Surgery in MotionVattikuti Institute Prostatectomy: Contemporary Technique and Analysis of Results
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.
References (22)
- et al.
Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations
Prostate
(1983) - et al.
Patient-reported urinary continence and sexual function after anatomic radical prostatectomy
Urology
(2000) - et al.
Laparoscopic radical prostatectomy: the Montsouris technique
J Urol
(2000) - et al.
Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy
J Urol
(2003) - et al.
Robotic radical prostatectomy in the community setting—the learning curve and beyond: initial 200 cases
J Urol
(2005) - et al.
Achieving optimal outcomes after radical prostatectomy
J Clin Oncol
(2005) - et al.
Robotic radical prostatectomy with preservation of the prostatic fascia: a feasibility study
Urology
(2005) Detrusor apron, associated vascular plexus, and avascular plane: relevance to radical retropubic prostatectomy—anatomic and surgical commentary
Urology
(2002)- et al.
An operative and anatomic study to help in nerve sparing during laparoscopic and robotic radical prostatectomy
Eur Urol
(2003) - et al.
Anatomical analysis of the neurovascular bundle supplying penile cavernous tissue to ensure a reliable nerve graft after radical prostatectomy
J Urol
(2004)
Cited by (462)
Clipless Robotic-assisted Radical Prostatectomy and Impact on Outcomes
2022, European Urology Focus