Vattikuti Institute Prostatectomy: Technique (2022)

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The Journal of Urology

Volume 169, Issue 6,

June 2003

, Pages 2289-2292

ABSTRACT

Purpose

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.

(Video) Introduction to the Vattikuti Institute Prostatectomy for Prostate Cancer

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.

Results

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.

Conclusions

Vattikuti Institute prostatectomy is a precise and safe minimally invasive technique of radical retropubic prostatectomy.

Section snippets

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

REFERENCES (17)

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  • W.W. Schuessler et al.Laparoscopic radical prostatectomy: initial short-term experience

    Urology

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  • G.W. Hull et al.Cancer control with radical prostatectomy alone in 1,000 consecutive patients

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  • C.C. Abbou et al.Laparoscopic radical prostatectomy: preliminary results

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  • 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

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    (Video) Vattikuti Institute Prostatectomy: Technical Modifications In 2009

    Urology

    (2002)

There are more references available in the full text version of this article.

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    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).

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    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.

    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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View full text

Copyright © 2003 American Urological Association, Inc. Published by Elsevier Inc. All rights reserved.

(Video) Double Layered Urethrovesical Anastomosis during Robotic Radical Prostatectomy

FAQs

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? ›

Disadvantages of robot-assisted surgery are:
  • 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.
Dec 15, 2021

Who is not a candidate for robotic prostate surgery? ›

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? ›

Here are nine tips for making your road to recovery after prostatectomy as smooth as possible.
  1. Plan Ahead. ...
  2. Listen to Your Doctor. ...
  3. Stay Ahead of Your Pain. ...
  4. Take It Easy. ...
  5. Treat Constipation. ...
  6. Call Your Doctor With Concerns. ...
  7. Protect Yourself from Accidents. ...
  8. Don't Let Sexual Side Effects Get You Down.

Can you still have an erection if your prostate is removed? ›

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.

Which prostate surgery is best? ›

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? ›

After 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.

Videos

1. Dr. Mani Menon: Step by Step Radical Prostatectomy
(Vattikuti Foundation)
2. Dr. Rajesh Ahlawat: Robotic Radical Prostatectomy - Techniques
(Vattikuti Foundation)
3. Dr. Jim Porter daVinci Prostatectomy Full Length Procedure
(Vattikuti Foundation)
4. Simplifying the Nerve Sparing Radical Prostatectomy
(Vattikuti Foundation)
5. Dr. Prokar Dasgupta: Radical Prostatectomy Step-by-Step...
(Vattikuti Foundation)
6. Developing the Menon Precision Prostatectomy
(Vattikuti Foundation)

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