Da Vinci Robotic Prostatectomy: The Retzius-Sparing Technique Explained

What is Da Vinci robotic prostatectomy?

Robotic radical prostatectomy is the surgical removal of the prostate gland for prostate cancer, performed using the da Vinci robotic system. The da Vinci Xi — the current generation system — uses a surgeon-controlled console with high-definition 3D visualisation and robotic arms that translate the surgeon's hand movements into precise micro-movements inside the patient's body.

The procedure involves five small keyhole incisions in the abdomen. The robotic arms pass through these ports, carrying instruments that can move with greater range of motion than the human hand. The magnification — up to 10× — allows the surgeon to identify and preserve nerves and blood vessels that would be invisible or at high risk with open surgery. Blood loss is typically under 100 ml, compared with 500–1000 ml for traditional open prostatectomy.

Robotic prostatectomy has become the standard surgical approach for localised prostate cancer in specialist centres across the UK and Europe. The outcome, however, depends critically on the technique used and the individual surgeon's volume and experience — not simply on the robot being in the room.

The Retzius-sparing technique — why it changes outcomes

All robotic prostatectomies remove the prostate, but they don't all approach it the same way. The standard technique approaches from the front of the prostate (the anterograde approach), entering the Retzius space — the anatomical cavity between the pubic bone and the bladder. The Retzius space contains structures including the puboprostatic ligaments, the endopelvic fascia and supporting tissue that contribute to urinary continence control after surgery. Dividing these structures is unavoidable with the standard technique.

The Retzius-sparing (or posterior) approach was developed specifically to preserve these structures. Instead of entering the Retzius space, the surgeon approaches the prostate from behind the bladder. The puboprostatic ligaments and endopelvic fascia remain completely intact. The result — supported by multiple published comparative studies — is faster recovery of urinary continence after surgery.

• Earlier continence: Most Retzius-sparing patients are continent (zero or one safety pad) within 4–6 weeks of catheter removal. Standard technique patients often take 3–6 months to reach the same milestone.
• Higher early continence rates: Published data show 70–80% of patients are pad-free at 4 weeks with Retzius-sparing, compared with 30–50% with standard technique at the same timepoint.
• Equivalent cancer control: Positive surgical margin rates and PSA recurrence rates are comparable between the two techniques — continence improvement does not come at the cost of oncological safety.
• Not suitable for every case: Very large prostates, certain tumour locations or prior pelvic surgery may make the standard approach preferable. The right technique is case-specific.

Mr Ameen's approach and outcomes

Mr Torath Ameen performs robotic prostatectomy exclusively using the Retzius-sparing technique, adapted to each patient's individual anatomy and tumour characteristics. He has performed over 500 cases, with operative metrics — including blood loss, positive surgical margin rates and nerve-preservation outcomes — independently benchmarked through European Association of Urology data registries, placing him consistently in the top 25% of European robotic surgeons.

Every operation is performed by Mr Ameen personally. There is no delegation to a trainee surgeon or assistant. Every patient receives a written care plan before surgery, with clear explanation of the planned approach, nerve-preservation intent and what to expect at each stage of recovery. Follow-up consultations — including PSA monitoring — are carried out by Mr Ameen directly.

Who is a candidate for robotic prostatectomy?

Robotic radical prostatectomy is appropriate for most men with localised or locally advanced prostate cancer who are fit for a general anaesthetic. It is one of several treatment options — alongside radiotherapy (with or without hormones) and active surveillance — and the right choice depends on tumour characteristics, the patient's age and fitness, and individual priorities around side-effect profile.

In broad terms, robotic prostatectomy is discussed with men who have:

• Localised prostate cancer (T1–T2) with a PSA under 20 and Gleason grade group 1–3 (and sometimes 4–5)
• Locally advanced disease (T3a–T3b) where surgery is part of a combined treatment plan
• High-risk disease where upfront surgery is preferred to radiotherapy, particularly in younger men
• A life expectancy of more than 10 years — surgery offers the most direct data on long-term cure
• A preference for knowing the prostate has been physically removed with a clear pathology result

Men who are unfit for surgery, have extensive comorbidities, or whose tumour has spread beyond the prostate will typically be directed towards radiotherapy, hormonal therapy or systemic treatment instead. A multidisciplinary team discussion and mpMRI review informs this decision.

What happens on the day of surgery

Robotic prostatectomy is performed under general anaesthesia and typically takes 2–3 hours. The key steps are:

• Five small keyhole ports (5–12mm) are placed in the abdomen; the robotic arms are then docked to the patient
• The space behind the bladder is developed (Retzius-sparing approach), and the prostate is carefully separated from the bladder, urethra and surrounding structures
• Nerve bundles running alongside the prostate are preserved where oncologically safe — this protects erectile function recovery
• The prostate and seminal vesicles are removed intact and sent for pathological analysis
• The bladder neck is reconstructed and sutured to the urethra (urethrovesical anastomosis)
• A urinary catheter is placed through the urethra at the end of surgery to allow healing

Most patients are on a ward within 3–4 hours of surgery finishing, walking the same afternoon or evening, and eating and drinking normally within 24 hours.

Recovery — what to expect week by week

Recovery after robotic prostatectomy is substantially faster than after open surgery, and the Retzius-sparing technique improves the early continence part of that recovery considerably.

• Days 1–2: In hospital. Catheter in situ. Light walking. Discharged home once comfortable and mobile.
• Days 3–10: At home with catheter. Light activity — short walks. Most men manage comfortably with minimal pain relief. Avoid lifting, straining or driving.
• Day ~10: Catheter removed at a clinic appointment. Urinary control typically begins immediately for Retzius-sparing patients — some leak when standing initially, which improves rapidly.
• Weeks 2–4: Most men using 1–2 pads per day maximum. Urinary control improving daily. Return to desk-based work typically possible within 2–3 weeks.
• Week 6: PSA check. Most men pad-free or using one light pad. Return to driving, light exercise, sexual activity.
• 3 months: Full urinary control achieved in the majority of patients. PSA should be undetectable (<0.1 ng/mL) — this is the first indicator of surgical cure.
• 6–12 months: Erectile function recovery, if nerve-sparing was performed, continues to improve through this period. Most men with nerve-sparing achieve satisfactory erections by 12 months.

What about single-port robotic prostatectomy?

Single-port prostatectomy — performed through a single small incision rather than five ports — is an evolving technique using the da Vinci SP system. It is being adopted at a small number of highly specialist centres and offers potential advantages in reduced incision size and wall recovery. Outcome data at scale is still emerging. Mr Ameen currently performs the established multi-port Retzius-sparing technique, which has the strongest evidence base for functional outcomes.

Choosing the right robotic prostatectomy surgeon in London

The da Vinci robot is a tool. What determines your outcome is the surgeon using it. Across the UK and Europe, there is significant variation in robotic prostatectomy outcomes between surgeons — even within the same hospital. When choosing a robotic prostatectomy surgeon, these are the questions that matter most:

• Volume: How many robotic prostatectomies have you performed yourself? (Not as a team. Personally.) The learning curve for Retzius-sparing technique extends beyond 150–200 cases.
• Technique: Do you perform the Retzius-sparing approach? If not, why not — and what are your continence outcomes at 4 weeks with the technique you use?
• Benchmarking: Are your outcomes independently verified? Benchmarking through national or European registries (e.g. ERUS) is the gold standard for outcome transparency.
• Consultant-led: Will you perform the entire operation yourself, or is any part delegated to a trainee? Is your follow-up personally delivered?
• Nerve preservation: What is your nerve-preservation rate for men with low-risk disease? What are your continence and potency outcomes at 3, 6 and 12 months?
• Cancer control: What are your positive surgical margin rates for pT2 disease? Rates above 15% suggest margin compromise.

Any surgeon who is reluctant to share personal outcome data — rather than institutional averages — should be treated with caution. Published data from specialist robotic units consistently shows that volume and technique are the most predictive factors for both functional and oncological outcomes.