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The Journal of Urology
Volume 169, Issue 6,
, Pages 2289-2292
We have performed more than 250 radical prostatectomies using the da Vinci (Intuitive Surgical, Mountain View, California) surgical system. Our initial cases were done using the classic Montsouris approach. However, after gaining familiarity with the robot we modified our technique to reflect our experience with open radical retropubic prostatectomy. We detail the Vattikuti Institute prostatectomy technique that we currently use.
Materials and Methods
The robotic technique requires 2 teams, namely a skilled laparoscopic team at the patient and a skilled open surgeon at the console. Dissection is started anterior to the bladder and it continues extraperitoneally. The endopelvic fascia is opened and the dorsal vein complex is secured. The apex of the prostate is dissected free, releasing the neurovascular bundles at the apex. The bladder neck is then incised, and the seminal vesicles and vasa are transected. Posterior dissection is done within the posterior layer of Denonvilliers’ fascia, preserving the neurovascular bundles and lateral prostatic fascia. The apex is transected and frozen sections are obtained from the parietal margins. Vesicourethral anastomosis is formed with 2 continuous sutures.
In the last 100 cases mean operative time was 2.5 hours and average blood loss was 150 ml. (range 25 to 525 cc.). Median specimen Gleason score was 7 and mean tumor volume was 7 cc. Four patients had a positive surgical margin, which was focal in 3. Of the patients 95% were discharged home within 23 hours. Mean catheterization time was 4.2 days.
Vattikuti Institute prostatectomy is a precise and safe minimally invasive technique of radical retropubic prostatectomy.
da Vinci robotic technology.
The da Vinci system uses a sophisticated master-slave robot that incorporates 3-dimensional visualization, movement scaling and wristed instrumentation. The system has 3 multijoint robotic arms with 1 controlling a binocular endoscope and the other 2 controlling articulated instruments. Two lenses (0 or 30 degrees) are used. Two finger controlled handles (masters) housed in a mobile console control the 2 robotic arms and a foot pedal controls camera movement. Instrument movement can be scaled
1) Development of the extraperitoneal space.
The peritoneal cavity is inspected using a 30-degree upward-looking lens (fig. 1). A transverse peritoneal incision is made extending from the left to the right medial umbilical ligament. The incision is extended in an inverted U to the level of the vasa on either side. The extraperitoneal space is developed after transecting the medial and median umbilical ligaments. When properly done, this dissection allows the bladder, prostate and bowel to drop posterior and the remainder of the operation
For our last 100 patients mean operative time was 165 minutes with and 135 without lymphadenectomy. Average blood loss was 150 ml. Median specimen Gleason score was 7 and mean tumor volume was 7 cc. Four patients had a positive surgical margin, which was unifocal in 3 and multifocal in 1. Of the patients 95% were discharged home within 23 hours. Mean catheterization time was 4.2 days. The complication rate was 4%. These results compare well with the results of open or laparoscopic radical
Laparoscopic radical prostatectomy was first reported by Schuessler et al, who found no advantage to performing the operation. 12 The procedure was subsequently developed and popularized by several groups in Europe and accepted more cautiously in the United States. 7, 13, 14, 15, 16, 17 Several European teams have reported small case series of robotic prostatectomy performed with the da Vinci system but to our knowledge we have the largest experience with this procedure to date.
We used a
Vattikuti Institute prostatectomy is a safe, effective and reproducible technique for removing the prostate. In most patients it can be performed within 3 hours with minimal blood loss and few complications. The procedure incorporates principles of laparoscopic and open radical prostatectomy. We find the operation to be technically challenging but less so than conventional laparoscopic prostatectomy. Vattikuti Institute prostatectomy is a feasible alternative to nonrobotic laparoscopic
- B. Guillonneau et al.Laparoscopic radical prostatectomy: the Montsouris technique
- C.-C. Abbou et al.Laparoscopic radical prostatectomy with a remote controlled robot
- W.W. Schuessler et al.Laparoscopic radical prostatectomy: initial short-term experience
- G.W. Hull et al.Cancer control with radical prostatectomy alone in 1,000 consecutive patients
- C.C. Abbou et al.Laparoscopic radical prostatectomy: preliminary results
- H. Lepor et al.Precise localization of the autonomic nerves from the pelvic plexus to the corpora cavernosa: a detailed anatomical study of the adult male pelvis
- I.S. Gill et al.Laparoscopic radical prostatectomy: technique
Urol Clin North Am
- R.P. MyersDetrusor apron, associated vascular plexus, and avascular plane: relevance to radical retropubic prostatectomy—anatomic and surgical commentary(Video) Vattikuti Institute Prostatectomy: Technical Modifications In 2009
There are more references available in the full text version of this article.
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- Retrospective Concomitant Nonrandomized Comparison of “Touch” Cautery Versus Athermal Dissection of the Prostatic Vascular Pedicles and Neurovascular Bundles During Robot-assisted Radical Prostatectomy
2022, European Urology
During robotic-assisted radical prostatectomy (RARP), the use of electrocautery near the neurovascular bundles (NVBs) frequently results in thermal injury to the cavernous nerves. The cut and “touch” monopolar cautery technique has been suggested to reduce desiccating thermal injury caused by bipolar energy when vessels are sealed.
To compare potency outcomes between an athermal technique (AT) and touch cautery (TC) to transect the prostatic vascular pedicles (PVPs) and dissect the NVBs.
A retrospective concomitant nonrandomized study of AT versus TC was performed in 733 men. A total of 323 undergoing AT had “thin” pedicles, easily suitable for suture ligation. TC was based on “thick” pedicles (n=230) difficult to suture ligate. Men were excluded for an International Index of Erectile Function (IIEF-5) score of <15 or adjuvant therapies (n=180).
Patient-reported outcomes with erectile function (EF) recovery defined as two affirmative answers to erections sufficient for intercourse (ESI; “are erections firm enough for penetration?” and “are the erections satisfactory?”), IIEF-5 scores 15–25, and a novel percent fullness score comparing pre- versus postoperative erection fullness. Logistic regression models assessed the correlation between cautery technique, covariates, and EF recovery.
In an unadjusted analysis, preoperative IIEF-5, age, body mass index (BMI), and prostate weight were significant predictors of potency recovery. Follow-up was similar (AT 52.7 mo vs TC 54.6 mo, p=0.534). In logistic regression, preoperative IIEF-5, age, and BMI were significant predictors of EF recovery, defined as IIEF-5 scores 15–25, ESI, and percent fullness >75%. Results were similar when IIEF-5 and percent fullness were assessed continuously.See AlsoTravel Planning Tools | TauckHow Alcohol Impacts the Risk of Blot ClotsFinally! 💰 Cheap 💰 & Fast "Write My Paper For Me" Service | WritePaperFor.meThe best ingredients and products to fight skin pigmentation and dark spots
During transection of the PVPs and dissection of the NVBs, TC did not impact EF recovery significantly, compared with an AT.
Electrocautery can be applied safely, with similar outcomes to those of an athermal technique.
- Relationship between robotic-assisted radical prostatectomy and retropubic radical prostatectomy in the learning curve of a single surgeon as a novice in radical prostatectomy: A retrospective cohort study
2020, International Journal of Surgery
We compared the learning curve and pathologic and functional outcomes of retropubic radical prostatectomy (RRP) and robotic-assisted radical prostatectomy (RARP) performed during the same time period by a novice to identify how the two surgical types affect each other.
We retrospectively reviewed 480 men who underwent RRP or RARP for prostate cancer between January 2008 and December 2012. Operation time, estimated blood loss (EBL), positive surgical margin (PSM) rate, urinary continence and potency recovery, and complications were compared. Scatter-graphs were drawn using locally weighted scatterplot smoothing (LOWESS).
Operation time reached the lowest point in the 90th case in RRP and the 200th case in RARP. EBL showed a similar pattern, reaching the lowest point in the 95th case in RRP and the 230th case in RARP. The lowest points for both operation time and EBL took about 3 years to reach for both surgical types. PSM rate was not significantly different (P=0.807). No pads were required at 6 and 12 months in 55.6% and 66.9% of patients in RRP, respectively, but in 79.6% and 88.4% of patients in RARP. The potency recovery rates were 59.1% in RRP and 70.9% in RARP at 12 months.
When RRP and RARP were begun contemporaneously by a novice, they showed similar learning curve patterns. The direct tactile feedback in RRP and the magnified field of view and detailed techniques in RARP help improve surgical skills complementarily to attain proficiency in both surgical types.
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Severe intraoperative bleeding predicts the risk of perioperative blood transfusion after robot-assisted radical prostatectomy
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Research articleVariations in the Open Market Costs for Prostate Cancer Surgery: A Survey of USHospitals
Urology, Volume 83, Issue 3, 2014, pp. 626-631
To examine variation in the open market cost of a radical prostatectomy (RP) procedure in the US hospitals for an uninsured patient, as many proposals for health care reform highlight the importance of individuals actively participating in selecting care. However, reports suggest that obtaining procedure prices remains challenging and highly variable.
We used 2011-2012 US News and World Report rankings to identify a cohort of 100 hospitals making an effort to include an equal distribution of both academic and private centers, city size, and geographic region. Each hospital was called and the essence of the script included a caller stating he was a healthy, uninsured 55-year-old man recently diagnosed with Gleason 3+ 4 prostatic adenocarcinoma with no metastases. Facility, surgeon, and anesthesia fees were solicited.
Seventy hospitals provided facility prices. Facility estimates averaged $34,720 (±20,335; range, $10,100-$135,000), which was statistically higher at academics centers. No significant differences were seen by region, population, or hospital ranking. Surgeon and anesthesia fees were provided by 10%, averaging $8280 (±$4282; range, $4028-$18,720). Thirty-three hospitals provided discounted fees for prompt payment averaging 34% (±16%; range, 10%-80%).
There is wide variation in pricing for RP, with higher rates found in academic centers. Wide variation in facility costs were observed, and nearly all were unable to provide surgeon and/or anesthesia fees. Currently, it appears to be unacceptably difficult for men with prostate cancer without insurance to obtain prices for an RP procedure.
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Understanding factors associated with variation in hospital charges may help identify means to increase savings. The aim of the present study was to define potential variation in hospital charges associated with hepatopancreatobiliary(HPB) surgery.
Patients who underwent an HPB procedure between 2009–2013 were identified. Total hospital charges were tabulated for room and board, surgical/anaesthesia services, medications, laboratory/radiology services and other miscellaneous charges.
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Research articleThe Stability of Physician-Specific Episode Costs for Urologic Cancer Surgery: Implications for Urologists Under the Merit-Based Incentive Program
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To evaluate the stability of physician-specific episode payments for prostatectomy, nephrectomy, and cystectomy in the context of value-based purchasing programs, such as the merit-based incentive payment system.
We utilized Surveillance, Epidemiology and End Results-Medicare data to identify patients aged 66-99 who underwent a prostatectomy, nephrectomy, or cystectomy from 2008 to 2012. We calculated each surgeon's average 90-day episode payment by procedure. Next, we examined payment differences between the most and least expensive quartile providers. For the most expensive quartile of physicians in 2010, we examined their spending quartile in 2011. Finally, we evaluated the correlation in spending over time and across procedures.
We identified 14,585 patients who underwent surgery by one of 1895 unique clinicians. Differences in payments between the highest and lowest quartiles were $5881, $17,714, and $40,288 for prostatectomy, nephrectomy, and cystectomy, respectively. Only 39%, 16%, and 13% of physicians that were in the highest spending quartile for prostatectomy, nephrectomy, and cystectomy in 2010 were also in the most expensive quartile in 2011. Although we observed weak correlation in year-to-year spending for prostatectomy (0.108, P = .033 to .270, P < .001), annual payments for nephrectomy and cystectomy were not significantly correlated. Finally, there was minimal correlation in surgeon spending across procedures.
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Research articleNew nomenclature for robotic-assisted thoracic surgery also gets rid of RATS
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Copyright © 2003 American Urological Association, Inc. Published by Elsevier Inc. All rights reserved.
Is robotic prostatectomy better than open? ›
, most prostatectomies are performed robotically. But it isn't the best choice. There is no qual- ity evidence that robotic procedures deliver better outcomes than open ones.What is the correct position for a robotic prostatectomy? ›
To provide surgical access to structures deep in the pelvis, the patient must be placed in the low-lithotomy position with stirrups to provide access to the rectum and to facilitate attachment of the robotic machine. For much of the procedure, a steep Trendelenburg position is needed to shift the bowel cephalad.What are the surgical approach of prostatectomy? ›
A common surgical approach to prostatectomy includes making a surgical incision and removing the prostate gland (or part of it). This may be accomplished with either of two methods, the retropubic or suprapubic incision (lower abdomen), or a perineum incision (through the skin between the scrotum and the rectum).How long does a robotic assisted prostatectomy take? ›
The procedure usually takes 2 to 3 hours under general anesthesia. Most patients experience only a small blood loss and blood transfusions are needed in less than one percent of patients.What is the success rate of robotic prostatectomy? ›
The positive margin rate was 9.4% for all patients; i.e. 2.5% for T2 tumours, 23% for T3a and 53% for T4. The overall biochemical recurrence free (PSA level<0.1 ng/mL) survival was 95% at mean follow-up of 9.7 months. There was complete continence at 3 and 6 months in 89% and 95% of patients, respectively.What are the cons of robotic surgery? ›
- Only available in centers that can afford the technology and have specially trained surgeons.
- Your surgeon may need to convert to an open procedure with larger incisions if there are complications. ...
- Risk of nerve damage and compression.
Patients with known metastatic or recurrent prostate cancer are not candidates for robotic prostatectomy. Although patients with very large prostate glands (e.g. > 100 grams) can undergo robotic prostatectomy, operative times are generally longer than in patients with smaller prostate gland sizes.Is the urethra cut during robotic prostatectomy? ›
The surgeon will cut away your prostate, the seminal vesicles, and some nearby lymph nodes and take them out through the small cuts. The urethra will be sewn to the bladder. A new catheter will be placed into the bladder.Who is the best robotic prostate surgeon? ›
Dr. Razdan is recognized as one of the highest volume and most experienced robotic prostate surgeons in the world. He has performed over 9,000 Robotic Surgeries and is considered by many to be one of the best in the world.What are the four approaches in prostate surgery? ›
Each arrow indicates the different possible approaches to the prostate: (1) conventional approaches (transperitoneal and extraperitoneal), (2) Retzius-sparing, (3) transvesical, and (4) transperineal. After the peritoneal space is gained, the peritoneum is incised to gain the pelvic fossa.
What is the least invasive prostate surgery? ›
HoLEP (Holmium laser enucleation of the prostate) is a minimally invasive surgical treatment for men with any degree of prostate enlargement who have urinary symptoms, and men who are suffering from retention of urine, repeated urine infections or bleeding due to their enlarged prostate.What is the difference between prostatectomy and radical prostatectomy? ›
Most often, prostatectomy is done to treat localized prostate cancer. It may be used alone, or in conjunction with radiation, chemotherapy and hormone therapy. Radical prostatectomy is surgery to remove the entire prostate gland and surrounding lymph nodes to treat men with localized prostate cancer.Is robotic prostate surgery painful? ›
There, the patient typically has little pain, but may feel as if he has to urinate due to the presence of the urinary catheter, which will stay in for 5-6 days. There will also be a drain coming from one of the five small incisions, and this will be taken out typically the next day just before going home.How many ports are needed for robotic prostate surgery? ›
Thus most patients will have 5 port sites. The procedure is performed under general anesthesia so the patient feels no pain during surgery and lasts an average of 3.5 hours.What is the fastest way to recover from prostate surgery? ›
- Plan Ahead. ...
- Listen to Your Doctor. ...
- Stay Ahead of Your Pain. ...
- Take It Easy. ...
- Treat Constipation. ...
- Call Your Doctor With Concerns. ...
- Protect Yourself from Accidents. ...
- Don't Let Sexual Side Effects Get You Down.
Most men who have normal sexual function and receive treatment for early prostate cancer regain erectile function and can have satisfying sex lives after robotic prostatectomy.How long does it take the urethra to heal after prostatectomy? ›
HOW LONG WILL I HAVE INCONTINENCE AFTER PROSTATE SURGERY? Men will typically have a urinary catheter (a tube) inserted which will help drain the urine from the bladder after the surgery. The catheter is needed until the urethra heals, which typically takes anywhere from 1-3 weeks.Are lymph nodes removed during robotic prostatectomy? ›
Radical perineal prostatectomy
In this open operation, the surgeon makes the cut (incision) in the skin between the anus and scrotum (the perineum), as shown in the picture above. This approach is used less often because it's more likely to lead to erection problems and because the nearby lymph nodes can't be removed.
TURP is generally considered an option for men who have moderate to severe urinary problems that haven't responded to medication. While TURP has been considered the most effective treatment for an enlarged prostate, a number of other, minimally invasive procedures are becoming more effective.Is robotic surgery safer than traditional surgery? ›
Like any surgery, both come with risks and benefits. But robotic surgery often has fewer complications and a lower risk of infection, among other benefits. Robot-assisted surgery often means patients have an easier and faster recovery.
Is robotic prostate surgery painful? ›
There, the patient typically has little pain, but may feel as if he has to urinate due to the presence of the urinary catheter, which will stay in for 5-6 days. There will also be a drain coming from one of the five small incisions, and this will be taken out typically the next day just before going home.Who is the best robotic prostate surgeon? ›
Dr. Razdan is recognized as one of the highest volume and most experienced robotic prostate surgeons in the world. He has performed over 9,000 Robotic Surgeries and is considered by many to be one of the best in the world.What is the cost of a robotic prostatectomy? ›
Results: Mean hospital cost per robot-assisted radical prostatectomy was $11,878 (95% CI $11,804-$11,952). Mean cost was $2,837 (95% CI $2,805-$2,869) in the low cost group vs $25,906 (95% CI $24,702-$25,490) in the high cost group.Is robotic surgery more painful? ›
Robotic-assisted surgery brings more benefits to the table than traditional surgeries and offers cancer patients an experience which is better, less painful, less risky and quicker to recover from.What are the two greatest advantages we can expect of robotic surgery? ›
For most patients, robotic surgery offers numerous benefits, including: Reduced post-surgery pain. Less blood loss. Fewer and smaller scars.