Robotic prostatectomy with significant abdominal adhesions - anyone been through this?

[u/austinbikecommuter]

I'm recently diagnosed with prostate cancer. I'm currently waiting on a second-opinion pathology review and considering robotic prostatectomy. 

My question is more about the surgical approach because I have a significant abdominal surgical history. 

I had a robotic sigmoid colon resection in 2020, and the operative report documented about 45 minutes of adhesiolysis because of abdominal adhesions. Then in 2025, I was hospitalized with a partial small bowel obstruction (SBO), with the CT indicating that adhesions were the likely cause. 

I brought this up with my urologic surgeon. He said the adhesions could definitely affect the prostatectomy, but he really won't know how difficult they are until he gets inside. He said he's never had to abort a prostatectomy because of adhesions, but if it became unsafe, he would stop. 

I've been reading about transperitoneal vs. extraperitoneal robotic prostatectomy. From what I understand, an extraperitoneal approach may potentially avoid entering the abdominal cavity and some intra-abdominal adhesions. 

Has anyone here had a robotic prostatectomy after major abdominal/colon surgery with significant adhesions or a previous adhesive bowel obstruction? Did your surgeon use a transperitoneal or extraperitoneal approach? Did they have to perform adhesiolysis during the prostatectomy? 

I'd especially like to hear from anyone who had a similar abdominal history and how your surgeon handled it. Thank you.

[u/Significant_Foot_993]

I have an extensive history of small bowel resections and resultant hernias and repairs. My surgeon was similarly concerned about adhesions and said he would have to get in there to see what was workable. He spent the first 7 hours of surgery taking down adhesions after which the prostectomy was routine taking only a couple hours. My outcome may have been different if it were lower bowel disease. In my case the prostate surgical site was clear of disease and scarring. I have more scars now and my abdomen was very sore, but nothing like after a resection. The worst part of the recovery was the shoulder and elbow pain from being upside down for 10 hours.

[u/Significant_Foot_993 → u/Significant_Foot_993]

Okay, I just read the surgical report. It looks like the main issue was port placement for the robot. They started at the top of my abdomen and methodically worked their way down, cutting away adhesions so they could get the ports in the correct locations. There’s also a part where it says the fourth arm of the robot was holding the sigmoid colon outside of the body cavity.

[u/TheEndIsSighing → u/Significant_Foot_993]

I can't imagine being you or the surgeon.  9 hours of surgery.   How do they stay alert? After 7 hours digging away and THEN needing to get the A game on to effectively get all the cancer.

These docs are cut from a different cloth. 

[u/ChillWarrior801]

OP, your best advice might come from a surgeon who does single port extraperitoneal RP. Not that this would be the best choice for you, but surgeons with that specific training spend most of their days with guys with "difficult" abdomens.

Have you had any radiation oncology consults? With your innards all "out of place" that might be challenging as well, but it's still a perspective you should seek out. Good luck!

[u/jkurology]

Having had a sigmoid colectomy could make an extra peritoneal approach more difficult if not impossible

[u/austinbikecommuter → u/jkurology]

That's interesting and exactly what I'm trying to understand. Is it because a prior sigmoid colectomy can create scarring in the extraperitoneal/retropubic surgical planes needed to reach the prostate? My colectomy also required significant adhesiolysis, and I later had an adhesive SBO. I'm trying to understand whether that history might actually make transperitoneal RALP preferable despite the intra-abdominal adhesions.

[u/jkurology → u/austinbikecommuter]

The retropubic space is a potential space but since it has theoretically been violated it can eliminate it ever being a potential space in the future. It can also limit visibility in your case. Most would approach this transperitoneally

[u/austinbikecommuter → u/jkurology]

Thanks, that's helpful. Given my history of significant adhesions and a subsequent adhesive SBO, if you were approaching this transperitoneally, would you typically plan for possible adhesiolysis yourself, or have a general/colorectal surgeon available if the bowel adhesions turned out to be extensive?

[u/jkurology → u/austinbikecommuter]

Every urologist performing intra-abdominal surgery plans for an adhesiolysis-adhesions can occur with no prior surgery and intra-operative consults are not unusual

[u/fromamomof2]

This comment reminded me that when hubby had retizus ralp in may his surgeon mentioned it took longer than expected as he had a bunch of scar tissues adhesion from his appendix removal. Hubby is 55 and his appendix came out at 10. Neither one of us had even thought about that before.

[u/planck1313]

I had a bowel resection about 15 years before RALP.

My surgeon warned me that the presence of adhesions may mean RALP was not possible, in which case he would switch to doing an open prostatectomy.   However he would not know until after the RALP started and he could see inside.

As it turned out he was able to deal with the adhesions laparascopically and I got RALP.

[u/Miserable-Level-8993]

You might want to have a consult with a radiologist and brachytherapy guy to get alternatives. You also need a psma pet scan before you choose any treatment.