Elsevier

European Urology

Volume 51, Issue 3, March 2007, Pages 648-658
European Urology

Surgery in Motion
Vattikuti Institute Prostatectomy: Contemporary Technique and Analysis of Results

https://doi.org/10.1016/j.eururo.2006.10.055Get rights and content

Abstract

Objectives

Contemporary techniques of radical prostatectomy achieve excellent oncologic outcomes; erectile dysfunction is the most common adverse effect. We have modified our technique of robotic radical prostatectomy (Vattikuti Institute prostatectomy [VIP]) in an attempt to minimize decrease of erectile function while maintaining the excellent oncologic outcomes achieved by the radical retropubic prostatectomy. We present our current technique of VIP with preservation of the lateral prostatic fascia (“veil of Aphrodite”).

Methods

A total of 2652 patients with localized carcinoma prostate underwent VIP. The salient features of our current technique are early transection of the bladder neck, preservation of the prostatic fascia, and control of the dorsal vein complex after dissection of the prostatic apex. Oncologic and functional outcomes were obtained through a questionnaire collected by a third party not involved in patient care.

Results

Complete follow-up information was obtained in 1142 patients with a minimum follow-up of 12 mo (range: 12–66 mo; median: 36 mo). The actuarial 5-yr biochemical recurrence rate was 8.4% and the actual biochemical recurrence rate was 2.3%. Median duration of incontinence was 4 wk; 0.8% patients had total incontinence at 12 mo. The intercourse rate was 93% in men with no preoperative erectile dysfunction undergoing veil nerve-sparing surgery, although only 51% returned to baseline function.

Conclusions

VIP with veil nerve sparing offers oncologic and continence results that are comparable to the results of conventional nerve-sparing radical prostatectomy. Early potency results are encouraging.

Introduction

Over several decades, open radical prostatectomy has developed into a refined surgical procedure, with excellent outcomes [1], [2], [3]. More recently several surgeons have developed minimally invasive surgical techniques for removing the prostate [4], [5].

In 2000, we started a robot-assisted radical prostatectomy program. Our technique, the “Vattikuti Institute prostatectomy” (VIP) was implemented for the routine surgical care of patients with localized prostate cancer in 2001 [6], [7] and has been adopted by others [8], [9], [10]. As of this writing we have performed >2600 robotic radical prostatectomy procedures. Our approach has evolved over the last 5 yr, during which time we have learned many lessons.

Because prostate cancer is being diagnosed earlier in the course of the disease, cancer cure rates have improved dramatically. A “Trifecta” analysis of outcomes following open radical prostatectomy has shown that erectile dysfunction is the most common adverse outcome that the patients sustain [11]. We have attempted to use the precision inherent in robotic surgery to develop enhanced techniques of potency preservation, without sacrificing cancer control. We found certain maneuvers helpful to us: approaching the bladder neck initially (first done in 2001), using a running suture for urethrovesical anastomosis (2001), and incising the prostatic fascia anterolaterally to release the nerves (2003). These techniques resulted in a decrease in operative times, of anastomotic leaks, and of erectile dysfunction, respectively. In 2004 (after >1000 cases!), we changed our technique of traction on the bladder neck and abandoned initial bulk ligation of the dorsal vein complex, in favor of precise suturing after urethral transection. These maneuvers made it easy to identify the bladder neck and resulted in a decrease in positive apical margins. Starting in 2002, we eliminated the use of monopolar cauterization after the transection of the seminal vesicle. In 2004, we stopped opening endopelvic fascia and started preserving the anterior fibromuscular stroma of the prostate in select patients with low-volume disease. We have not been able to detect a significant improvement in operative parameters or outcomes with these latter maneuvers. As we continually try to improve our technique, we despair that robotic radical prostatectomy, like golf, is easy to learn, but difficult to master. In this paper, we describe our current technique, early oncologic outcomes, and functional results.

Section snippets

Patient selection

Although patient preference drives the decision to undergo surgery, we generally recommend that men with low prostate-specific antigen (PSA) levels and focal Gleason 6 cancer of the prostate undergo active monitoring with follow-up biopsies. We offer surgery for men with nonfocal Gleason 6 (30% of our patients), Gleason 7 (60%), and Gleason 8–9 cancer (10%). Patients with >25% Gleason 7 disease get conventional nerve-sparing surgery [1], [2] on the ipsilateral side; all others get the veil

Preoperative and operative parameters

From March 2001 to September 2006, we have operated on 2652 patients, 2582 at our own institution. Preoperative and operative parameters are detailed in Table 1. In keeping with our philosophy, patients in this series had higher grade disease (66% > Gleason 6) than those in many contemporary studies on radical prostatectomy.

The average operative time decreased from 195 min in the first 100 patients to 131 min in the last 100 patients and robotic console time decreased from 165 min to 92 min,

Summary

Radical retropubic prostatectomy has evolved over the last three decades to a precise, sophisticated procedure with minimal mortality and excellent surgical outcomes. Our own experience suggests that equally good results can be obtained with robotic assistance. Our VIP technique continues to evolve with experience, much as “open” radical prostatectomy does. In our hands, the veil nerve-sparing procedure offers superior erectile function compared with conventional nerve-sparing surgery without

Conflicts of interest

The authors have nothing to disclose.

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