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Robotic Radical Prostatectomy and the Vattikuti Urology Institute Technique: an Interim Analysis of Results and Technical Points

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Robotic Radical Prostatectomy and the Vattikuti Urology Institute Technique: an Interim Analysis of Results and Technical Points ROBOTIC RADICAL PROSTATECTOMY AND THE VATTIKUTI UROLOGY INSTITUTE TECHNIQUE: AN INTERIM ANALYSIS OF RESULTS AND TECHNICAL POINTS MANI MENON, ASHUTOSH TEWARI, AND MEMBERS OF THE VATTIKUTI INSTITUTE PROSTATECTOMY TEAM ABSTRACT We have performed Ͼ350 robotic radical prostatectomies in the last 2 years. A single surgeon (MM) performed 250 of these procedures using a technique developed at our institution, the Vattikuti Urology Institute. This article summarizes the technical highlights and interim results of the Vattikuti Institute Prostatectomy (VIP) technique. We prospectively collected baseline demographic data, such as age, race, body mass index (BMI), serum prostate-specific antigen values, prostate volume, Gleason score, percentage cancer, TNM clinical staging, and comorbidities. Urinary symptoms were measured with the International Prostate Symptom Score, and sexual health with the Sexual Health Inventory of Males. In addition, patients received the Expanded Prostate Inventory Composite at baseline and at 1, 3, 6, 12 and 18 months after the procedure via mail. Data collection is complete on 200 of the first 250 patient cases. Gleason score Ն7 was noted in 40% of patients. The average BMI was high (28), and 86% patients were classified as pathologic stage pT2a to pT2b. The mean operative time was 160 minutes and the mean blood loss was 153 mL. No patient required blood transfusion. At 6 months, 82% of the men who were Ͻ60 years of age and 75% of those Ͼ60 years of age had return of sexual function, and 64% and 38%, respectively, had sexual intercourse. At 6 months, 96% patients were continent. UROLOGY 61: 15–20, 2003. © 2003, Elsevier Science Inc. obotic assistance offers an open surgeon so- proach based on our first 30 cases has been Rphisticated tools to perform complex lapa- published.3 In this article, we expand on newer roscopic surgery. A technologically advanced modifications and provide an update of our prelim- ergonomic operation is achieved because of 3-di- inary results. mensional visualization; wristed instrumentation; intuitive, finger-controlled movements; and a comfortable seated position for the surgeon. We PATIENTS AND METHODS started performing robotic prostatectomy in No- vember 20001,2 and have done 350 such operations PATIENTS AND DATA as of December 2002. Our current approach—Vat- Men with Gleason score Ͼ5 prostate cancers with a Charl- Ͻ tikuti Institute Prostatectomy (VIP)—is based on son comorbidity score of 3 are candidates for this procedure. We prospectively collected baseline demographic data, such the palimpsest of conventional anatomic “open” as age, race, body mass index (BMI), serum prostate-specific prostatectomy, overwritten by technical nuances antigen, prostate volume, Gleason score, percentage cancer, that are derived from robotic technology as elabo- 1992 TNM clinical staging, comorbidities, and previous ab- rated by the da Vinci surgical system (Intuitive Sur- dominal surgery. Urinary symptoms were measured with the gical, Sunnyvale, CA). An early version of this ap- International Prostate Symptom Score (IPSS), and sexual health with the Sexual Health Inventory of Males score. In addition, the patients were interviewed on the telephone by a From the Vattikuti Urology Institute, Henry Ford Health System, third party and were also mailed the Expanded Prostate Inven- Detroit, Michigan, USA; and Department of Urology, Case West- tory Composite, a quality-of-life instrument.4 The quality-of- ern Reserve University School of Medicine, Cleveland, Ohio, life instruments have been validated previously in patients USA. with prostate cancer.4–6 The local Institutional Review Board Reprint requests: Mani Menon, MD, Vattikuti Urology Insti- approved the study and consent forms. Questionnaires were tute, Henry Ford Hospital, 2799 West Grand Boulevard, K-9, collected at baseline and at 1, 3, 6, 12, and 18 months after the Detroit, Michigan 48202. E-mail: [email protected] procedure. © 2003, ELSEVIER SCIENCE INC. 0090-4295/03/$30.00 ALL RIGHTS RESERVED doi:10.1016/S0090-4295(03)00116-X 15 DATA COLLECTION the movements to allow precise and delicate dis- Details of each surgical procedure were entered on a com- section. prehensive data collection sheet, which was completed by a third party. These details included the times of entry into the operative room, induction of anesthesia, and the various steps SURGICAL TEAM of the operation: (1) port placement, (2) development of ret- The VIP team includes 1 console-side and 1 pa- roperitonal space, (3) lymph node dissection, (4) ligation of tient-side team. The operating surgeon sits at the the dorsal venous complex, (5) retroapical release, (6) bladder console and is not scrubbed. neck transection, (7) exposure of vas and seminal vesicles, (8) control of pedicles, (9) incision of posterior layer of Denon- villier fascia, (10) neurovascular bundle release, (11) urethral PATIENT POSITIONING AND PORT PLACEMENT transection, (12) apical biopsies, and (13) anastomosis. We place the patient in the Trendelenburg po- Additional data elements that were measured were (1) sition, and pneumoperitoneum is created with a blood loss (determined by the anesthesiologist), (2) the post- Veress needle (Ethicon Endo-Surgery, Inc., Al- operative pain score (using a visual analog score), (3) days of buquerque, NM) introduced through a left peri- hospitalization, (4) hemoglobin levels at discharge, and (5) duration of catheterization. Any untoward event within 30 umbilical puncture. As previously described, 6 3 days of surgery was recorded as a perioperative complication.7 ports are used (Video Clip 2: Patient position- ing and port placement; http://www.goldjournal. net). HISTOPATHOLOGIC ANALYSIS The surgical specimen was inked and processed for his- topathologic analysis.8 Margins were considered positive if SURGICAL STEP MODIFICATIONS:POINTS OF TECHNIQUE there was tumor present at ink. For the apex, margins were The steps have been described previously; we considered positive if the margins of the apical biopsies (see will highlight modifications from the original de- “Results” section), which represent the actual margin of the scription. apical dissection, showed cancer. Positive margins were either Development of the Extraperitoneal Space, Apical focal (Յ1 mm cancer) or extensive (Ͼ1 mm cancer). Dissection and Control of Dorsal Venous Complex. For the VIP approach, the initial incision is made DATA ANALYSIS just above the pubic symphysis. The incision Data were entered in a custom-made Access software (Mi- should be as low as possible, but high enough to crosoft Corporation, Redmond, WA) database and analyzed avoid entering the dome of the bladder. It may be using Statistical Analysis System (SAS) data analysis software (SAS Institute Inc., Cary, NC).9 Between-group comparison of useful to start the incision on either side of the nominal variables were done using Fisher exact test and ␹2 medial umblical ligaments, and to end with ura- analysis, and continuous variables were compared using anal- chal transection. The extraperitoneal space is de- ysis of variance. The days to continence, erection, and inter- veloped (Video Clip 3: Development of the extra- course were recorded and used in the time-dependent survival peritoneal space; http://www.goldjournal.net), analysis using the Kaplan-Meier method. and the bladder is “dropped” posteriorly. The same exposure can be obtained with a purely extraperi- TECHNICAL VIDEO STORAGE toneal placement of the ports. In our hands, the The intraoperative video footage was recorded using a dig- VIP approach combines the virtues of a large work- ital video camera and stored in miniature digital video and digital storage devices. Nonlinear editing was performed using ing space with those of an extraperitoneal a Macintosh computer (Apple Computer, Inc., Cupertino, dissection. CA). Early in our experience, we would transect the puboprostatic ligaments and dissect out the poste- rior urethra and the dorsal vein complex. For the RESULTS last 12 months, we have adopted a minimalist ap- The da Vinci system (Video Clip 1: The da Vinci proach, leaving the puboprostatic ligaments intact System; http://www.goldjournal.net) uses a so- and dissecting out as little of the urethra as is nec- phisticated master-slave robot that incorporates essary to place the dorsal vein stitch (Video Clip 4: 3-dimensional visualization, scaling of movement, Apical dissection and control of dorsal venous and wristed instrumentation. The system has 3 complex; http://www.goldjournal.net). This ap- multijoint robotic arms: 1 arm controls a binocular proach has improved our early continence results. endoscope, and the other 2 arms control articu- The prostatic stitch is placed primarily for traction lated instruments. In addition, 2 lenses—0° or and rotation of the prostate during posterior dis- 30°—are used, and 2 finger-controlled handles section, not to decrease back bleeding. (the “masters”) housed in a mobile console control Preservation of Neurovascular Bundles. Although the 2 robotic arms. Together with a foot pedal, the we initially used electrocautery for the entire pos- arms move the lens and visual field. Instrument terior dissection, we now avoid use of electrocau- movement can be scaled from 1:1, which allows tery. This has been associated with a clear improve- exact finger movements to be transmitted to the ment in early potency rates. We use articulated instrument tip, to 1:3 and 1:5, which scale down robotic scissors to incise the prostatic fascia ante- 16 UROLOGY 61
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