By Dr. Richard Bevan-Thomas

This is the final chapter of the DocRBT Essentials series.

In Parts 1 and 2, we focused on erectile recovery and urinary control — the quality-of-life outcomes that matter deeply after prostate cancer surgery.
Today, we get to the reason we are doing this operation in the first place:

Making sure the cancer is truly gone.

As a surgeon practicing in Arlington and across the DFW Metroplex, my philosophy is simple. Quality of life after surgery matters — but none of it matters unless we first do a good cancer operation.

What Cancer Control Really Means

Cancer control after a robotic radical prostatectomy isn’t a single result or lab value. It’s the outcome of a series of decisions made before, during, and after surgery.

When I talk to patients about cancer control, I focus on four questions:

• Did we remove the cancer completely?
  
• Was the cancer confined to the prostate, or had it begun to grow outside of it?
  
• Were the lymph nodes involved?
  
• Does the PSA drop to undetectable and stay there?
  

Each of these helps us understand where things stand and what to expect moving forward.

Why Planning Matters So Much in Prostate Cancer Surgery

Precision during surgery is everything.

Robotic prostate surgery allows us to operate with extraordinary clarity and control. Using the da Vinci system, I work with a high-definition, three-dimensional view at up to 10-times magnification, which allows careful identification of tissue planes, nerves, blood vessels, muscle layers, and areas where anatomy is especially tight.

But that precision only helps if we know where to use it.

This is where prostate cancer surgery becomes a bit of a tightrope walk.

At all times, we are balancing two competing priorities:

• Preserving nerves, fascia, and urethral length to protect quality of life
  
• Minimizing the chance of leaving cancer behind
  

That balance is not guessed at during surgery. It’s planned carefully before we ever enter the operating room.

Why We Can’t Rely on “Seeing” Cancer During Surgery

Patients often ask whether we can actually see prostate cancer during surgery.

The honest answer is: most of the time, we can’t.

Prostate cancer is usually microscopic. It doesn’t behave like a visible mass that can be reliably identified and avoided. While there are occasional moments during surgery where tissue appearance raises concern — and when that happens, we absolutely adjust our approach — those situations are uncommon.

As a whole, prostate cancer is very difficult to visually distinguish from normal tissue during surgery, even with excellent magnification.

That’s why planning matters so much more than reacting in real time.

Why Frozen Sections Are Rarely Used Today

In the past, surgeons sometimes sent tissue to the pathologist during surgery — called a frozen section — to check for cancer at the margins.

In robotic prostatectomy, frozen sections have proven to be unreliable. The tissue samples are small, altered by freezing, and difficult to interpret accurately in the moment. False reassurance or false concern can lead to poor decisions.

Because of this, frozen sections are rarely used in modern robotic prostate surgery.

Instead, the most reliable approach is:

• Careful preoperative planning
  
• Thoughtful intraoperative judgment
  
• And a thorough final pathology report examining the entire prostate
  

This strategy leads to better cancer control and fewer unnecessary trade-offs.

How We Decide Where to Stay Close — and Where to Go Wider

Before surgery, I carefully study your case and ask several key questions:

• Where is the cancer most likely located within the prostate?
  
• Are there areas where it may be close to the capsule?
  
• Are there warning signs that it could be extending beyond the prostate?
  

Those answers come from combining:

• MRI findings
  
• Biopsy grade and cancer volume
  
• PSA level and trends
  
• The pattern and location of positive biopsy cores
  

These don’t give certainty — but they give probability. And in surgery, understanding probability is how we stay balanced on that tightrope.

In some areas, the plan may be to work very close to the prostate to preserve nerves and supporting structures. In other areas, the plan may be to intentionally take more tissue to reduce the risk of leaving cancer behind.

That strategy is determined before the operation begins.

Surgical Margins: The “Orange” Rule

One of the first things patients look for on their final pathology report is the word “negative.”
Specifically, negative surgical margins.

I often explain this with a simple analogy.

Think of the prostate like an orange.

My job is to remove the orange without cutting into the fruit, while still staying as close as possible to protect nearby nerves and muscles.

This is another place where we’re walking that same tightrope. Staying too far away risks unnecessary damage to function. Staying too close risks cutting into cancer.

• Negative margins mean cancer cells do not reach the edge of the removed tissue.
  
• Positive margins mean cancer cells are found at the edge, suggesting microscopic disease may remain.
  

Achieving negative margins isn’t about being aggressive everywhere — it’s about knowing where to stay close and where to step back.

Extraprostatic Extension (EPE): When Cancer Pushes Outside the Prostate

Sometimes prostate cancer grows right up to the capsule and begins to extend beyond it. This is called extraprostatic extension (EPE).

We look for signs of this using:

• MRI
  
• Biopsy grade and volume
  
• PSA trends
  

If EPE is suspected in a specific area, the plan is to remove a wider margin of tissue there. That shifts the balance of the tightrope toward cancer control in that location.

Finding EPE on final pathology does not mean surgery failed. Often, it confirms that taking additional tissue was the right decision.

What the Final Pathology Report Tells Us

After surgery, every patient receives a final pathology report. Unlike a biopsy, this examines the entire prostate under the microscope.

From this report, we learn:

• The true cancer grade
  
• Whether the cancer was confined to the prostate
  
• Whether extraprostatic extension was present
  
• Whether surgical margins were clear
  
• Whether lymph nodes were involved (if removed)
  

For many patients, this report provides clarity and reassurance — turning estimates into definitive answers.

Lymph Nodes: Completing the Cancer Picture

In many cases, we remove pelvic lymph nodes during surgery.

Lymph nodes act as early checkpoints. If prostate cancer spreads, this is often the first place it goes.

• Negative nodes increase confidence that surgery alone is sufficient.
  

Positive nodes don’t mean surgery failed. They give us valuable information and allow early, targeted treatment when appropriate.

PSA: The Proof After Surgery

Because the prostate is the primary source of PSA, once it is removed, the PSA should fall to undetectable levels.

For many men, seeing that first undetectable PSA is when the emotional weight finally starts to lift.

We continue to monitor PSA closely over time. A stable, undetectable PSA is one of the strongest signs of durable cancer control.

If the Cancer Ever Comes Back: We Still Have Options

If PSA begins to rise after surgery, it does not mean we’re out of options.

In many cases, early, targeted radiation therapy can be very effective at controlling recurrence — especially when caught early.

Because the prostate has already been removed:

• PSA is a very sensitive early warning signal
  
• Radiation can be delivered more precisely
  
• Treatment decisions can be made before symptoms develop
  

Surgery doesn’t close doors. It often creates clarity and keeps future options open.

The Bigger Picture

Robotic radical prostatectomy is not just a technical procedure.

It’s a carefully planned balance — a tightrope — between removing cancer thoroughly and preserving the structures that matter for life afterward. When guided by planning, experience, and close follow-up, surgery offers an excellent chance at long-term cancer control and quality of life.

Take the Next Step in Arlington & DFW

If you’ve been diagnosed with prostate cancer, you don’t have to navigate this alone.

Whether you’re in Arlington, Mansfield, Southlake, or anywhere in the DFW Metroplex, let’s review your MRI, biopsy, PSA, and options together and build a plan that prioritizes both cancer control and life after surgery.

Call: 866-367-8768
Location: Urology Partners of North Texas | Arlington, TX
Book Online: Schedule Your Consultation
Watch: Cancer Control & Robotic Surgery on the DocRBT YouTube Channel

Welcome to Part 2 of the DocRBT Essentials series.

In this series, I’m breaking down the three outcomes that matter most to men undergoing robotic surgery for prostate cancer:

• Cancer control
  
• Urinary continence
  
• Erectile function
  

(In Part 1, we discussed erectile recovery. See the full article here: Preserving Erections After Robotic Prostatectomy: The DocRBT Approach)

Important: Radical vs. Simple Prostatectomy

Before we dive in, it’s important to clarify which operation we’re discussing, because recovery expectations are very different.

This guide is specifically for men undergoing a Robotic Radical Prostatectomy for prostate cancer.

Radical Prostatectomy

The entire prostate gland and seminal vesicles are removed to eliminate cancer. Because the prostate sits directly between the bladder and the urethra, this surgery requires a complete reconstruction of the urinary channel.

Simple Prostatectomy

A different procedure used for an enlarged prostate (BPH), where only the inner portion of the prostate is removed to improve urine flow.

Urinary control is a much bigger focus after a radical procedure, which is why surgical technique and recovery planning matter so much.

The Big Question: “Am I Going to Be Incontinent?”

For my patients in Arlington, the DFW Metroplex, and across North Texas, this is often the most pressing concern after a cancer diagnosis.

The short answer is that most men regain urinary control.

How quickly that happens depends on planning, surgical technique, and what you do after surgery.

Overviews

The Goal

Remove the entire cancerous prostate while preserving the structures that allow urinary control to return.

How We Do That

Protect the endopelvic fascia, preserve urethral length, perform a careful reconstruction — and allow the urinary channel to heal with as little irritation as possible.

What to Know Up Front

Early leakage is common. Long-term incontinence is not. Recovery happens in stages, and there are real, proven ways to improve the odds.

Where Urinary Control Really Comes From

Urinary continence is not controlled by a single muscle.

It depends on multiple structures working together, including:

• The bladder neck
  
• The external urinary sphincter
  
• The levator ani muscles
  
• The connective tissue that supports them (called fascia)
  

Fascia is the body’s natural scaffolding.

It’s a thin but strong layer of tissue that surrounds muscles, holds them in position, and allows them to contract together instead of pulling against one another.

In the pelvis, the endopelvic fascia helps anchor the pelvic floor muscles so they function as a coordinated unit. When this support system stays intact, urinary control tends to return faster and more reliably.

What Happens During Surgery That Influences Continence

Just like erectile preservation, continence preservation begins during the operation itself.

One of the most important — and often overlooked — factors is preserving the endopelvic fascia.

Why the Endopelvic Fascia Matters

The endopelvic fascia acts like a supportive hammock for the pelvic floor.

It allows the levator ani muscles to work together, tightening around and supporting the urethra when you cough, stand, or move. When those muscles contract as a unit, urinary control is stronger and more durable.

If this layer is overly disrupted during surgery, the muscles may still be present — but they don’t work together as efficiently. That can slow continence recovery.

Whenever the cancer anatomy allows, preserving this fascia helps maintain pelvic floor support and improves both early and long-term outcomes.

Other Surgical Details That Influence Recover

Bladder Neck Preservation – When it’s safe to do so, preserving the natural bladder neck supports earlier urinary control.

Preserving Urethral Length – The more healthy urethra that remains, the better the sphincter can function.

Gentle Tissue Handling – Limiting traction and avoiding unnecessary heat reduces temporary muscle and nerve dysfunction.

Careful Reconstruction – A tension-free, well-aligned reconnection of the bladder and urethra supports healing and continence.

No single step guarantees immediate dryness, but together these details make a meaningful difference.

What to Expect After Surgery: A Realistic Timeline

Some degree of leakage early on is normal, especially when standing, coughing, or during physical activity.

• Weeks 1–6: Gradual improvement as swelling decreases
  
• 3–6 months: Most men regain good urinary control
  
• Up to 12 months: Continued improvement in endurance and confidence
  

A smaller group takes longer, and a very small percentage may need additional treatment.

Why Pelvic Floor Exercises Only Work If Done Correctly

Pelvic floor exercises (Kegels) aren’t optional busywork — they’re rehabilitation.

In my practice, I give patients specific Kegel exercises to perform four times a day. When done correctly and consistently, they can significantly improve urinary control after surgery.

Kegels aren’t about squeezing as hard as possible. They’re about:

• Activating the correct muscles (imagine gently pulling the scrotum toward the belly button)
  
• Holding for the right amount of time
  
• Fully relaxing between contractions
  
• Repeating the pattern consistently
  

When done incorrectly or inconsistently, improvement is often slow at best.

The “Rule of 2s”: Simple Habits That Help Recovery

Once the urinary channel has begun to heal, bladder habits matter.

I recommend what I call the Rule of 2s:

• Try to urinate every two hours during the daytime
  
• Avoid drinking fluids within two hours of going to bed
  

This prevents the bladder from becoming overly full and reduces pressure on the healing urinary channel. Avoiding late fluids also improves sleep, which plays a real role in recovery.

Why I Use a Suprapubic Tube Instead of a Urethral Catheter

After robotic radical prostatectomy, the connection between the bladder and urethra needs time to heal.

Most surgeons use a urethral catheter (through the penis). I almost always use a suprapubic (SP) tube, which drains the bladder through a small opening in the lower abdomen.

This approach offers several advantages:

• Comfort: No one wants a plastic tube in their penis for a week
  
• Rest: The urethra can heal without constant irritation
  
• A “voiding trial”: We can safely test urination without re-inserting a catheter
  

Many patients find this approach far more tolerable during early recovery.

If Leakage Persists

If leakage continues beyond the typical recovery window, there are effective options, including pelvic floor therapy, medications, minimally invasive treatments, and surgical solutions when appropriate.

Persistent incontinence is treatable, and it’s addressed step by step.

The Bigger Picture

Robotic radical prostatectomy isn’t just about removing cancer.

It’s about preserving anatomy so the body can recover function. When the pelvic floor muscles and their supporting fascia are respected during surgery — and rehabilitation is done correctly — most men regain urinary control over time.

Take the Next Step in Arlington & DFW

If you’ve been diagnosed with prostate cancer, schedule a consultation so we can talk honestly about your recovery and create the right plan for you.

Call: 866-367-8768
Location: Urology Partners of North Texas | Arlington, TX
Book Online: Schedule Your Consultation
Watch: Continence Recovery After Prostate Surgery on the DocRBT YouTube Channel

Over the next three articles, I’ll walk through the three outcomes that matter most to men undergoing robotic prostatectomy for prostate cancer:

• Cancer control
  
• Urinary continence
  
• Erectile function
  

Today, we start with the most common concern I hear in my Arlington office

“How do we remove the cancer and still preserve my erections?”

The answer isn’t luck. It comes down to planning ahead, careful technique, and patience during recovery.

Overview

The Goal
Remove the cancer completely while protecting the delicate nerves responsible for erections.

How We Do That
A personalized surgical plan built from PSA trends, imaging, and biopsy pathology, tailored to your cancer and your anatomy.

What’s Different About My Approach

• No heat near the nerves whenever possible
  
• Absorbable clips instead of permanent metal
  
  

What to Know Up Front

If pills or pumps aren’t enough early on, that doesn’t mean recovery has failed. We have reliable next steps, including injection therapy, to keep things moving while healing continues.

How We Plan Before Surgery

Preserving erectile function starts well before the day of surgery.

To plan safely, we look at several pieces of information together:

• PSA level and how it has changed over time
  
• Multiparametric prostate MRI
  
• Biopsy pathology (grade and volume of cancer)
  
• PSMA PET imaging, when appropriate
  

Each tells us something different.

• PSA helps estimate overall cancer burden and behavior.
  
• MRI shows where cancer appears to be located and whether it looks contained.
  
• Biopsy results tell us how aggressive the cancer is and how much of it is present.
  
• PSMA PET scans, when used, can reveal disease extending beyond the prostate or involving lymph nodes.
  

No single test gives the full picture. But when we put them together, they help us decide how close we can safely work to the prostate and how much nerve tissue we can reasonably preserve.

Robotic surgery allows careful execution — but the most important thinking happens before we ever step into the operating room.

How Close We Work to the Prostate — And Why That Matters

The erection nerves don’t exist in a single layer. They are arranged in multiple thin layers along the outside of the prostate, with some fibers right against the capsule and others sitting farther away.

I often explain this using layers of wallpaper on a wall.

Nerve-sparing during robotic prostatectomy isn’t all-or-nothing. The real decision is how close we can safely work to the prostate while minimizing the chance of leaving cancer behind.

One important reality is that we usually can’t see prostate cancer directly during surgery. Because of that, we have to make an educated decision ahead of time based on PSA behavior, imaging findings, and biopsy results.

Cancer can extend outside the prostate capsule, especially when:

• PSA is higher or rising quickly
  
• The cancer is higher grade
  
• There is a larger volume of disease
  
• MRI or PSMA PET findings are concerning
  

In those situations, we may intentionally go wider, removing more layers of “wallpaper” along with the prostate to reduce the risk of leaving cancer behind.

When PSA is lower, the cancer is lower grade and lower volume, and imaging suggests the disease is well contained, we may be able to work closer to the prostate, leaving more nerve layers behind.

The more nerve layers we can safely preserve, the better the chance erections return sooner and more completely. The balance is always between curing the cancer and preserving function.

Which layer we choose depends on PSA, MRI findings, biopsy results, and cancer grade and volume. This is why nerve-sparing decisions are individualized, not formula-based.

Why I Avoid Heat Near the Nerves

The nerves responsible for erections are extremely sensitive.

Many surgeries use electrical cautery to control bleeding. The issue is that heat spreads, and even small amounts of thermal injury can affect nerve recovery.

Whenever possible, I rely on athermal techniques:

• Cold dissection using robotic scissors
  
• Absorbable clips instead of permanent metal
  

This approach is slower and more deliberate, but it reduces unnecessary nerve trauma.

Going Home the Same Day

Most of my robotic prostatectomy patients go home the same day.

Being in your own bed, eating familiar food, and moving early improves circulation, recovery, and overall comfort.

You’re not stuck in a hospital room — you’re already moving forward.

Helping the Nerves Recover

Even with excellent nerve-sparing, the nerves often go into a temporary shutdown, called neuropraxia.

Think of it like a limb in a cast. Without use, tissue weakens.

That’s why we start penile rehabilitation early:

Daily Cialis
Supports ongoing blood flow and tissue oxygenation.

Vacuum Erection Device (VED)
Essentially physical therapy for the penis, helping prevent scarring.

Injection Therapy
If pills or the pump aren’t enough, injections bypass the nerves entirely and are very effective during recovery.

A Reality Check on Timing

Surgery won’t improve erections beyond your baseline going in. The goal is to protect what you already have.

Nerves heal slowly. Improvement often continues well beyond the first year, sometimes up to four years after surgery.

Consistency matters. Patience matters.

Looking Beyond the Operation

Robotic prostatectomy isn’t a one-day event.

It’s a process that starts with careful planning and continues through rehabilitation and follow-up. Adjusting therapy when needed and staying engaged over time makes a real difference in outcomes.

Take the Next Step

If you or a loved one has recently been diagnosed with prostate cancer, schedule a consultation so we can review PSA trends, imaging, and biopsy results together and build a thoughtful plan focused on recovery during and after surgery.

Call: 866-367-8768
Book Online: Schedule Your Consultation
Watch: Erectile Recovery Explained on the DocRBT YouTube Channel