser and subsequently morcellates the tissue within the bladder.

Robotic simple prostatectomy approaches the prostate through the abdomen and bladder or prostate capsule.

Recent evidence suggests that both produce substantial and broadly comparable improvements in urinary symptoms, urinary flow and bladder emptying.

HoLEP generally has the advantages of:

  • No abdominal incisions
  • Shorter catheterisation
  • Shorter hospitalisation in many series
  • Very low blood loss
  • Excellent durability

Robotic surgery may be particularly attractive when:

  • The prostate is exceptionally large
  • There are very large bladder stones
  • Concomitant bladder reconstruction is required
  • Prostate anatomy makes a robotic approach advantageous
  • The surgeon has extensive robotic experience
  • Endoscopic enucleation expertise is not available

The best procedure is therefore not determined by prostate volume alone.

Robotic enucleation versus TURP

TURP remains an excellent operation for appropriately sized prostates, but attempting to resect an enormous prostate piece by piece can become a lengthy undertaking.

Robotic enucleation removes the adenoma anatomically and is therefore particularly suited to large-volume disease.

For very large prostates, current guidelines support simple prostatectomy and anatomical endoscopic enucleation rather than assuming conventional TURP is the optimal treatment.

Recovery after robotic prostate enucleation

Hospital stay varies according to the technique, prostate size and individual recovery.

After discharge, patients are generally encouraged to walk regularly but avoid strenuous exercise and heavy lifting during the early healing period.

Blood in the urine may come and go for several weeks, particularly after physical activity.

Patients should seek medical attention for:

  • Inability to pass urine
  • A catheter that stops draining
  • Heavy persistent bleeding
  • Large blood clots
  • Fever or chills
  • Increasing abdominal pain
  • Chest pain or shortness of breath
  • Significant calf swelling or pain

Is robotic-assisted enucleation right for every large prostate?

No.

The decision should take into consideration:

  • Prostate volume and anatomy
  • Severity of urinary symptoms
  • Urinary flow and residual urine
  • Bladder function
  • Previous urinary retention
  • Presence of bladder stones or diverticula
  • PSA and prostate cancer risk
  • Previous prostate surgery
  • Anticoagulant or antiplatelet medication
  • General health
  • Anaesthetic risk
  • Patient priorities regarding ejaculation and sexual function
  • Availability and experience of the treating surgeon

Alternatives may include HoLEP, other forms of endoscopic enucleation, bipolar TURP, GreenLight laser surgery, Aquablation, prostate artery embolisation, medical therapy or continued observation, depending upon prostate size, anatomy and the individual patient’s circumstances.

The bottom line

For men with a very large benign prostate causing significant urinary obstruction, robotic-assisted prostate enucleation offers a powerful and durable surgical solution.

Rather than trimming away small amounts of tissue, the surgeon follows the natural anatomical plane around the prostate adenoma and removes the obstructing tissue almost in its entirety.

The trade-off is that this remains a significant operation, usually requiring several days of catheterisation and a period of recovery. Retrograde or absent ejaculation should be expected, and complications including bleeding, infection, temporary incontinence, bladder neck contracture and urethral stricture can occur.

For the appropriately selected patient, however, the combination of substantial adenoma removal, excellent urinary flow improvement, low retreatment requirements and the precision of robotic surgery makes robotic-assisted simple prostatectomy an important contemporary option for the very large benign prostate.

This information is intended for general patient education and does not replace individual assessment and advice from a urologist.